Once a week, troubled children in Plymouth battling emotional problems can slip out of lessons and speak to a mental health professional – at their own school.
Teams of mental health staff started working across 27 secondary schools in September as part of an early-intervention scheme aimed at supporting city youngsters when they need help. Backed up by counsellors, the teams offer a wide-ranging package of support including talking therapies and play therapy.
The £1.2m project, one of the first of its kind, comes at a time of growing concern over children’s mental health. Figures revealed last month by the Guardian showed that almost 250,000 under-19s in England are receiving NHS mental health care. The Plymouth scheme aims to build resilience in youngsters before problems escalate.
The scheme stems from a partnership between schools, the city council and the local NHS, in the form of child and adolescent mental health services and the Northern, Eastern and Western Devon clinical commissioning group (CCG). They have pooled their budgets to co-commission the schools service from a range of providers.
Developed in consultation with young people and parents, the initiative is the latest product of a quiet revolution in Plymouth that is integrating a range of services with the aim of improving the local population’s health and wellbeing.
In April last year, the council and CCG set up an integrated finance system for wellbeing, covering a large range of services including not just health and social care, but also leisure, housing and education. It was a radical move by the city’s debt-laden health and care system and, as its leaders say, one that benefitted from flying “under the radar” of central government: by not being part of any national integration programmes, the city agencies can follow their ambitions in their own way and at their own pace.
What distinguishes Plymouth’s integration journey are the barriers that have been faced and overcome. The CCG is not “co-terminous” with the council – in other words, it has different boundaries – and it has been in severe financial distress, with one of the worst records for hospital discharge in the country. The council, meanwhile, has undergone political upheaval – Labour lost control last year to a Conservative/Ukip alliance.
Yet demand for services is soaring – the city’s population of 261,000 is expected to pass 300,000 by 2031 – and it was a determination to find new ways of working that prompted the setting up of the cradle-to-grave, integrated fund, as well as the creation of Livewell South West, an integrated community health and adult social care provider.
The result has been significant and encouraging improvements in services in the first year, with joint and co-located teams carrying out single assessments of people’s needs and a reduction in hospital stays. However, the ambitions go much further.
“Plymouth has been in Torbay’s shadow for too long,” says Gerry Clough, chief operating officer at the CCG, referring to neighbouring Torbay’s reputation for integrating health and social care. “There was a feeling we wanted to do something on integration. We have adopted the slogan ‘one system, one budget’ – the right care, at the right time at the right place.
“What is distinct about Plymouth is that we started a programme of integration of health and wellbeing and didn’t want to limit it. We have widened it as much as possible.
“We are not a ‘pioneer’ or ‘vanguard’, which means we have been off the radar. This has allowed us to retain local control and ambition and meant we have had nobody measuring what we are doing and nobody to report to.”
By pooling resources, the council and the CCG created a net integrated fund of £483m – cash that could be spent on four aims: improving health and wellbeing outcomes; reducing health inequalities; improving people’s experience of care; and improving the sustainability of health and wellbeing. This meant setting up an integrated commissioning board and creating Livewell South West, which, in turn, necessitated the transfer of more than 170 council staff.
In the first 12 months, services were changed dramatically, as money was directed into new models of care and support. The city’s urgent-care system was transformed (see below) and new initiatives were launched to support people with chronic illnesses, avoid unnecessary hospital admissions and help them continue living independently for as long as possible. Dementia diagnoses rose 12% and dementia-friendly services were opened across the city.
A special “place of safety” was set up for vulnerable adults and children who would previously have ended up in custody, while an “early-help gateway” for children and young people brought quicker assessment of need.
With integration entering its second year, change continues apace. Following the launch of mental health support in Plymouth’s schools, there are now plans to reduce the number of children in care by offering more early help to families.
However, there is a recognition that effective change doesn’t happen overnight. Carol Burgoyne, the council’s strategic director for people, says: “It really takes time to change the way of doing things. We are tackling some really challenging topics – like how we deliver emotional and health wellbeing of young people. It is important to get things right, which can take extra time, and involves the co-design of services.
“The fact that we delivered an integrated budget in our first year is incredible and is thanks to the sheer commitment of staff. We have lots of stories here: integration has made a real difference to people. If staff can see that things make a difference, it makes them want to go even further.”
Clough thinks that the achievements of the past 18 months have been the highlight of his career. Yet he says that the journey is only just beginning.
“Hospital discharge procedures have shown a steady improvement, with the area going from having one of the worst records for delayed discharge to just below average. This has been achieved without extra funding, but through recycling money and creating integrated discharge teams.
“There is still more to be done, but there is a huge amount of creative thinking. What has happened has been remarkable. I have spent most of my life talking about meeting short-term targets. Yet we have purposefully changed the system for future generations.”
June Willis: ‘The fall was a bit of a shock, but all the staff were very helpful’
It is 9.30am on a hot and sticky morning in August and staff at the Robin community assessment hub in the Mount Gould area of Plymouth brace themselves for the day ahead.
Within minutes, a coordinator from South West Ambulance Service receives details of a “frail fall” patient who needs help.
Half an hour later, 90-year-old June Willis, from nearby Plympton, is being assessed at the hub, which organises urgent care. Staffed by a multi-disciplinary health and social care team, the GP-led unit offers a range of onsite investigations, from X-rays to full blood screening, as well as intravenous rehydration, oxygen therapy and access to mobility equipment and aids for daily living.
With eight beds, eight treatment chairs and high- and low-observation areas, the clinic – set up on the principle of “keeping care closer to home” – is open seven days a week and can offer treatment for up to 72 hours.
It is just one of a number of Livewell South West urgent care services aimed at supporting people with acute conditions to stay in their own homes and prevent inappropriate emergency hospital admissions. Other services include a community crisis response team - a multi-disciplinary squad that offers access to physiotherapy, occupational therapy and social work to people in their own homes – and an acute care team, which carries out tests and medical investigations for diagnosis in the home and can provide intravenous therapy.
For patients such as Willis, who has a recent history of falls and walks with a frame, the Robin hub offers a calm and reassuring environment. Many of its patients are old and may, like her, be seen after a fall.
As if to prove that the hub is not about diverting people from hospital at all costs, it emerges that Willis does need hospital treatment – but for a skin infection, not the fall – and she is admitted to Derriford hospital, where she stays for a fortnight before being discharged to Mount Gould district hospital for rehabilitation.
Now back in her bungalow in Plympton, where she has lived on her own for five years, Willis has nothing but praise for the care she received. “What happened was a bit of a shock, but all the staff at Robin were very helpful,” she says. “It was very relaxing. People from the home recovery team are now coming in to see how I am doing. I am hoping that with some physio I can get back to walking with two sticks.”
