mental health commissioning workshop: using economic ... health... · tackling unmet mental health...

www.england.nhs.uk

• Andy Bell, Deputy Chief Executive, Rebecca Campbell, Quality Improvement Manager and

Sarah Boul, Quality Improvement Lead

• Twitter: @YHSCN_MHDN #yhmentalhealth

• July 2017

Mental Health Commissioning Workshop:

Using economic evidence to

improve services for adults

Cloth Hall Court, Leeds

11 July 2017

www.england.nhs.uk

@YHSCN_MHDN

#yhmentalhealth

Housekeeping:

www.england.nhs.uk

Welcome, Introductions and Apologies

Andy Bell, Deputy Chief Executive, Centre for Mental Health

www.england.nhs.uk

Keynote Address

Debbie Taylor, Creative Minds Peer Project

Physical and mental health: the economic evidence (so far) Andy Bell, 27 June 2017

Mental health care funding

NHS currently spends about £14bn on mental health care (13% of the total budget)

Not treating mental ill health costs a further £14bn:

People with long-term conditions

Medically unexplained symptoms

Other complex needs

Mental and physical health overlap

Mental health and long-term conditions

20-50% of people with cardiovascular diseases have depression

People with diabetes twice as likely to have depression

Anxiety ten times as prevalent among people with COPD

One third of women with arthritis also have depression

The impact of co-morbidity

Mortality from asthma is doubled if you also have depression

People with chronic heart failure and depression eight times more likely to die within 30 months

Higher mortality and more complications from diabetes

Impact on NHS costs

Costs of healthcare rise by at least 45% regardless of severity of physical illness

The more comorbidities, the higher the costs

The costs of co-morbidity in hospitals

Half of hospital inpatients have a co-morbid mental health problem

Less than half of those are identified

15% A&E cases relate to mental illness or alcohol misuse

Mental ill health costs £25m for a 500-bed hospital (15% of all expenditure)

Benefits of liaison psychiatry

Liaison psychiatry services can:

Reduce admissions from A&E

Reduce lengths of stay (2-5 days per elderly patient)

Reduce readmissions and enhance independent living after discharge

Build skills and confidence of hospital staff

Savings estimated at £5m per hospital

Integrated care and support

Structured approach to care outside hospital involving:

Care coordination by a case manager

Systematic management and outcome tracking

Multi-disciplinary team

Collaboration between primary and specialist care

Key role for voluntary sector

Economic evidence for integrated care

US evidence shows every $1 invested generates social benefits of $5

Cost per QALY estimated by NICE at £4,000

Strongest evidence base for patients with diabetes and depression

Some small-scale studies show benefits for coronary heart disease and COPD

Scale and cost of medically unexplained symptoms

Estimated 25% of people in GP surgeries and up to 60% in some outpatient departments

2-3 times higher use of health services

Costs £3bn a year to NHS (for adults of working age)

Cost per case £700 a year (and £3,500 for most costly 5%)

Supporting people with medically unexplained symptoms

Limited evidence for benefits of GP training

Strong evidence for CBT and other structured psychological interventions

Some evidence that these lead to reduced use of other health services

Primary care outreach for complex needs

City & Hackney Primary Care Psychotherapy and Consultation Service

Supports people with ‘complex needs’ including medically unexplained symptoms

Offers advice and support to GPs in managing patients

Provides direct service to patients with a range of psychological therapies

Evaluation results

High recovery rates (55% recovery; 75% reliable improvement)

Cost per QALY of £11,000

Saves NHS one-third of its cost within 12 months

Very high GP satisfaction

Physical health for people with psychosis

15-20 year shorter life expectancy

Excess mortality related to physical ill health

Smoking cessation based on NICE guidelines:

Average gain of seven years of life per person who quits smoking

Likely savings from reduced healthcare costs

Meeting physical health needs

Annual physical health checks (Bradford)

Medical liaison in inpatient services (West London)

What hinders integration?

