New Eating Disorders' Services for Powys

A Happy New Year to all our readers! 

Just over a year ago one of our Powys citizen reps, Helen Missen, (pictured above) a passionate advocate for improved Eating Disorders' services, wrote about the Eating Disorders’ Service review in Wales which had just taken place.

Roll on twelve months, and so much has developed in Powys as a result of this review (you can read the Executive Summary). At our mental health partnership board meeting just before Christmas we were very pleased to find out more about the new services from our colleagues at Powys Teaching Health Board along with Dr Jacinta Tan (Consultant Child & Adolescent Psychiatrist at Aneurin Bevan Health Board) who led the Review Team, Menna Jones (newly appointed National Clinical Lead for Eating Disorders) and Helen.

The underlying principles which people wanted

• Early detection and intervention. Helping people, like teachers and parents, to identify people who might have an eating disorder to have access to support and help.
• Inclusivity. Never turn people away. Anyone in distress who thinks they are, or a loved one who might have an eating disorder, deserves a response.
• To be person-centred. To have prompt expert help for those who might have eating disorders. Giving people what they need and trying as far as possible to deliver it to them where they are. To provide person-centred and holistic care for the person and the whole family.
• Relationship based.
• Recovery focussed
• Trauma informed.

In total there were 22 recommendations made by Jacinta which the government took on board. 

Where we go from here

Eating Disorders’ services were highlighted, as one of five key areas, for additional funding from the Welsh Government’s Mental Health Improvement Fund. There was a specific focus on Early Intervention as an area which the government wanted to prioritise. The first funding stream came through in Summer 2019 and coincided with a large consultation with clinicians across Wales looking at the response to the recommendations as well as some of the barriers that might come up.

In January 2019 it was announced that there would be a dedicated post created to take some of this work forward – a National Eating Disorders’ Lead in NHS Wales. Menna Jones officially started in this full-time role, the first of its kind for Eating Disorders, on 1 January this year, with the placement due to continue until March 2022. Menna’s role will be to work with clinicians, and those using services, to set up an Implementation Plan which sets long-term goals for improving services based on the Review’s recommendations and also facilitating changes to happen.

Some of the key areas include: early intervention, moving to increased delivery of eating disorder services by specialist teams, creation of physical health clinics within Community Mental Health teams, and to join up Child & Adolescent Mental Health Services (CAMHS) and adult services – looking at transitions but also at what can be learned from each of these services around models used and approaches to work.

The vision of the service review

Jacinta emphasized that the plan will focus on equity of access to specialist and high quality care across Wales, including in rurally isolated areas of large parts of Mid Wales such as Powys. There will also be joined-up working with other teams – patients are complex, they have many needs, they have comorbidities (the presence of one or more conditions at once) and it is important to interface with other services such as Autism services. In promoting specialism Eating Disorders Services will not be pulling away from the rest of the system.

The lived experience view from Helen

"From all mental health conditions eating disorders still have the highest mortality rate of any and that needs to be at the forefront of people’s thinking. I started advocating for families because I just didn’t want them to go through what we went through 11 years ago. I now sit on the Executive Committee for the Royal College of Psychiatrists’ Eating Disorders faculty and the European Board for the Academy of Eating Disorders. I really believe in change. I believe we can get it right in Powys. And I know (from my daughter’s experience) that recovery is possible." 

Plans for Powys 

Sam Shore – Head of CAMHS

Currently CAMHS has an eating disorder element to the service already, including specialist practitioner support and our own CAMHS dietician as well as support from psychology. Each CMHT does have a link eating disorder worker who will give advice to anyone open to adult mental health services and support any new referrals into the service.

Practitioners link with GPs for support in the first instance if someone’s physical health is deteriorating.

Following receipt of additional funds, however, we now are going to develop a specialist Eating Disorder Service, which is going to be an age-less service. We want to address issues such as transition and early intervention. We will be working more closely with GPs in Powys, and looking at our referrals into the service.

Following receipt of funding the following new posts have been created and we will be recruiting very soon:

• Team leader.
• Specialist practitioner.
• Dietician.
• Occupational therapist technician.
  
