The most significant item on the agenda is a report on the Decision-Making Business Case for Acute Mental Health Services in the City of Westminster and the Royal Borough of Kensington and Chelsea. The Committee will also receive the minutes of its previous meeting.

Decision-Making Business Case for Acute Mental Health Services

The report pack contains the Decision-Making Business Case (DMBC) for acute mental health services in Westminster and Kensington and Chelsea. It has been prepared following a public consultation on proposals to permanently change those services.

A Pre-Consultation Business Case (PCBC) was approved by the North West London Integrated Care Board (ICB) in October 2023. This set out a preferred option to:

• Enhance the range of community services that had been put in place since the temporary closure of inpatient beds at the Gordon Hospital in 2020.
• Further develop the Mental Health Crisis Assessment Service (MHCAS) so that it could offer patients a short stay within the service and move it to the Gordon Hospital from St Charles Hospital.
• Not re-open the inpatient beds at the Gordon Hospital which had been temporarily closed, but instead to continue to use the 67 beds at the St Charles Centre for Health and Wellbeing as the single inpatient site in the area.

The ICB went to public consultation to allow the public to comment on this option and to consider two other options:

• Option A1: This would closely resemble the position in 2019, with more inpatient beds but less community based services
• Option D: This would have 13 beds at the Gordon and fewer community services (e.g. not the MHCAS).

There was a high level of engagement with the consultation. Responses were received through a consultation questionnaire, public meetings and submissions from organisations. The ICB has received 200 responses to the questionnaire: 90 people in favour of the preferred consultation option, 71 against it and 39 neither agree nor disagree. The report pack also includes the Consultation Evaluation Report. This report draws together and assesses all of the feedback received and identifies 5 key areas for further consideration which are:

• The overall model in terms of the number of inpatient beds, and the ability of community services to provide an effective alternative for some patients.
• The needs of homeless people experiencing acute mental illness, and whether the preferred option provides a good enough service.
• Impacts on other vulnerable groups (e.g. in terms of travel times).
• The appropriateness of the MHCAS service model, including its location.
• How information was provided in the consultation and the effectiveness of the process.

The report pack also includes an updated Integrated Impact Assessment (IIA). The IIA identified a number of issues which would need mitigating action if the proposals went ahead. They are:

• Travel time increases for service users and their visitors from the area of South Pimlico needing admission.
• Potential impact on carers from South Westminster.
• Impact on the needs of the residents of North Kensington, and specifically for the community affected by the Grenfell Tower fire.
• Mitigating the potential impact on black people in KCW.
• Mitigating the potential impact on homeless people in KCW.
• The report pack also includes an updated Equality and Health Inequalities Analysis (EHIA). This sets out a plan to address identified equality issues, including developing a bespoke service for homeless people with mental health issues, and ensuring all staff receive appropriate training in cultural awareness and how to meet the needs of people from diverse backgrounds.

The DMBC includes a revised options appraisal. Following the consultation feedback, the Project Team has identified that there is a suitable location within the St Charles site for the expanded MHCAS service. The appraisal therefore considers two options based on the consultation proposal. The first option (Option C1) is the same as the consultation proposal with the MHCAS located at the Gordon. The second option (Option C2) has the MHCAS remaining at St Charles. The options appraisal concludes that Option C2, with the expanded MHCAS at St Charles is the best way forward. The reasons identified are:

• It is the best option in terms of quality of care, and in promoting equality.
• It is the cheapest in revenue terms.
• It is equally affordable in capital terms, as the costs are still within the threshold.
• It is significantly better than Option C1 in terms of access for people from Brent. The DMBC therefore proposes that Option C2 be implemented.

The DMBC also includes responses to feedback and questions received by both the Inner West London JHOSC and the Mayor of London, Sadiq Khan.
The Mayor's Office has six tests by which it evaluates proposals for service change. These are:

• Health and Healthcare Inequalities
• Hospital Beds
• Financial Investment and Savings
• Social Care Impact
• Clinical Support
• Patient and Public Engagement. The DMBC shows that all of these tests have been met. It also addresses issues raised by the JHOSC in its previous report, such as:
• The need to better define the model for the MHCAS and demonstrate its ability to deliver effective services for people in a crisis, and in particular for people who are homeless.
• The need to develop a clearer and more transparent financial case, explaining in detail how funds have been used since the temporary closure of the Gordon, and the affordability of the options.
• How the service change will impact on inequalities, in particular for the black population, and the need for a system-wide plan to address inequalities in mental health.
• Whether the proposal has considered the impact of the Right Care Right Place policy.
• The need for better data and collective analysis to be carried out by the ICB with system partners.

The DMBC recommends that Option C2 is implemented, and that the mitigations identified be put in place.

The report pack includes the North West London Mental Health Strategy which sets out how acute mental health services will be developed. It identifies three key ambitions:

• Raising awareness and promoting wellbeing
• Increasing equity and equality of access
• Ensuring care is delivered in the right place.