Cultural divides between mental and physical health care

Separate training for professionals

Different funding streams and accountability systems

Benefits don’t always accrue to same organisations that carry costs

Stigma

Tackling unmet mental health needs

Collaborative care for people with long-term conditions and mental health problems

Psychological therapies for people with medically unexplained symptoms and complex needs

Liaison psychiatry in every hospital for all patients

www.england.nhs.uk

Bridging the Gap

Dr Christian Hosker, Leeds and York

Partnership Trust

The Leeds Liaison Psychiatry Service

Bridging the Gap

ME

Consultant Liaison Psychiatrist Lead Clinician - Ward based service for general hospital

inpatients - ED and Self harm presentations A general liaison psychiatry clinic - Specialist outpatient clinics - Transplant psychiatry clinic

Special interest in palliative care psychiatry & psycho-oncology -hospice based palliative care clinics -A psycho-oncology clinic at the Leeds Oncology Institute

The service in Leeds

HMHT

HMHT

HMHT

HMHT

WA HMHT

OP

OP HMHT

OP NICPM ALPS PSM CFS

OP YCPM ALPS PSM CFS

OP YCPM

1970s

1980s

1990s

2000s

2010s

Current service provision

4000 assessments PA 18 band 6-7 staff

3 WTE 500 Assessments PA

8 beds 25 admission PA

471 Assessments PA

669 Assessment PA

2770 assessments PA

8465

LIAISON PSYCHIATRY OUTPATIENT SERVICE

Bridging the Gap

Mission

• Improve the health outcomes for patients with co-morbid physical and mental health disorder

• Using

– Best evidence

– Timely intervention

The MDT

• Consultant psychiatrists 1 WTE

• Professor of psychiatry 0.2 WTE

• Band 7 CBT therapists 3 WTE

• Band 6 RMNs/OT 3 WTE

• Band 6 Physio 0. 4 WTE

• Psychiatric trainees

Interventions

• Psychiatric treatment • CBT • ACT • EMDR • Hypnosis • Mindfulness • Psychodynamic interpersonal therapy • Interpersonal therapy • Solution focused therapy • Physiotherapy

Pathways

• MUS pathway

• Chronic pain pathway

• Long Term Conditions pathway

• Specialist pathways

– Pal care

– Bariatrics

– Live liver transplantation

http://www.leedsandyorkpft.nhs.uk/our_services/Specialist-LD-Care/liaisonpsychiatry

Referral criteria

LTC

• 30% of population have LTC – 2-3 times more likely to develop mental health

problems

– General population : 5-10% depression prevalence

– Diabetes : 18%

– Coronary heart disease : 23%

• Multiple LTC – 7 times more likely to be depressed

• Mental illness predicts:

– Poor health outcomes

• Increased mortality

• More presentation

• Reduced independence

• Low QoL

• Poor treatment engagement and self management

Costs

12-18% of all NHS expenditure on LTC linked to mental health Increased service use

More admissions More acute episodes Greater length of stay

Wider economy

Greater unemployment Cost sits within the most complex patients (Kings Fund 2012)

Interventions will pay for themselves (King’s fund)

Interventions: LTC pathway Function

Time

Intervention

Medically Unexplained Symptoms

Terminology…

…cases that present with physical symptoms that are a problem and which may have a psycho-social origin but are also possibly

mediated by organic brain processes (PSPWPOPMOB)…

MUS: What are we talking about?

• Illness versus disease – 5-7% of population (SSD)

• MUS

• Functional somatic symptoms

• Somatisation

• Somatic symptom disorder

• Confusing for patients/staff…!!!!

Typical case:

• JD has been troubled by medically unexplained symptoms within the context of a long history of anxiety, depression, dyslexia and dyspraxia. He has been assessed by a private neurologist and had a normal MRI scan, nerve conduction and EMG and there were no abnormalities on a range of blood tests (autoantibodies, B12, Folate etc). His function is poor and he was described as spending most of his time in bed and not washing.