  

We’ve been working closely with Helen too and listened particularly to her tips and hints on moving forward. So we have an idea of what the new service will look like in terms of family intervention and family work. Menna has also offered to support us in the development of the service.

Whilst normally we would have 4 – 5 on our caseload we are actually working with 20 children and young people at the moment (mid December 2020). Covid has had a massive impact on the referrals and they are very complex – there are significant physical health issues, family dynamic issues and cases of anxiety as well as eating disorders.

Joy Garfitt – Assistant Director Mental Health & Learning Disabilities' Services

The model we’re going for is a small dedicated team of specialists who can link to the national Eating Disorder team. Within our five CMHTs and our CAMHS teams we have a small nucleus of specialism, whilst others practice as general mental health practitioners, so we’re creating a staff team which has a general mental health practice element to their role and a special interest element to their role. The special interest might be eating disorders, or perinatal, or trauma-informed services. This means that community psychiatric nurses, and social workers in the field, can also access that specialist support locally in Powys. We can’t provide an eating disorder service in every CMHT as might happen in a big city, so that’s why we’re looking at a different model. 

All in all it was great to hear the enthusiasm and commitment to reshaping Eating Disorder Services, not just in Powys, but across Wales, and we look forward to receiving further updates as the new team settles in and starts work.

Back to the Floor: Katie Blackburn, Powys Community Health Council at Newtown Community Mental Health Team

Katie Blackburn (top left) with Newtown Community Mental Health team

In August last year I observed Superintendent Jon Cummins go Back to the Floor at the mental health inpatient unit in Powys, Felindre Ward, and wrote about the idea behind the activity and Jon’s experience on this blog. Put simply the concept is that Chief Officers, Service Directors and other high-level staff have the opportunity to experience a day in the life of a member of staff at the operational end of a service. This gives them the opportunity to find out what is really happening on the ground, and what consequences strategic decision-making can have on people who are in receipt of a service.

In late 2017 I was pleased to observe Katie Blackburn, the Chief Officer of Powys Community Health Council, go Back to the Floor at Newtown’s Community Mental Health Team. The county CHC is the “Healthcare Watchdog for Powys - an independent statutory organisation that represents the interests of patients and the public in the National Health Service in Powys”. Katie has been in post since January 2017.

Lauraine Hamer, Senior Practitioner AMHP (Approved Mental Health Professional) at the CMHT, met us at the start of the morning with details of what she had planned for Katie’s visit. This included chance to find out more about her work and that of her colleagues, plus an opportunity to join a Multi-Disciplinary Team meeting and also to accompany a Community Psychiatric Nurse on a visit to a client. In the event we had to stay flexible as circumstances changed throughout the morning… but such is life at a busy mental health service.

Before the visit: Katie’s view

I had no idea about the work of this particular CMHT in Newtown before my visit. From my previous life, I have an understanding of the roles of CPNs and social workers. I was CEO of a drug and alcohol charity and mental health is an issue there. To a lesser extent with The Prince’s Trust, I was working with vulnerable young people in the care system.

I was very keen to shadow and meet the team and listen. I felt that perhaps I could ask questions that other people were perhaps uncomfortable asking.

The key barrier I am aware of – which I know of from my domestic abuse background – is that whilst aspiring to put individual people at the heart in reality individuals are often bounced from pillar to post. For example, they might have to continually provide their national insurance number, or relate details of stressful events to different people. The journey should be (and could be) much smoother and easier. Sometimes we need to make a decision there and then, which might not fit in with governance and procedure. For example, the question of who pays to get people from A to B often comes up. If there is an individual who needs to be transferred from Brecon to Nottingham……who pays? Agencies can become tied up in which budget is paying for this journey and can lose sight of the individual’s needs.

When it comes to strategic issues, I am not aware of any recent changes within the CMHT, but, I am aware of, and have been involved with the development of the Health & Care Strategy and the intention to align health and social care in Powys. It will be nice to see the operational impact of that.

