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Devon Mental Health Crisis Pathway

‘To Be’ VSM Scenario Testing Report

Report Prepared for: Gavin Thistlethwaite, Joint Commissioning Manager – Mental Health, NEW Devon CCG

and Devon County Council

Prepared by: Steve McLauchlan, Managing Consultant, Alexander

Contact Tel: 07554 012119

Email: [email protected]

mailto:[email protected]

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VERSION CONTROL

Author Version Issue Date Details & Reason for Issue

Steve McLauchlan 0.1 24.11.15 First draft for review and feedback

Steve McLauchlan 0.2 07.12.15

Second draft following feedback from Emily Faircloth and alignment with SG presentation to Devon MH SG on 4.12.15

Keith Pople 1.0 8.12.15 Quality review for release to Gavin Thistlethwaite

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Table of Contents

1. Executive Summary ................................................................................. 4

2. Background ............................................................................................. 5

Previous phases of work on the MH Crisis Care Pathway ............................................. 5

3. MH Crisis ‘To Be’ VSM Scenario Testing .................................................. 8

Purpose of the phase ..................................................................................................... 8

What we did – preparation for scenario testing ........................................................... 8

What we did – testing the scenarios ............................................................................. 9

4. MH Crisis ‘To Be’ VSM Scenario Testing - outputs ................................. 10

Participation ................................................................................................................ 10

Rigour in scenario testing ............................................................................................ 10

What we found ............................................................................................................ 10

Implications for MH Crisis ‘To Be’ VSM ....................................................................... 17

Recommendations ....................................................................................................... 18

5. Piloting the MH Crisis ‘To Be’ VSM ........................................................ 19

Critical Success Factors ................................................................................................ 19

Planning & Preparation ............................................................................................... 19

Assumptions & Interdependencies ............................................................................. 20

6. Appendices............................................................................................ 21

Appendix 1 – ‘As Is’ VSM ............................................................................................. 21

Appendix 2 – ‘To Be’ VSM pre scenario testing .......................................................... 23

Appendix 3 – updated ‘To Be’ VSM post scenario testing .......................................... 25

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1. Executive Summary

Starting in March 2015, Alexander supported the Devon-wide MH multi-agency working group in preparing a plan to meet the requirements of the MH Crisis Care Concordat and to identify opportunities for improving the Devon and Plymouth MH Crisis Care Pathway.

Outputs from this work included: o An ‘As Is’ Value Stream Map (VSM) (see Appendix 1) delineating current system

arrangements for dealing with MH Crisis. o A set of priorities for improving response to and experience of individuals with

urgent MH needs. o A plan for improvement that was accepted as meeting requirements of the MH

Crisis Care Concordat. o Definitions of what ‘good’ looks like – from the perspectives of people with lived

experience of MH crisis and of provider organisations in the MH system.

In June 2015, Alexander were asked to support the working group in developing an MH Crisis ‘To Be’ VSM, building on outputs from the previous phase.

An MH Crisis ‘To Be’ VSM (see Appendix 2) was presented to the MH ACP Steering Group in July 2015 and it was agreed that this should be subject to ‘scenario testing’ prior to taking decisions around piloting / rolling out a new model for responding to MH Crisis Care needs.

Alexander were asked to provide support to the Scenario Testing phase in September 2015.

This report sets out the approach, methodology and outputs of scenario testing including implications for new key components of a redesigned MH Crisis VSM (see Appendix 3):

o A ‘single, unique, point of contact’ (SUPOC) to address issues around access to MH Crisis response services and with capacity to operate 24/7 and respond to all callers.

o ‘Intoxication Support’ to address issues around the impact that intoxication (in all forms) has on the way that the system responds to MH Crisis.

o A redesigned ‘Crisis Service’ to address issues around responsiveness of current Crisis teams.

It is recommended that these implications are addressed in moving to detailed design as part of preparing and planning a pilot of the ‘To Be’ MH Crisis VSM.

Based on outputs from scenario testing and to inform a decision on moving to detailed design and planning and preparation for a pilot, a set of initial Critical Success Factors, workstreams, assumptions and interdependencies are described.

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2. Background

Previous phases of work on the MH Crisis Care Pathway

In March 2015, Alexander were asked to support a Devon-wide multi-agency working group in preparing a plan to meet requirements of the MH Crisis Care Concordat and identifying opportunities for improving the Devon and Plymouth MH Crisis Care Pathway.

The Alexander approach adopted is shown in Figure 1 below and work in the initial phase focused on Feasibility and Analysis stages:

Figure 1: Alexander approach - FARIC

The scope of that phase – MH Crisis in the ACP – is illustrated in Figure 2:

Figure 2: MH Crisis in the ACP

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The objectives of the phase were to:

Keep personal experience – and its improvement – at the centre of planning.

Agree what ‘good’ looks like.

Make an express commitment to acting on a system view of meeting urgent MH needs in Devon that is informed by personal experience.

Describe the critical parts of the Value Stream Map (VSM) leading up to when an individual, with urgent MH needs, makes contact with professional MH services so that a course of therapy / treatment may start.

Agree appropriate actions for improving arrangements for: o First contact with services / first response. o Health Based Places of Safety (HBPoS). o S136 detention, including conveyance. o Street Triage.

The outputs of that phase included:

An ‘As Is’ VSM (see Appendix 1) delineating current system arrangements for dealing with MH Crisis.

A set of priorities for improving response to and experience of individuals with MH Crisis needs.

A plan for improvement that was accepted as meeting requirements of the MH Crisis Care Concordat.

Definitions of what ‘good’ looks like – from the perspective of people with lived experience of MH crisis.

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And from the perspective of provider organisations in the MH ACP system.

Alexander were then asked, in June 2015, to further support the working group in developing an MH Crisis ‘To Be’ VSM, building on outputs from the previous phase.

This work focused on the Redesign stage in Figure 1 and was completed with input from people with lived experience and clinical professionals, paramedics and police officers.