School difficulties

Work difficulties

Tinnitus

10 year work absence Employment support Near employment

Illness Functional decline

2017 Rhuematology consultation 2016 MRI 2016 EMG 2016 Nerve conduction studies 2015 CXR

2016

MUS: Why are we talking about it?

The cost of MUS

The sufferer Health economy

• Chronic

• Loss of function

• Distressing

• Co-morbidity (40%)

• Over investigated

• Iatrogenic harm

• Stigmatised

• Dissatisfied!

• NHS £4 billion

• Society £18 billion

• 15-30% GP contacts

• 20% of outpatient contacts

• Added value?

MUS: Challenges

• Uncertainty about how to deliver care

• Engagement

– “Difficult to help”

– Acceptability of what’s on offer

• Dissatisfaction

Liaison psychiatry

Mind Body

MUS: Treatment

Pharmacological

MUS: Non-pharmacological

CBT Back pain Move less frequently Exacerbates stiffness Creates stress Reattribution 1. Making patient feel understood 2. Change the agenda 3. Make links to psycho-social stress

Enhanced care Looser, integrated approach

MUS PATHWAY

The Leeds Liaison Psychiatry Service

Development

• Within existing commissioning arrangements

• Clinician led

• Aim: Improvement in quality, efficiency, consistency, outcome

• T & F group

• Evidence led

• R & D support

The pathway

• Medical triage

• CBT default position – Woolfolk & Allen

• Alternative, less manualised arm

• Launched Oct 2015

Pathway - detail

• Referral – correct pathway identification

• Assessment booklet sent out

– EQ-5D-5L

– SF36

– PHQ-9

– CORE 10

– TOMS (CROM)

Medical assessment

Referred patients

• N = 40

• Referral source – 1/3 GP

– 1/3 General Hospital

– 1/5 Mental Health Trust

• PHQ-9 14 Mod depression

• GAD-7 12 Mod anxiety

• WSAS 20 Significant functional impairment

Referred patients

EQ-5D-5L Mobility 3

EQ-5D-5L Self-care 2

EQ-5D-5L Usual activities 3

EQ-5D-5L Pain 3

EQ-5D-5L Anx/dep 3

EQ-5D-5L Your health today 45

fibromyalgia, migraine,

depression, non

epileptic attacks

non cardiac chest pain,

anxiety, PTSD, pre-

existing cardiac

disease

face and head tingling

Giloma and secondary

epilepsy. Dissociative

attacks

depression, anxiety,

non epileptic attack

disorder, self injury,

bulimic symptoms

post concussional

syndrome, PTSD,

generalised anxiety

throat burning, urgency

NEAD

Non epileptic seizures,

Lupus with possible

cerebral involvement.

REM Sleep disorder.

Adrenal insufficiency,

Fibromyalgia, Chronic

constipation.

None epileptic attack

disorder, ? Epilepsy

MUS, CFS, epilepsy

1Emotionally unstable

2Cyclical vomitting

3Headaches

Other

1Dissociative Motor

Disorder

2

3

Other

1Somatoform

autonomic dysfunction

(IBS)

2

3

Other

1 psychologic non

epileptic attacks.

2 Psychogenic

movement disorder

3

Other

Our experience…

• Hard work!

• Solid process

• Pathway leaders

• Feedback to clinicians

• Improved focus

• Improved training

• Improved patient experience

• Live process - adaptable

Our experience

• Integrated across health setting???

• Capacity issues

• Cant help everyone

• Lacking a forum for shared experience…

Future ambitions

Questions…

www.england.nhs.uk

Group discussion 1:

How can we bridge the gap?

What provision do you have now?

What are the main gaps and concerns you

have about this area?

How might you go about addressing these?

What support do you need to do this?