I am conscious that services are very stretched because of pressures on staff and budgets, and that things can sometimes become more complex and complicated than they need to be.

I hope that Powys’ Health & Social Care Strategy will bring change – whilst recognising that not everyone likes change; there is a risk of unsettling an already stretched workforce.

There will undoubtedly be a growing use of digitisation going forward – however, it’s about putting the individual first. With regard to a future workforce we need to identify what skills Powys needs.

Lauraine Hamer and Katie Blackburn

Back to the Floor exercise

Lauraine is an extremely experienced and knowledgeable Senior Practitioner, and was able to give Katie a very thorough grounding in the work of the team at Newtown CMHT. At the MDT meeting we met CPNs, members of the North Powys Crisis Resolution Home Treatment Team, Admin staff, a trainee AMHP, Social Workers, and a Support, Time and Recovery (STR) worker. Later we learnt more about the Accredited Accommodation Scheme* from the Co-ordinator Wendy Laws, and Katie spoke to Dr Fran Foster, a Consultant Psychiatrist.

Unfortunately, we were unable to shadow CPN Kelle Hall on a home visit to a client. This was due to a last minute change in the person’s circumstances.

After the visit: Katie’s view

When deciding whether my understanding of what the services does is correct, I think “no” is the simple answer. There were elements of it that I knew, however, other elements were new to me. Staff in the MDT meeting worked co-operatively very well together. Particularly when sharing information - the team focussed on the needs of the individual rather than their specific jobs.

The “seeing is believing” approach is very important. It would have been nice to sit in on a visit with an individual using services, but I understand the issues around confidentiality and the vulnerable lives people lead.

My main observation is that the people in this team are doing the best they can in the circumstances. There is clearly an issue around staff capacity. Other obvious issues include – cross-border, cross-boundary provision and the lack of in-county beds for people. In the MDT meeting, the real focus was on the discussion of high-end/vulnerable situations and not on the preventative side of the service. I wonder if there is an opportunity for reflection and discussion on what might have prevented a specific situation and what changes could be made in the future (if any)?

Staff are very much dealing in the here and now. They are not looking at people’s pasts or where they might be in five years’ time. I wonder - is there an opportunity to look at where resources should be channelled?

This experience will definitely mean I’m able to contribute more effectively at times when strategic decisions about services are made. I am a big believer in real-life examples. There are also pressures on recruitment for the CMHT. There appears to be an element of disjoint between strategic and operational. The staff clearly work well as a team, and there are a number of opportunities to build on (and share) existing good practise across Powys. In addition, their working environment is extremely poor, despite this, it strikes me that they are a dedicated, professional team doing their best in the circumstances.

Going forward, I am keen to do something in my role at the CHC around listening to vulnerable voices. There is definitely an opportunity to start with this service - certain groups do not access our service or receive support including young people and young carers. Listening to Vulnerable Voices will be a priority for Powys CHC in 2018-2019.

* Wendy Laws co-ordinates the Accredited Accommodation scheme in Powys, which is the only one of its kind in Wales. People supported by secondary mental health services are entitled to access day visits or overnight stays with registered accommodation providers who have their own lived experience of mental health distress. People accompany their hosts on shopping trips or days out to the seaside, for example, and enjoy a caring and nurturing environment. This service prevents hospital admission and people have described the incredible benefits of feeling part of an extended family.

Finally receiving treatment - a personal view

I was speaking to someone in Powys recently about their experience of "going outside of the NHS towards private talking therapy... a really positive step". A positive step seemed like a good subject for a blog post, and our guest author agreed. Read on....

As an individual I have been in contact with mainstream services for over nine years, both in Powys and in other areas of the UK. Over these years, a combination of GPs, psychiatrists and occasionally other staff such as Community Psychiatric Nurses and support staff from Community Mental Health Teams have made efforts to try and alleviate the severe difficulties that go along with a diagnosis of schizophrenia.

I have found that during times of crisis access to support has been available, given that it is asked for in the right way. The problem however, for me and many others, has been with the issue of getting back to being able to live and function on a daily basis and to a level where it would be possible to believe that the goal of full and complete recovery is not only a real thing but something worth pursuing.