The principal output of this phase was a ‘To Be’ VSM incorporating several new and / or fundamentally redesigned components:

A ‘single, unique, point of contact’ (SUPOC) to address issues around access to MH Crisis response services and with capacity to operate 24/7, respond to all callers and, in particular:

o Respond to GP, Paramedic and Police calls for information, advice and guidance. o Mobilise MH specialist resources to attend where necessary.

With regards to definition of ‘all callers’, it should be noted that this includes demand involving people of all ages and with needs from seeking information / signposting, through needing someone to ‘talk to’, to needing urgent MH Crisis response.

An ‘Intoxication Support Unit’ to address issues around the impact that intoxication (in all forms) has on the way that the system responds to MH Crisis.

A redesigned ‘Crisis Service’ to address issues around responsiveness of current Crisis Teams.

The MH Crisis ‘To Be’ VSM

An MH Crisis ‘To Be’ VSM (see Appendix 2) was presented to the MH ACP Steering Group in July 2015 and it was agreed that the VSM should be subject to ‘Scenario Testing’ prior to taking decisions around piloting / rolling out a new model for responding to MH Crisis Care needs.

Alexander were asked to provide support to the Scenario testing phase in September 2015.

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3. MH Crisis ‘To Be’ VSM Scenario Testing

Purpose of the phase

The purpose of the VSM Scenario testing phase was to:

Develop the ‘To Be’ VSM through a series of scenario testing and review workshops and enable stakeholders to ‘visualise’ benefits of the redesigned model for people with lived experience, families, carers, communities, provider organisations, emergency services and staff

Evaluate readiness of the VSM for piloting including stakeholder commitment, scope, plan, resources, pathway, area, crucial data / data points and measurable CSFs / outcomes

What we did – preparation for scenario testing

In preparing for scenario testing sessions, we:

Gathered a set of scenarios to be tested based on case studies and examples of ‘typical’ demand experienced across the system. These were provided by a range of stakeholders including people with lived experience, support organisations, provider organisations and emergency services.

Designed a ‘scenario template’ to ensure consistency in presentation.

Tested and refined the ‘scenario template’ to facilitate ‘flexing’ of scenarios and ensure rigour in testing of the ‘To Be’ VSM.

Defined components of the ‘To Be’ system and invited organisations representing all components to provide people with experience of responding to MH Crisis to attend the scenario testing and review sessions.

Designed an approach and methodology for conducting scenario testing and review sessions and capturing outputs.

Tested and refined the approach and methodology through workshops with people with lived experience, carers, support organisations and the MH ACP working group.

The approach and methodology for scenario testing included a recognised methodology known as Failure Modes & Effects Analysis (FMEA).

FMEA is a structured approach to identifying ways in which a service or process can fail, assessing the impact of failure and identifying actions to prevent and / or reduce the risk of failure.

Figure 3 (next page) illustrates how the approach was embodied in scenario testing and review workshops.

The ‘expert panel’ comprised representatives of provider organisations, emergency services and stakeholder organisations.

‘Devil’s Advocates’ included individuals with lived experience of MH Crisis, carers and support organisations.

‘Observers’ included Alexander consultants and NEW Devon CCG officers.

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Figure 3: Failure Modes & Effects Analysis approach to scenario testing

What we did – testing the scenarios

A series of scenario testing and review sessions were scheduled over 2 weeks i.e. 3rd – 5th and 10th, 11th November at Exeter Community Centre, St David’s Hill, Exeter.

Separate sessions were scheduled for mornings and afternoons to enable the widest possible range of attendees.

Each scenario testing session started with an ‘orientation’ presentation – ensuring all attendees were familiar with background to the work being undertaken and briefed on the FMEA approach and their roles during scenario testing.

Brief background / contextual details around an example of MH Crisis demand were then introduced by a facilitator (Alexander consultant) and members of the expert panel asked to work through a ‘To Be’ response – starting with an initial point of contact.

As responses were developed, all attendees were able to challenge, identify potential ‘failure modes’ and their effects and vary elements of the scenario to explore a wide range of options at each stage of the VSM.

Outputs were captured by observers and these comprised:

Descriptions of component ‘failure modes’.

The impact of component ‘failure modes’ on other elements of the VSM.

The impact of component ‘failure modes’ on the experience or ‘journey’ of people through the VSM – people, in this context, included everyone involved i.e.

o People experiencing MH Crisis, family members, carers. o Members of the public, employers etc. o GPs, Paramedics, Police Officers, clinical and MH professionals.

Each scenario testing session ended with a review of ‘Organisation’ and ‘People’ learning points to be reflected in adjusting the ‘To Be’ VSM and / or addressed in planning and preparing for piloting.

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4. MH Crisis ‘To Be’ VSM Scenario Testing - outputs

Participation

The scenario testing sessions were attended by representatives of all components of the VSM, people with lived experience, carers, support organisations and other stakeholder organisations.

In particular, all sessions were attended by representatives from DPT (including AMHPs), Police, Psychiatric Liaison, people with lived experience and support organisations.

Rigour in scenario testing

Throughout scenario testing sessions, participants ensured that all components of the ‘To Be’ VSM were examined by ‘flexing’ the scenarios to adjust key factors, including:

Person or organisation receiving initial contact.

Person or organisation making initial contact.

Gender, age (including children and older adults), nationality of person experiencing MH crisis.

Time of day.

Physical health issues, MH issues / symptoms.

Attitude of person experiencing MH crisis (co-operative, resistant, violent etc.).

Capacity of person experiencing MH crisis (including a range of forms of intoxication).

Location of person experiencing MH crisis.

What we found

Potential failure modes as they relate to components of the ‘To Be’ MH ACP VSM are set out below with assessments of potential failure effects on organisations and people and required actions:

System component - SUPOC

Potential failure modes Potential failure effects Action required

Insufficient capacity to accommodate demand

Organisation / System:

Unable to provide timely response to demand

Demand escalates to other services e.g. Police, Ambulance, EDs

People:

Inability to access timely response causes confusion, frustration and sub-optimal decision making

Delay in response exacerbates crisis

Inappropriate response exacerbates crisis

Reputation and confidence in MH system is undermined

Collect and analyse data to understand current demand volumes across whole MH Crisis pathway: - Sources of demand - Profile of demand - Range of responses

Model capacity requirements.