In relation to acute inpatient care the strategy says:

We continue to implement the principle that acute inpatient care should only be used when there is no better alternative.

It also says:

When hospital-based care is required, it will be delivered in a timely way, by an expert team, within a therapeutic and compassionate environment... We will provide inpatient facilities that meet modern standards of acute mental health care, supporting patient dignity and privacy, with ease of access where required.

The Strategy sets out a capacity and demand analysis. This concludes that North West London will have the right number of inpatient beds over the next 5 years. It identifies a need for 23 additional beds to be put in place by 2029 to reduce inappropriate out-of-area placements, reduce the need for long waits in A&E and meet increasing demand. However, it also says that:

Service changes, including addressing patient flows and enhancing community-based provision, will reduce the overall need for beds by 40. This reduction will be achieved through a 6% reduction in admissions across North West London. It also assumes a 6% improvement in length of stay. The strategy says that: Av. LoS could be reduced by 16% if each site were able to achieve the NWL upper decile performance (27.6 bed days).

The strategy also sets out an action plan to address this which includes:

• Agreeing updated expectations for admissions
• Improving recording of the Estimated Date of Discharge (EDD)¹ to focus on earlier discharge.
• Holding weekly meetings to discuss patients who are clinically ready for discharge

The date on which the clinician expects the patient to be medically ready to leave the ward. The strategy expects a 6% reduction in length of stay which will be achieved by

reducing the number of patients still in beds despite being clinically ready for discharge.

This would mean that there would be 10% of beds unoccupied, on average, across the ICS. The report pack also includes a report on achieving reductions in admissions, length of stay, and breaches.

The DMBC includes a section on governance and implementation, setting out how Option C2 will be implemented, should it be approved, with oversight from the ICB. The key elements of the model already exist, and the main additional work needed to be carried out will be:

• Relocating and expanding the MHCAS at St Charles.
• Continuing the work to improve bed occupancy levels through reductions in length of stay and admissions.
• Delivering the agreed mitigations.
• Implementing the wider plan to reduce inequalities in mental health. The implementation will be carried out in partnership with a range of organisations, including local authorities, the voluntary and community sector, and service users and carers.

Appendix 1: North West London Mental Health Strategy

The report pack also contains the North West London Mental Health Strategy. This identifies three key areas of focus. These are:

• Raising Awareness and Promoting Wellbeing
• Increasing Equity and Equality of Access
• Care in the Right Place.

The strategy says that while North West London has been increasing its investment in mental health services,

our relative investment in mental health services in North West London is low.

The report highlights the need to:

• Engage more proactively with people.
• Raise awareness of services.
• Tailor services to meet needs.
• Ensure that our workforce reflects the local community.
• Address inequality and stigma.
• Improve professional and public understanding of mental health.

It is noted in the strategy that, while a comprehensive analysis of workforce capacity, capability and skills is required:

Staff are finding it hard to recruit to some key roles such as mental health nurses and psychiatrists. High vacancy rates cause pressure on existing staff who take on additional work to make sure services continue.

The report says that:

The NHS Long Term Plan brought an enormous opportunity to build on previous progress, and direct our attention to new areas of improvement and previously under- represented groups.

The strategy includes a detailed analysis of the need for adult acute mental health beds over the next five years, concluding that with the planned service changes and additional investment that, in 2029, the system will have well balanced capacity. This will provide slightly more beds than what will be required to meet the needs of the local population while working to an overall bed occupancy of 90%.

The strategy includes a recommendation to:

Optimise inpatient lengths of stay so that no patient stays in hospital longer than they need to, by improving early discharge planning with system partners and post-discharge support to reduce readmission to hospital.

In particular, it notes that:

A key focus will be on reducing the number of patients still in beds despite being clinically safe for discharge.

The strategy sets out a high level plan to achieve this which includes:

• Agreeing clear expectations around admission
• Ensuring that estimated dates of discharge are recorded for all patients to ensure timely discharge
• Holding weekly meetings across each borough to discuss discharges.

In terms of the key themes identified by local residents during engagement exercises carried out to support the development of the strategy, the report says the following:

• Access - residents want more mental health support available for inpatients in hospitals and for those who are being discharged. It was suggested by one resident that more use should be made of facilities and services provided by charities such as Hestia.
• Waiting times - Residents were concerned that the wait to access support from psychologists and therapists was too long.
• System integration - The view was expressed that accountability for patient care was poor and, as a result, patients were often ‘passed from one person to another’ without effective support being put in place.
• Service approach - Suggestions to improve the approach of services included making them more accessible, using social media platforms such as TikTok to raise awareness, and in particular to support the needs of women with mental health needs. Residents also expressed a desire for a more holistic and compassionate approach, that emphasised empowerment, respect, and kindness. They also highlighted the need to involve community organisations in delivering trauma-informed care.