Although there can never be a guarantee that severe distress, mental ill health or challenges to wellbeing won’t occur either in someone who has previously had first-hand experience of these things, or in someone who hasn’t, the journey I have been on leads me to believe in one or two controversial things.

Firstly, like many others, and as supported by a growing body of evidence, I have a problem with the medical model of mental ‘illness’. The medical model is not a simple view and advanced neuroscience is often used to highlight areas of the human brain which may sometimes work differently in those who are labelled as ‘schizophrenic’ (to use but one example).

That shouldn’t detain us here, for as well as the causes for this diagnosis being perhaps still largely unknown and certainly not agreed upon amongst medics, the issue of how best to treat the condition is a big problem.

In my experience the first and last option for many practicing psychiatrists has been to prescribe powerful anti-psychotic medication, which especially since the second generation of a-typical anti-psychotics have been used, can and do alleviate or suppress ‘symptoms’ (such as psychosis) and with less pronounced side effects than the original first generation medications.

After talking to a pleasant local GP about the possibility of finding other ways to treat my own condition than medication alone, we loosely agreed that some combination of medication and talking therapy would be a sensible plan. However, in Powys the availability of talking therapy through the NHS is highly limited and the waiting list spans several years. One person I met has waited for more than 6 years already.

There are organisations such as Mid Powys Mind in Llandrindod Wells who are able to offer a free counselling service and having tried a couple of months of weekly sessions with a volunteer counsellor I found that the ability to share problems confidentially and in a non-judgemental setting brought much relief. 

More recently though, the view that a deeper and longer level of talking therapy could bring improvements to the way a person feels and functions is something which I managed to pick up from sources such as this blog and which in turn led me to explore the availability of private psychotherapy in our area.

Despite living on benefits, with advice on Employment and Support Allowance (ESA) and Personal Independence Payment (PIP) from the Citizens Advice Bureau it has finally been possible to find just enough capital to arrange for regular sessions with a practicing psychotherapist. Partly this is enabled by my practitioner’s policy of subsidising out of work patients with a slightly lower rate to those who are in work.

When making the long decision to proceed, the view of my psychiatrist was that for certain conditions which they believe to be entirely inherent or set in stone within a person’s biological constitution, there would be a risk associated with stirring up long lost memories or otherwise suppressed thoughts and feelings. I was glad of the discussion we had but, in the nicest possible way, could not disagree more strongly with any view which maintains it is not worth pursuing.

After the first couple of months of psychotherapy the tangible areas that many doctors ask about such as mood, sleep and appetite showed marked improvement and once more it seemed that the future could hold prospect and possibility rather than simply being a drab and bleak inevitability, where, to put it frankly, death would have been a welcome event.

I can’t speak highly enough of the time and space that I am lucky enough to have found within which help is given by another mind to sort through the problems and issues which we otherwise face on our own. This would include issues that an individual is aware of and also issues which it is almost impossible to be aware of by yourself.

As for ‘symptoms’, although my therapist is mindful of these and very respectful of the view of GP and psychiatrist, the outlet for me to unburden and unpack life’s major and minor worries means that as long as any possible reduction in medication is done gradually and carefully there is someone else to help keep a watch should difficulties arise.

There is still lots to do, but finally having some level of regular support has been a great relief not just to me but to remaining friends and family. As for the financing of this I would make the case to individuals, health professionals, charities and funding bodies to give increased engagement with other therapy some serious thought.

Have you had experience of talking therapies in Powys recently, whether provided by the NHS, by the voluntary sector or privately? Or are you still on the NHS waiting list? Let us know about your experiences in the comments' section below.

North Powys Crisis Resolution Home Treatment Team

I first wrote about the introduction of a Crisis Resolution Home Treatment Team for North Powys (Montgomeryshire) in February 2013 (Home Treatment Team for the North) when Mike Shone unveiled the plans for the new team. Earlier this month I met with the team’s manager, Graham Batha, and asked him for an update about the service.