Feed in to SUPOC design.

Plan to over resource SUPOC at start of pilot.

Review early intervention / prevention models.

Insufficient breadth / depth of skills, knowledge and experience to respond effectively to full range of demand


Unable to provide effective response to demand

Collect and analyse data to understand nature and range of current demand:

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Note: Scenario testing sessions identified that design of initial contact / conversations is crucial to effectiveness of response and engagement of people experiencing MH Crisis.

Specifically, behaviours / attitudes / tone of voice can have substantial impact on whether response is effective

Delays in decision making

Sub-optimal decision making



People:

Inability to access effective response causes confusion, frustration and sub-optimal decision making



- Sources, Types of demand - Age ranges - Language / cultural range - Complexity re related issues e.g.

physical health; family/social context

Model ‘core’ and ‘extended’ ranges of demand and feed into SUPOC design and job design.

Plan to over resource SUPOC at start of pilot.

Review training provision.

SUPOC staff unable to effect seamless hand offs / transfers of calls to other organisations.

SUPOC not able to access full range of information.

SUPOC not able to share information with other organisations.




Delays in connecting people to appropriate services


People:

Requirement to make multiple calls to access appropriate sources of support and / or response causes confusion, frustration and sub-optimal decision making

Delay in receiving support / appropriate response exacerbates crisis

Define policy to 'pass through' calls to a range of agencies.

Define information system and technology requirements.

Review policy regarding information sharing.

Develop policy for positive, proactive approach and 'can do' attitude whilst observing legal / regulatory requirements.

Staff training, education and coaching.

Access to a comprehensive directory of services for MH crisis.

Overlap / duplication regarding role / responsibilities of SUPOC and: 1. Other initiatives around ‘single

points of contact’ e.g. DPT, CAMHS.

2. Other components of MH Crisis ‘As Is’ VSM e.g. 111 services, EDT

3. Components of other pathways e.g. MASH

4. Other organisations in wider MH system e.g. My Devon, Bay 6, Samaritans.


Proliferation of ‘single points of contact’ causes confusion

Lack of clarity regarding roles and responsibilities

Demand ‘bounces’ around the system




People:

Confusion regarding appropriate sources of support and / or

1. Engage with DPT, CAMHS to

explore detail of proposals and align / rationalise to achieve vision of a SUPOC for the whole MH Crisis pathway.

2. Engage with 111 service re-commissioning project and DPT to align design of SUPOC.

3. Engage with components of other pathways and identify requirements around information sharing, cross-referral etc

4. Gather information regarding full range of organisations and their various offers and consider in commissioning arrangements.

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Potential failure modes Potential failure effects Action required response causes confusion, frustration and sub-optimal decision making

Delay in receiving support / appropriate response exacerbates crisis

System component – Intoxication Support Unit


Inconsistency in system response to MH crisis where person is intoxicated i.e. people are ‘pushed away’.

Lack of clarity around purpose, role and functionality of an ‘Intoxication Support Unit’.

Wide range of potential need with regards to severity and cause of intoxication – giving rise to a need for a wide range of responses and capacity / capability.

In cases beyond ‘mild / simple’ intoxication appropriate response is to convey to ED.

Inappropriate attitude to intoxication undermines parity of esteem


Does not provide timely and or effective response

Provides inappropriate / sub-optimal response


Legal Highs – significant impact on ED and / or hospital wards


People:

Inability to access support and / or response whilst intoxicated causes confusion, frustration and sub-optimal decision making



Amend MH Crisis ‘To Be’ MH ACP VSM to remove ‘Intoxication Support Unit’.

Collect and analyse data relating to intoxication and MH Crisis.

Research best practice models e.g. Birmingham & Solihull Compass service.

Review policy and define options for providing ‘Intoxication Support’ at appropriate points in the MH Crisis ‘To Be’ VSM including who is responsible for making decision re fitness for MH assessment.

System component – Crisis Service


Lack of current Crisis Team capacity to provide a ‘Crisis Response’.

Current Crisis Teams do not provide 24/7 cover.

Current Crisis Teams are not open to all ages.

Lack of current EDT capacity to provide a consistent 'Crisis Response' across Devon.

Lack of Street Triage capacity to provide consistent support 'on the street'.

Lack of Psychiatric Liaison capacity / capability to deal with all ages.


Does not provide comprehensive, consistent, timely and effective response to urgent need for professional MH services



People:

Inability to access urgent response causes delay, confusion, frustration and sub-optimal decision making


Amend MH Crisis ‘To Be’ VSM to remove ‘Crisis Service’.

Collect and analyse data relating to demand requiring ‘Crisis Response’: - Sources of demand - Profile of demand - Points at which demand arises - Range of responses required

Feed in to design of policy and capacity planning around ‘Crisis Response’ at appropriate points in the MH Crisis ‘To Be’ VSM.

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System component – Crisis Service

Potential failure modes Potential failure effects Action required Inappropriate response

exacerbates crisis

System component – Ambulance Service


Paramedic do not have access to patient records.

Information systems do not enable electronic transfer of information from control room to paramedics.


Paramedics need to repeat process of gathering information

Delay in assessment of MH needs

Sub-optimal decision making based on insufficient / incorrect information

People:

Repeating process of information gathering causes delay, confusion and frustration and can exacerbate crisis

Paramedics lose confidence in 'the system' and their own competence

Collect and analyse data around demand on Ambulance Service that involves MH needs.

Review information system requirements and functionality.

Review process to identify work-rounds.

Consider options for fulfilling demand for ‘real time’ information / guidance.

Variation in Paramedic confidence and competence for handling conversations around MH needs effectively and sensitively including: - Family members / carers having

different view of 'need' from individual.

