Going the extra mile

Summary

Stephen Tyrer's commentary on Fair Horizons was generally supportive of the principles underpinning the model, while offering a number of questions and caveats. In this response, we provide responses to the points made and offer further insights into the practicalities of the Fair Horizons model.

We are grateful for the opportunity to respond to Professor Tyrer's commentary, ¹ which is both balanced and considered. Recognising the potential benefits of the Fair Horizons model at both patient and organisational levels, he raised the entirely valid point that we lack, as yet, data to support the approach, although we are at an advanced stage of implementation and thus committed, as an organisation, to its success. We would like to provide a brief response to the specific questions raised in the commentary.

Since the concept was developed, over 5 years ago, Fair Horizons has been honed through an iterative process of clinical engagement on the basis of a number of unarguable principles: that services must be clinically driven, equitable, person-centred and non-discriminatory, and that they must include prevention of mental ill health and promotion of well-being and recovery. Further, there is a commitment to early intervention across the spectrum of mental disorders, engagement of service users and carers, and quality and best practice. These principles were tested through consultation events with clinicians, service users, carers and commissioners, and have had a 97% positive acceptance and a willingness to engage with the change process.

Although acknowledging the ‘sound theoretical underpinning’ of the service model, Professor Tyrer has voiced concerns about its requiring significant commitment from all staff. Staff engagement with the process of change is part of an externally funded research project in collaboration with Queen Margaret University, Edinburgh, using the Flight Gate practice development tool. ²

It is likely that our paper was insufficiently detailed to indicate that the first-point-of-contact centre has clinician support for the administrative function. The current process of allocating referrals is largely administrative within teams but may differ according to the culture of that team. Providing a central pathway avoids idiosyncrasies of culture and overcomes boundaries so that patients are less likely to become lost or to ‘bounce’ from team to referrer. Under Fair Horizons, administrative staff complete the initial information gathering and follow an algorithm, but this process is overseen by a clinician, with access to consultant psychiatric input for complicated cases.

We do acknowledge the concerns about Improving Access to Psychological Therapies, but consider this to be a national priority, with locally agreed, population-based figures outlining the wider service. Specialist psychological therapies continue to be an integral part of clinical services within Fair Horizons.

In the financial year 2010/2011, the trust received about 11 000 referrals, of which 380 were for people with an intellectual disability. It is envisaged that the people supported directly by the learning disability service will be at the more severe end of the spectrum, with people at the mild end of the spectrum accessing generic services. This is supported by payment by results ‘clustering’ data, which show that only 1.7% of the current case-load of learning disability services can be assigned to a Health of the Nation Outcome Scales (HoNOS) payment by results cluster. ³ If trusts with a less specialist learning disability service were to adopt this approach, they may anticipate a move of patients with mild intellectual disability into generic services.

Consultant psychiatrists will retain their ‘geographic’ catchment areas, but with opportunities to develop specialist roles to provide ‘specialisms’ within each geographical hub. Workforce plans for the hub interdisciplinary teams’ areas are based on referrals, cluster profile and deprivation index, thus providing ‘capable teams’ tailored to their localities. All staff will have job plans appropriate to their profession that enable them to work across teams if required.

We are in the midst of a period of unprecedented policy and fiscal pressure. As clinicians, we have a responsibility to ensure that the services that emerge are smart, lean and clinically driven to derive the maximum benefit for the populations we serve. Although organisations will reach their own conclusions on the most appropriate structures for their future services, it is essential the we, as leaders within our services, abandon silos and vested interests to drive change on the basis of sound principles. We believe that the Fair Horizons model is based on just such a set of principles.

Wherever you work, your staff will need to work smarter in the years ahead, not harder. We believe that we all need to respond to Professor Tyrer's invitation to ‘go the extra mile’.