Tell us a bit about your background

I am a registered mental health nurse, and have been registered in this profession for approximately 10 years. I trained at the University of Central Lancashire, and then worked in Preston in an acute inpatient setting before moving to the Preston home treatment team. I later went on to work within the Wrexham home treatment team before moving to this post as the team manager for the Crisis Resolution Home Treatment Team in April 2013. My professional interests include service user involvement in the development of services, and professional education for students.

Tell us more about the service

The CRHT in North Powys opened in May 2013. To date we have received 419 referrals into the team, and our service is open 7 days a week, from 9am to 9pm Monday to Friday, and 11am to 7pm at weekends and Bank Holidays. The objective of the team is to provide an equal alternative to inpatient care, and to facilitate early discharge from hospital when it is safe to do so.

What staff roles do you have on the team?

The team consists of one team manager, one team secretary, one health care support worker and six registered nurses. The team is also having an additional 3 members of staff in the future. The team is also supported by a dedicated Consultant Psychiatrist.

Who can refer people for the CRHT service?

The Community Mental Health Team can refer people into our service, during the hours of 9am to 5pm. Out of hours, the CRHT does accept referrals from ShropDoc, which is the out of hours GP service.

Can people of all ages be referred?

We look after people aged 18 or over with a functional* illness.

What happens if someone experiences a crisis outside of your usual hours?

It can be useful to write a contingency plan with your care coordinator (if you have one), which can be used to highlight what needs to happen in an emergency. I would suggest that you contact your on call GP or in an emergency attend your local Accident and Emergency Department.

What is the nature of the service provided by a Crisis Resolution Home Treatment Team?

The CRHT is a short term but intensive service. The team visits service users on a frequent basis, up to twice a day, providing the same service as you would receive in hospital. When someone is referred into the CRHT team, the team will arrange an assessment as soon as possible. The team will then develop a care and treatment plan with that person, with the aim of supporting and aiding recovery. 

How do you promote a person’s recovery?

Twice a week, the whole team meets in a confidential environment to discuss each person that the CRHT is caring for. This allows the team to do its very best for the people we care for, and to support recovery in a timely manner. People who have used our service have been positive about their experience with us. The team does share the entire CRHT caseload, and people who do use our service can see all members of the team.

As a relatively new service in North Powys, how has the CRHT impacted on provision of mental health services generally?

The CRHT has had huge benefits in supporting those who really don’t want to go into hospital, and would rather stay at home. The team does, however, understand that sometimes hospital is necessary, and the CRHT will try to facilitate an early discharge with our support at the earliest opportunity when it is safe to do so.

Are there any specific needs that can be well-addressed by the CRHT?

The CRHT can help with practical issues such as housing etc, and will do all they can to ensure carers are supported.

Do you refer people on to other services?

When someone has recovered in the CRHT, their care is either referred on to additional mental health services or another appropriate service, or their care is handed back to the GP. In all cases the CRHT writes to the GP to ensure that the GP is aware of our intervention and any changes we may have made to the person’s care or treatment.

What are the challenges for a CRHT in a large rural area like North Powys?

The distance of travel that is required within this area is a challenge for the team, but it does not cause us too many problems once you become familiar with the area.

What are the most rewarding aspects of the work you do?

For me it is rewarding to see people recover at home, within a familiar setting, as opposed to a hospital setting. I feel that you are able to work with people more creatively and independently at home, as hospital can sometimes be restrictive.

How would you like to see mental health services developing in North Powys in the next few years?

From the view of the CRHT we would like to help and support more people to recover at home. We understand that hospital admissions will always be needed at times, but if we can reduce the stress of going into hospital for the client and their family, this may limit the amount of time it takes to recover.

Many thanks to Graham for the update. If you have any queries relating to the Crisis Resolution Home Treatment Team in North Powys, you can comment below.

*This term is defined online on an NHS jargon-busting website: "A term for any mental illness in which there is no evidence of organic disturbance (as there is with dementia) even though physical performance is impaired".