- Interpretation of 'capacity' under MHA / MCA.

- Finding reasons for not being able to help e.g. confidentiality.

- Lack of clarity regarding powers re restraint, prescribing etc.


Delay in assessment of MH needs

Sub-optimal decision making based on insufficient / incorrect knowledge

Inappropriate response

People:

Delay, indecision, dispute can exacerbate crisis

Paramedics lose confidence in 'the system' and their own competence

Develop policies for positive, proactive approach and 'can do' attitude whilst observing legal and regulatory requirements.

Design and deliver training, education and coaching.

Ambulance is not necessary and / or most appropriate mode of conveyance.


Sub-optimal use of vehicles

Delay in response

Inappropriate response

People:

Stigma can exacerbate crisis

Resistance to being conveyed in an Ambulance

Heightened tension and stress for individuals, family members, carers, Paramedics

Ambulance service to review policy regarding timing / mode of conveyance.

Delivery in accordance with what is 'promised'.

Assess capacity required and align with service specification.

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System component – Police


Control Room - delay in assessing need and providing appropriate response to callers.

Variation in Police officer confidence and competence for identifying MH needs effectively and sensitively.

Lack of clarity around ownership of responsibility for individuals and limits of respective duties / powers e.g. vis-à-vis Paramedics.

HB PoS lack capacity to accommodate individuals in crisis.


Delays in providing appropriate support / treatment

Lower order needs escalate to MH crisis

Inappropriate use of s136 powers and / or powers of arrest

Use of inappropriate modes of conveyance.

Use of inappropriate accommodation e.g. police suite, ED open space / cubicle

People:

Delay in receiving appropriate support / treatment for MH needs causes confusion, frustration and sub-optimal decision making

Inappropriate use of S136 powers and / or modes of conveyance escalates crisis and impacts Police officers time

Avoidable exacerbation of MH crisis

Increased risk to person in MH crisis and others

Police officers lose confidence in 'the system' and their own competence

Collect and analyse data around demand on Police that involves MH needs.

Identify root causes of inappropriate use of S136 powers and / or powers of arrest.

System component – GPs


Variation in GP competence and confidence for recognising and dealing with MH issues.

GPs not having timely access to help regarding MH Crisis.

Inconsistency in GPs’ response to MH Crisis.


Does not recognise lower order MH needs and provide timely and / or effective response


Delays in providing appropriate support / treatment


People:

Delay in receiving appropriate support / treatment for lower order MH needs causes confusion, frustration and sub-optimal decision making


GPs lose confidence in 'the system' and their own competence

Consider feasibility of enabling GP access to patients' MH records and plans.

Collect and analyse data relating to MH demand in Primary Care services.

Identify and evaluate options for driving and supporting improvement in GP confidence / competence.

Incorporate provision of ‘real time’ support to GPs in SUPOC capacity planning.

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System component – CAMHS


Weakness around Out of Hours coverage.

Variations in services across Devon - age; geography; situation.

Variations in services re Safe Places for Adults and Children e.g. Safe Places work underway does not cover Plymouth.

CAMHS redesign does not align / integrate with wider MH Crisis pathway redesign




People:

Inability to access urgent response to MH crisis causes delay, confusion, frustration and sub-optimal decision making



CAMHS are working on issues relating to Out of Hours coverage and consistency in services across Devon.

Align / integrate CAMHS work with wider MH Crisis pathway redesign.

Ensure current work around Safe Places takes account of needs for Adults and Children.

Review scope to understand why Plymouth not included.

Single HB PoS for children covering Devon / Torbay / Plymouth is situated in Plymouth.


Lack of capacity to provide, consistent, timely and effective response to urgent need for professional MH services


People:




Collect and analyse data re demand.

Consider need for increased capacity across Devon.

Current service design based on chronological age - clinical debate as to whether this is most effective.


Sub-optimal design?

Consider scope for clinical professionals to inform judgements on most effective model.

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System component – Emergency Departments


Inappropriate environment for a person in MH crisis.

Requirement to provide information several times.

Delays in physical health assessment.

Delays in MH assessment.

Variation in ED staff competence and confidence for recognising and dealing with MH issues.

Inappropriate attitude / response to MH crisis – particularly when discussing person’s symptoms / background.

Variation in coverage of Alcohol Liaison services.

Information relating to physical health and MH is held on separate systems.

Where S136 is used, person in MH crisis is responsible for information.



ED environment exacerbates crisis

Inappropriate attitude / response to MH crisis escalates crisis

Requirement for other services e.g. Police, Ambulance to maintain presence to keep person in MH crisis and others safe.

People:




Escalating crisis affects everyone in ED environment

Crisis Care Concordat action plan addressing need for appropriate environment in EDs and ‘Safe Places’.

HB PoS – collect and analyse demand.

Consider need for increased capacity.

Evaluate opportunity for SUPOC, GPs, CMHTs and emergency services to provide early warning where person in MH crisis is being referred or conveyed to ED.

System component – Psychiatric Liaison


Service not available 24/7.

Inability to access information 'out of hours' where person in MH crisis is known and / or open to MH services.

MH assessment is carried out in inappropriate location and can include several professionals.

MH assessment methodology is sub-optimal.

Failure to consider 'whole situation' of an individual.

Failure to explain what is happening / will happen to the individual.

Inappropriate attitude / behaviours of clinical staff.



ED environment exacerbates crisis

Inappropriate attitude / response to MH crisis escalates crisis

People:




Escalating crisis affects everyone in ED / Hospital environment

Collect and analyse data relating to demand requiring ‘Crisis Response’: - Sources of demand - Profile of demand - Points at which demand arises - Range of responses required

Feed in to design of policy and capacity planning around ‘Crisis Response’ at appropriate points in the MH Crisis ‘To Be’ VSM.

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Implications for MH Crisis ‘To Be’ VSM

SUPOC

The SUPOC concept seeks to address issues of access to the MH Crisis pathway; and to provide a wide range of advice, guidance and support, which facilitates both navigation and prevention.

