Agenda item

To include a verbal update on the use of Electroconvulsive Therapy, as requested at the previous meeting.

The Committee received a performance update from the Camden and Islington Mental Health Trust. Mr Mafu, Managing Director Islington Division informed the Committee that there had been a divisional restructure that was helping to better support their community mental health transformation programme and the delivery of their priorities. It was highlighted that priorities included keeping people safe and providing a focus on ensuring care and treatment worked for the people who received it.

It was also explained that the Clinical Strategy within Camden and Islington (C&I) was focused on an integrated, community mental health service and improving patient flow and experience. The Committee were informed that during the trusts last Care Quality Commission (CQC) inspection, which took place in 2019, they were rated good overall.  They had been working to ensure the rating was sustained and to improve the areas CQC had recommended needed improvement.

It was highlighted that an area of focus in C&I was community mental health transformation. Here Central, North and South teams had been launched, in primary care, that would be multiagency and multidisciplinary, with a focus on prevention. New roles within the teams included population health nurses with a focus on physical health. As part of the transformation, they would also be looking to expand their interventions and to ensure greater collaboration within North Central London (NCL). There was work around eating and personality disorders being carried out at the NCL level. They were facing some challenges around recruitment; estates and there would be more work around stakeholder engagement.

A partnership between C&I and Barnet, Enfield and Haringey (BEH) were working together to reduce health inequalities, improve patient outcomes and create a sustainable workforce. Nine priorities had been identified including community mental health transformation, improving the crisis offer and having a single bed management plan for NCL.

The St Pancras Transformation Programme was progressing within C&I. Some services at St Pancras were being moved temporarily in order to complete the work within the trust. The Islington hub would be at Lowther Road. This included the community teams. Inpatient services would be at the Highgate Campus.

It was highlighted that Islington had the third highest prevalence of serious mental illness and the fifth highest prevalence of common mental health disorders. The trust would continue to remain agile and would adapt its strategy to meet any challenges, including those following Covid-19. Recruitment was a key challenge, and they would continue to ensure there was the right workforce within services. In August 2022 there was a cyber-attack that was managed nationally. Staff worked hard to ensure risks and the impact on services were minimised. There were some minor disruptions but no significant impact on patient care. Work was also underway to address inequalities and all services were assessed to prevent discrimination.

The appendix to the report included the services of the trust and a more detailed performance report.

Following a request by the Committee, Mr Mafu gave an update on the trusts use of Electro-Convulsive Therapy (ECT). It was explained that there were two groups of people that would benefit from ECT, people with catatonia and those with psychotic depression. Referrals for treatment would usually be by a multidisciplinary team of professionals including a qualified mental health practitioner, not a General Practitioner (GP).

  ECT was supported by the National Institute of Health and Care Excellence (NICE) guidelines and the Royal College of Psychiatrists. It was administered to approximately twenty people per year and was described as a lifesaver by some as it reduced debilitation caused by catatonia or psychotic depression creating a pathway for further treatment. There was a legal framework for the use of ECT that included the need for consent, although some people could have ECT under the Mental Health Act or could give an advanced directive regarding whether they would agree to ECT.

ECT was an expensive procedure and required four professionals, who could decline going ahead with treatment depending on the risks presented. This year there were two patients who didn’t see improvements however the team also received thank you cards from individuals and families whose ECT was successful. There was no upper age limit for treatment but those under eighteen wouldn’t usually receive it. The average age of those who received treatment was sixty. Sixty percent of recipients were female, and forty percent were male, usually white, and from less socially deprived areas. The ECT service was accredited. The accreditation looked at whether there was the right expertise, in the right environment and, treatment was delivered safely and efficiently.

In summary, Mr Mafu informed the Committee, ECT worked for some people but not everyone; it was never used as the end treatment; it helped to take people out of a debilitating situation and the trust only used it if it was necessary, it would not be promoted. The Committee were informed that colleagues from the ECT team would be happy to attend to talk more about the evidence base.

Councillor Craig asked why safety was one of the areas identified as requiring improvement in the CQC report and what was being done to address the issue; whether staff satisfaction feedback surveys were being carried out and what outcomes they were getting from them and what could be done to ensure residents were not being treated outside of borough. It was explained that safety was related to caseload size and issues around recruitment. The number of people allocated to a single practitioner had been reduced and casework had been separated into four pathways including support by a care co-ordinator, psychological input, social worker or senior medical practitioner. A staff feedback survey was circulated every year and they would meet with individual teams to identify priorities. It was explained that morale had fallen across the NHS, there was difficulty retaining staff, rates of pay were determined nationally and were not in-line with inflation and there were huge demands on staff because of demands on the service. There were initiatives to try and support staff such as reduced canteen prices. The trust would try to support people closer to home wherever possible however there could be more appropriate placements out of area. A placements team reviewed out of area placements to ensure, where possible, people could return.

Councillor Clarke felt ECT was a brutal practice that damaged the brain and asked if there was a breakdown of who received it, in particular she queried why more women received treatment. The trust was questioned about moving people out of St Pancras at a cost of £116,000 per month whilst they waited for the Highgate site to be finalised. It was explained that ECT was recommended by NICE under limited circumstances and with the equivalent of twelve women to eight men receiving it within a year, it was difficult to find statistical significance. The Trust said an update on the St Pancras programme could be provided at a later committee meeting.  It was explained that the cost implications for Moorefield’s ran into millions of pounds, so 9 patients would be temporarily placed elsewhere for 9 months.

Councillor Gilgunn asked about side effects caused by ECT. It was explained that the treatment was recommended by NICE, under limit circumstances and, outcomes were mostly positive. If the Committee wanted more detail on the side effects a clinical colleague that practiced ECT could be invited to a future meeting.

Councillor Zammit asked what could be done to help children and young people due to an increase in severe mental illness, about the new role of population health nurses and whether community centres had been approached where there were problems with space. It was explained that access to services by children and young people was good, an indicator in the report showed those presenting with first episodes of psychosis were treated within two weeks of referral. They were working closely with universities to support students and early intervention was key, with the mental health transformation teams focusing on prevention. There were four population health nurses in the north, central and south localities who were undertaking outreach at different locations. Events were held and attended at community centres.

Councillor Croft referring to the key performance indicators (KPI’s) asked what was causing the ‘waiting times for beginning treatment within 6 weeks of referral’ to have gone below target from February 2022 and, why the proportion of people completing treatment who move to recovery was also below target and what was being done to improve and learn from any best practice at Kingston where they were more frequently hitting their targets. Ms McGrath explained that gaps in recruitment and greater complexity post pandemic had affected their targets. Kingston had a different population, and the figures were linked to the demographics of the population and the social determinants of health.

Councillor Russell, asked about section nine in the report, which considered the addressing of inequalities. She asked whether any specific training was provided to staff to ensure trans and non-binary people had a welcoming experience. Mr Mafu explained all staff members undertook equality and diversity training, the training emphasised all people must be treated with respect.

The Chair asked how the trust were tackling stigma related to mental health in Black and Minority Ethnic (BME) communities and whether a shortage of staff, due to recruitment issues, was affecting the service. Mr Mafu explained there were several initiatives to ensure a more inclusive service was being provided. There was a system wide approach that included forums, a ‘no wrong door’ approach by services and KPI’s that monitored ethnicity. The trust endeavoured to fill vacant posts and would use skills mixing and temporary staff to ensure patient safety. Every board meeting would consider a safe staffing report and were necessary vacancies would be filled by bank and temporary staff. They were also working with the police to help reduce violence and aggression on wards.

RESOLVED:

To send any further questions on ECT to Camden and Islington Mental Health Trust for their written reply.