Potentially responding quickly and effectively to all demand from everybody on a 24/7 basis requires:

A wide range of skills, knowledge and experience.

Access to a full range of information sources and systems

Critical functionality for ‘warm’ transfer of calls with full data / information

Requirement to develop protocols for sharing information between services is a key factor in SUPOC design.

DPT and CAMHS ‘SPOC’ / ‘referral hubs’ need to be coordinated and aligned a MH Crisis SUPOC acting for the whole system.

Intoxication Support / Crisis Service

It is not easy to present either ‘Intoxication Support’ or ‘Crisis Service’ in the MH Crisis VSM by a ‘place’, ‘unit’ or ‘team’.

Critical ‘failure modes’: o Lack of responsiveness and judgemental attitudes towards ‘intoxication’ o Lack of capacity to provide consistent, timely and effective response to MH crisis.

Further redesign of the MH Crisis VSM should focus on developing policy and approaches for dealing with intoxication and crisis response – applied consistently throughout the VSM.

Links between components of MH Crisis pathway

Links between components of the VSM are critical to system performance – scenarios involving MH crisis invariably include several organisations and agencies.

Critical failure modes: o Inability to effect seamless transfer of a person in MH crisis from one component to

another. o Inability / failure to share information and reduce / remove need for repeated

‘interrogation’. o Lack of clarity / understanding around respective roles and responsibilities: failure of

one component to respond effectively drives ‘failure demand’ into the system and exacerbates crisis and impact on family members, carers and professionals. Inability to effect seamless transfer of a person in MH crisis from one component to another.

Data

Demand covering MH needs and / or MH crisis provision is not well understood: lack of reliable, up to date, quantitative data is a major issue.

Lack of evidence-informed understanding clearly undermines effective decision-making – particularly around alignment of appropriate resources to need.

This critical weakness must be addressed effectively as part of preparation and planning for a pilot of the ‘To Be’ MH Crisis VSM.

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Recommendations

It is recommended that these implications are addressed in moving to detailed design as part of preparing and planning a pilot of an updated MH Crisis ‘To Be’ VSM (see Appendix 3).

It is also recommended that:

The SG is the higher governance body for a pilot and: o Champions the project, collectively and individually, as a joint initiative of the Devon

public service system. o Agrees the mandate; the CSFs; and the required benefits of implementation. o Agrees the immediate process for selecting the pilot geography and then selects the

geography (for the pilot and for implementation). o Agrees (or not) that the whole MH Crisis pathway is within scope. o Raises the profile of MH Crisis-related data / information and commissions work now

to gather and assimilate relevant data / information from across the Devon public service system.

o Invites the CCG to consult with people and to return to the SG with a plan, making recommendations on all these points; those in the P&P slides; and funding / commercial arrangements.

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5. Piloting the MH Crisis ‘To Be’ VSM

Critical Success Factors

Criteria for assessing success in the pilot should include:

Proof of concept for a SUPOC reflected in increased confidence of all stakeholders in the MH Crisis pathway and active commitment of MH Crisis pathway stakeholder organisations to leading change.

GPs have increased confidence and competence for dealing with MH issues reflecting their pivotal role in identifying lower order MH issues and preventing escalation.

Improved patient experience reflecting tangible change in the extent to which MH issues are understood across the MH Crisis pathway (non-stigmatising / parity of esteem) and demonstrated through appropriate attitudes and response to MH crisis and associated issues.

Improvement in MH Crisis pathway capacity and competence for coping with intoxication.

Development of consistent, co-ordinated and effective ‘Crisis Response’ reflecting deep understanding of the nature and flow of demand across the MH Crisis pathway and alignment of appropriate resources in appropriate places.

Incorporating initiatives underway and delivered as part of the Crisis Care Concordat plan reflected in understanding what has been done, learning from effects of change and building on progress to improve the MH Crisis pathway.

Sustained reduction in use of S136 powers by Police officers based on appropriate use of powers and more effective support in responding to MH crisis.

Sustained reduction in demand on EDs based on appropriate migration of demand to other part of the MH Crisis pathway.

Development of a comprehensive performance management framework and approach underpinned by shared commitment to a set of performance measures that enable effective, continuous, improvement (Plan, Do, Check, Act). To include feedback from ‘Box 3’.

Planning & Preparation

It is a key assumption that a pilot would need to be ‘commissioned’ and that, in turn, would be informed by detailed planning and preparation including the following workstreams:

Pilot governance arrangements: o Steering Group. o Working Group. o Programme office purpose, role and capacity.

Pilot communications programme: o Stakeholder analysis. o Communications strategy – including public and patient involvement. o Communications plan – channels, media.

Scoping the pilot: o Geography. o Categories of demand. o Component functionality – to include information and communication systems.

Critical Success Factors and key performance measures

Performance management framework and processes: o Approach and methodology. o Performance reporting and analysis. o Benefits capture. o Continuous Improvement. o System Control.

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Defining data requirements and sources:

o Baseline current performance. o Defining a ‘control’ area – rest of Devon.

Defining resource requirements based on data analysis to inform: o Component capacity requirements. o Component capability requirements. o Job design.

Agreeing funding arrangements for pilot.

Capturing and recording learning.

Assumptions & Interdependencies

Key assumptions for planning and preparation include:

The timeline for planning and preparation is governed by the need to agree funding arrangements as part of budget setting processes for financial year 2016/17 that are currently underway. The aim is to be ready to start a pilot in April 2016.

Stakeholder organisations will be able to complete internal decision making processes and commit to supporting a pilot by the end of December 2015.

Stakeholder organisations will commit dedicated resource to planning and preparing for the pilot including data specialists.

Interdependencies for planning and preparation include:

Outputs of work completed and ongoing in delivering the Crisis Care Concordat plan.

Initiatives such as the ‘Integrated Care for Exeter’ (ICE) partnership.

Initiatives referred to in this report i.e. DPT and CAMHS ‘single points of contact’ and ‘referral hubs’.

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6. Appendices

Appendix 1 – ‘As Is’ VSM

Street triage

(advice,

intervention,

deployment)

Consult Police

data

Attend

No. of calls where

purpose is MH

crisis

Assess physical

and mental health

needs

Encounter in

public place

Check clinical

history

Physical health

emergency?

Yes

Assess physical

and mental health

needs Yes

Mental health

crisis?

No

Yes

Physical health

emergency?

Yes

Mental health

crisis?

Referral

Yes

Physical risk to

self or others?

Yes

Physical health

emergency?

Mental health

crisis?Consult CRHT

Yes

No

On caseload?

Yes

Gather and

evaluate

information

No

Need for

ambulance?

Affected by

alcohol /

drugs?

Yes

No

Yes

Call Ambulance

Need for

ambulance?Transfer to

Ambulance

Physical risk to

self or others?

Yes

Call Ambulance /

Police

No

Call Police

Yes

Physical health

emergency?

Mental health

crisis?

Yes

No

Transfer to

Hospital ED

Transport to

appropriate place

Telephone risk

assessment

111 service

MH professional

calls back

(Devon pilot)

Community Mental Health Team

No

Crisis Resolution & Home Treatment Team

No

Primary Health - GP

NoPrescribe / refer

for treatment

Police

Provide advice

Call Ambulance

Attend

Ambulance

No

Provide advice /

signpost

Transfer to

Hospital ED

No

Acute relapse plan

(Plymouth)

Emergency Duty TeamOut of Hours?

Se

rvic

e U

se

r; F

am

ily

me

mb

er;

Me

mb

er

of

Pu

blic;

Em

plo

ye

r e

tc

MHA

assessment?

MHA

assessment?Yes Yes

Gather and

evaluate

information

MHA

assessment? No

Yes

3rd sector

Crisis House

Samaritans

MIND

WAND

Rethink

Community Support

Organisation

Gather and

evaluate

information

Affected by

alcohol /

drugs?Co-ordinate S12

doctor / AMHP for

assessment

Complete MHA

assessment

Complete MHA

assessment

Detain?

MHA / MCA /

DOLs?

Primary Health – S12 doctor

Approved Mental Health Professional

Yes

No

Yes

No

Recovery plan

No

Follow up / referral

to ACP for

recovery plan

Transport to bed

Find available bed

Yes

Ambulance

Follow up / referral

to ACP for

recovery plan

No

Yes

Detain S136 in

police cell

Take to PoS /

HBPoS

Call Ambulance

Criminal

offence?

No

No further action

No

Detain S136

Take to PoS /

HBPoS

Refer to CRHT

No

The person

moves into

the ACP in a

controlled way

with a plan

supervised by

a competent

professional

The person moves

into a hospital

emergency

department to

address physical

and / or mental

health needs

No of referrals

where person

is known to MH

services

No of calls

requiring MH

professional

call back

Outcome of calls

Evaluation of

assessment

outcomes

Evaluation of

assessment

outcomes

The person I spoke to was really helpful and kind

Huge delays – people with immediate need often reach an answering service

The Crisis Team made my sense of crisis worse!

I found it difficult having them in my home – 3 people you do not know

Not recognised that people with mental

illness and drug / alcohol problem are

at serious risk - GPs / Psychiatrists

seem to think the person is at fault

Being ‘sectioned’ should not be a

humiliating experience and it often is

The MHA assessment – which is

intimidating – can cause symptoms

to escalateRoot cause

analysis – no. of

cases where a

social intervention

could have

prevented crisis

Lead time

VA time

Waiting time

No of

professionals

involved

Lead time

VA time

Waiting time

No of

professionals

involved

Where do GPs

go for help with

MH crisis?

How does one get help from

Crisis in a ‘crisis’? They tend

to hand off people like me

Crisis House –

‘Box 1’ or Box 2’?

Lead time

VA time

Waiting time

No of

professionals

involved

Lead time

VA time

Waiting time

No of

professionals

involved

GP data re people

suffering from depression,

on medication and / or

referred for psychological

assessment

When called, police explained

they could not resolve ‘crisis’

Police need to give assurance

to person – even if they are

cuffing them

Volume / source

of demand

involving MH

crisis, profiled by

day / time etc

It is often frightening to call the

police. They made me feel stupid

as if I was wasting their time

Pre-conceived opinions affected

Police handover – long wait in

A&E

Breakdown of

social factors

leading to

crisis in

Primary Care

and onwards

Volume / source

of demand

involving MH

crisis, profiled by

day / time etc

It is frightening to be in a

Police cell for very long

Conveyance post

assessment – who is

doing it and volume of

activity

Proportion of

demand involving

alcohol / drugs

Conveyance post



activity

Volume / source of

demand

Outcomes

of 26

The person leaves

the emergency

pathway in a

controlled way

with a plan

supervised by a

competent

professional

Psychiatric Liaison

Physical health

assessment /

triage

Mental health

matrix

(ED staff)

Hospital Emergency Department

Matrix output?

Refer to

psychiatric

liaison / CRHT

Refer to

psychiatric

liaison / wait in

Obs unit / ED

Discharge /

signpost support /

notify GP

Psychosocial

assessment / full

history

Red

Green

Amber /

Yellow

Detain S5(2)

waiting for MH

assessment

Informal

admission to

bed / psych bed

MHA assessment

Transport to bed

Care plan: care

coordinator /

signposting / rainy

day plan

Assessment

output?

ReferralSignpost to other

services

Co-ordinate S12

doctor / AMHP for

assessment

Complete MHA

assessment

Complete MHA

assessment

Detain? Find available bed





Yes

No

Ambulance

Hospital Medical Wards

Refer to

psychiatric

liaison / CRHT

Referral

Gather and

evaluate

information

Recovery plan

Very kindly care offered at Torbay

ED after episode of self harm. Also

excellent nursing care that led to

psychiatric assessment

Clinicians not accessing previous MH history /

notes; not acknowledging extent of previous

self harm; transfer to inappropriate physical

ward

Medical staff on all wards to know

what Psychiatric Liaison does and how

to access it – it should not be the

responsibility of the person to ask

Lead time

VA time

Waiting time

No of

professionals

involved

Volume / source

of demand

involving MH

crisis, profiled by

day / time etc

Proportion of

demand involving

alcohol / drugs

Evaluation of

assessment

outcomes

Lead time

VA time

Waiting time

No of

professionals

involved

Root cause

analysis – no. of

cases where a

social intervention

could have

prevented crisis

Conveyance post



activity

Chaotic spaces – no appropriate, calm

place to talk to Psychiatric Liaison

No appropriate place to talk to

Psychiatric Liaison – have been seen

in staff room where interrupted or at

bedside where there is no privacy

Time spent in A&E should be kept to a minimum –

especially when being watched by Police Officers

Lack of information sharing between

services leads to stigma

Lead time

VA time

Waiting time

No of

professionals

involved

Lead time

VA time

Waiting time

No of

professionals

involved

of 26

Appendix 2 – ‘To Be’ VSM pre scenario testing

Consult Police

data

Speak to a MH

nurse / specialist

Assess physical

and mental health

needs

Encounter in

public place

Devon / Plymouth MH Crisis

High Level ‘To Be’ VSM draft

v0.3 03/07/15

Mental health

needs?

Yes

Yes

Physical health

needs?

Yes

Yes

Mental health

needs?

Yes

No

Physical health

emergency?

Output?

No

Yes Arrange

appropriate

conveyance to ED

Physical risk to

self or others?Yes

Call Police

Physical health

emergency?

Control room

receives call

Single, Unique Point of Contact Crisis Service

Primary Health

Prescribe / refer

for treatment

Police

Arrange

appropriate

conveyance to ED

Attend / Assess

situation

Ambulance

Warm transfers of call to

appropriate services i.e.

with relevant background

info and systems access

No

Intoxication Support Unit

Convey person to

ISU

Keep safe until fit

for assessment

Complete F2F

assessment Output?

Output?

Structured conversation:

- physical health?

- mental health?

- affected by alcohol; drugs;

other substances?

- in a safe, appropriate

place?

- wider social needs?

- known to MH services

(now and / or in the past)?

Output?

Conversation

meets need

Refer / signpost to

other services e.g.

Crisis House?

Refer to Crisis

service

Refer to ISU

Arrange

conveyance

Request MHA

assessment

Update systems

Advise GP / others

No further action

Refer / signpost to

other services e.g.

Crisis House?

Request MHA

assessment

Refer to Home

Treatment /

Inpatient services

Devon geography;

response times

Alignment with

concept of Street

Triage?

Skills, knowledge

required

Access to

information

systems

Capacity, capability,

confidence in assessing

moderate MH needs

Refer to CMHT

Co-ordinate S12

doctor / AMHP for

assessment

Complete MHA

assessment

Complete MHA

assessment

Output?

Find available bed



Detain

Refer to other

services

Need for behaviour change if

demand on Police resources

is to reduce sustainably

Provision of appropriate

conveyance

No further action

Provide advice /

guidance

Convey person to

ISU

Convey person to

HB PoS

Convey person to

ED

Arrest / Detain

s136 etc

No further action

Provide advice /

guidance

Convey person to

ISU

Convey person to

HB PoS

Health Based Places of

Safety – officers having to

make several calls to

ascertain status / access

Physical &

Mental health

needs?

Advise Psychiatric

Liaison if person

being conveyed to

ED

Assess situation

Mental health

needs?

Physical health

needs?

Physical &

Mental health

needs?

Offence

committed?

Physical risk to

self or others?

Yes

Attend?

Yes

Physical health

needs?

Physical health

emergency?

Yes

Yes

Yes

Yes

Call paramedics

Physical &

Mental health

needs?Yes

Convey person to

ED

Yes

Sources of contact:

People experiencing / anticipating

MH crisis

Family members / carers

Care organisations - residential;

domiciliary; general; specialist

Friends

Members of the public

3rd sector / community

organisations

Workplace colleagues / managers

Social services – children;

adolescents; adults; older people


Schools

of 26

The person leaves

the emergency

pathway in a

controlled way

with a plan

supervised by a

competent

professional

Psychiatric Liaison

Physical health

assessment /

triage

Mental health

screening

(ED staff)


Matrix output?

Refer to

psychiatric

liaison / CRHT

Refer to

psychiatric

liaison / wait in

Obs unit / ED

Discharge /

signpost support /

notify GP

Psychosocial

assessment / full

history

Red

Green

Amber /

Yellow

Detain S5(2)

waiting for MH

assessment

Informal

admission to

bed / psych bed

MHA assessment

Transport to bed

Care plan: care

coordinator /

signposting / rainy

day plan

Assessment

output?

Refer to CRHT

Discharge / refer

to community MH

services

Signpost to other

services

Co-ordinate S12

doctor / AMHP for

assessment

Complete MHA

assessment

Complete MHA

assessment






Yes

No

Ambulance



v0.3 03/07/15

Redesign to be addressed in

separate workshop

of 26

Appendix 3 – updated ‘To Be’ VSM post scenario testing

Mental Health Act Assessment

Consult Police

data

Speak to a MH

nurse / specialist

Assess physical

and mental health

needs

Encounter in

public place



v0.7 20/10/15

Mental health

needs?

Yes

Yes

Physical health

needs?

Yes

Yes

Mental health

needs?

Yes

No

Physical health

emergency?

Output?

No

Yes Arrange

appropriate

conveyance to ED

Physical risk to

self or others?Yes

Call Police

Physical health

emergency?

Control room

receives call

Single, Unique Point of Contact

Crisis Response

Primary Health

Prescribe / refer

for treatment

Police

Arrange

appropriate

conveyance to ED

Attend / Assess

situation

Ambulance

Need to define requirements

for communications systems

to enable and support ‘warm

transfers’ of calls to

appropriate services.

No

Intoxication Support

Output?

Structured conversation:

- age; gender etc

- physical health?

- mental health?

- affected by alcohol; drugs;

other substances?

- in a safe, appropriate

place?

- wider social needs?

- known to MH services

(now and / or in the past)?

- evaluate need

- decide appropriate

response

Output?

Conversation

meets need

Refer / signpost to

other services

Initiate Crisis

Response

Arrange

conveyance

Request MHA

assessment

Update systems

Advise GP / others

Data requirements to baseline current demand categories / volumes /

profiles

Need to design range of

protocols for dealing with

wide range of demand.

Need to define content

and tone of

conversations.

Need to define range of

‘appropriate responses’.

Need to define range of

skills, knowledge and

experience required – job

design.

Need to define

requirements for access to

information systems.

Need to support development of

competence and confidence of

GPs in assessing MH needs.

Refer to CMHT

Co-ordinate S12

doctor / AMHP for

assessment

Complete MHA

assessment

Complete MHA

assessment

Output?

Find available bed



Detain

Refer to other

services

Need to support and enable

sustained reduction in

inappropriate use of S136Need to define policy and

protocols relating to provision

and use of ‘appropriate

conveyance’.

No further action

Provide advice /

guidance

Convey person to

HB PoS

Convey person to

ED

Arrest / Detain

s136 etc

No further action

Provide advice /

guidance

Convey person to

ED / HB PoS etc

HB PoS – need to provide

officers with information on

status / capacity

Physical &

Mental health

needs?

Advise ED /

Psychiatric Liaison

if person being

conveyed to ED

Assess situation

Mental health

needs?

Physical health

needs?

Physical &

Mental health

needs?

Offence

committed?

Physical risk to

self or others?

Yes

Attend?

Yes

Physical health

needs?

Physical health

emergency?

Yes

Yes

Yes

Call paramedics

Physical &

Mental health

needs?Yes

Convey person to

appropriate place

(including ED)

Yes

People experiencing / anticipating

MH crisis

Family members / carers / friends

Care organisations

Members of the public 3rd sector / community

organisations


Social services – children;

adolescents; adults; older people

Schools / Colleges / Universities

PDCA

Plan

Do

Check

Act

Evaluate effectiveness of support

and guidance to GPs etc

PDCA

Plan

Do

Check

Act

Evaluate effectiveness of

assessment and output

PDCA

Plan

Do

Check

Act

PDCA

Plan

Do

Check

Act


assessment, appropriate

response and decision

making

Refer to CAMHS

Yes

PDCA

Plan

Do

Check

Act

Evaluate opportunity to

migrate demand to most

appropriate point of contact

Need for

conveyance?

Yes



Need to define policy and

protocols relating to provision

and use of ‘appropriate

conveyance’.

Speak to a ‘call

handler’Need to evaluate need and impact of

having ‘call handlers’ to address needs

for information / non-MH Crisis cals.



paramedics in assessing MH

needs.

Need to align / integrate

purpose and function of

SUPOC with:

- DPT single point of contact

- CAMHS referral hubs /

single point of contact

Need to consider alignment /

integration of purpose and

function of SUPOC with:

- Emergency Duty Teams

- Street Triage

- MASH



Police officers in assessing MH

needs.

See Scenario Testing outputs re failure modes.

Need to collect and analyse data relating to demand requiring ‘Crisis Response’: Sources of demand Profile of demand Points at which demand arises Range of responses required

Feed in to design of policy and capacity planning around ‘Crisis Response’ at appropriate points in the ‘To Be’ MH ACP VSM.


Need to collect and analyse data relating to intoxication and MH Crisis.

Need to review policy and define options for providing ‘Intoxication Support’ at appropriate points in the ‘To Be’ MH ACP VSM including who is responsible for making decision re fitness for MH assessment.

of 26

Mental Health Act Assessment

The person leaves

the Crisis element

of the ACP in a

controlled way

with a plan

supervised by a

competent

professional

Psychiatric Liaison

Physical health

assessment /

triage

Mental health

screening

(ED staff)


Matrix output?

Refer to

psychiatric

liaison / CRHT

Refer to

psychiatric liaison

Discharge /

signpost support /

notify GP

Psychosocial

assessment / full

history

Red

Green

Amber /

Yellow

Detain S5(2)

waiting for MH

assessment

Informal

admission to

bed / psych bed

MHA assessment

Transport to bed

Care plan: care

coordinator /

signposting / rainy

day plan

Assessment

output?Refer to CRHT

Discharge / refer

to community MH

services

Signpost to other

services

Co-ordinate S12

doctor / AMHP for

assessment

Complete MHA

assessment

Complete MHA

assessment






Yes

No

Ambulance

Provision of appropriate

conveyance

Immediate

response?

Yes

NoMove to a safe

place in / near ED

Need to review protocols / processes

to enable Police officers / Paramedics

to provide ED with information relating

to MH needs ahead of arrival.

Need to review protocols / processes

to enable ED staff to provide ‘Crisis

Response’ to MH needs

PDCA

Plan

Do

Check

Act

Continuous Improvement:

Need to establish a series of feedback

loops - from ‘Box 3’ - that enable

ongoing evaluation of system

effectiveness and adjustment to policy /

process.

PDCA

Plan

Do

Check

ActEvaluate effectiveness of


PDCA

Plan

Do

Check

Act





v0.7 20/10/15

Data requirements to baseline current demand categories / volumes /

profiles

Crisis Response

Intoxication Support


Need to collect and analyse data relating to demand requiring ‘Crisis Response’: Sources of demand Profile of demand Points at which demand arises Range of responses required

Feed in to design of policy and capacity planning around ‘Crisis Response’ at appropriate points in the ‘To Be’ MH ACP VSM.


Need to collect and analyse data relating to intoxication and MH Crisis.

Need to review policy and define options for providing ‘Intoxication Support’ at appropriate points in the ‘To Be’ MH ACP VSM including who is responsible for making decision re fitness for MH assessment.

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