The acute care pathway: crisis services and out of area placements Andy Bell, 27 June 2017

Economic evidence on the acute care pathway

Limited evidence about cost-effective interventions

Major cost pressures:

Inpatient admissions: account for 51% of mental health care spending but 11% of activity

Out of area placements

Delayed discharges and transfers of care

Economic evidence for crisis services

Strong evidence of economic benefits of faithfully implemented Crisis Resolution and Home Treatment (CRHT) teams

Net savings estimated at £2,300 per person

Limited economic evidence for crisis houses and other alternatives to admission

The many costs of out of area placements

Hard to quantify but will include:

Time taken finding a bed: key role of AMHPs

Trauma for the individual and family members

Transport (ambulance and police)

Ongoing contact with local authority & CCG

Opportunity cost of spending on services outside local area (and NHS)

Poorer outcomes, including higher suicide risk

What causes delayed discharges?

Housing difficulties (which escalate the longer a person is in hospital)

Complex needs requiring multiple agency contributions

Lack of contact with local areas (for people in long-stay out of area placements)

Possible solutions: learning from Bradford

Close working with the police to respond quickly to crises

Embedding AMHPs in community teams

Alternatives to admission

Housing rights help and advice

Joint health & care commissioning

Shared discharge planning

Rehabilitation services

10-20% people with psychosis require longer term support

80% rehabilitation referrals are from acute inpatient wards

Two-thirds recover well with effective rehabilitation (c. 12 month inpatient admission followed by community support)

Many of these services have been cut or reduced…

Long-stay inpatient admissions

Growth in out-of-area placements and private sector provision

Emergence of ‘locked rehab’ wards

Evidence of individuals spending many years in wards: dislocated from family, community and local services

Need for recognition of this group & locally based support

www.england.nhs.uk

Time for some lunch?

www.england.nhs.uk

Improving Rehabilitation

Pathways

Dr Mike Hunter, Sheffield Health and

Social Care Trust

The “Other” Out-of-Area Story

Mike Hunter, Medical Director @SHSCFT

Associate NCD @NHSImprovement

@DrMikePsych

Do Something Novel to Liberate Resources

Our Out-of-Area Experience

Our Local Service Experience

Are the Service Users Different?

Getting a Grip

Cumulative admissions Cumulative total

Looking to the Community

See the Person in the System

Socially Based Care

‘Bricks and Mortar’ tenancies

For example:

Sheffield City Council

South Yorkshire Housing

Care for J

Social Care via SDS /

Supporting People

For example:

Tenancy support

Vocational support

Befriending

Domestic services

Healthcare

For example:

SHSC– SORT/CERT

CPA

Manage/contain risk

GP

Housing Benefit

Crisis Provision

For example:

Overnight support

Crisis House

Short-term care beds

A Credible Social Housing Partner

Staffing Establishment

Team Manager and Deputy Team Manager

Senior Psychologist

Psychologist and Assistant Psychologist

Consultant Psychiatrist

Occupational Therapist

Administrative Support

Mini Teams

Mini Teams for 8 Service Users

Two Band 6 CPNs

One Band 4 Development Role

Eight Band 3 Recovery Workers

+/- Apprentice

[2 3 1]

[6 9 3]

Planning Every Day

Reflective Practice

• “You can see it can’t you the fluctuations in the team alongside the service users, that we go up and down as well and kind of mirroring their experiences.”

• “It helps us notice breaks we need, it allows us to come away from and think about what we’re doing.”

“I don’t think that anybody feels like they can’t bring an issue, like it doesn’t matter who you are or what the issue is if its there and we talk about it … and if things have gone ‘wrong’ there hasn’t been finger pointing or blame its been more of a ‘well, ok what can we do from this point’ ... it’s never been like ‘oh well, that failed’ or ‘that was rubbish’ its been ‘ok lets try something different’ which from my experience as working as nurse is very very rare”

Sad, fear, guilt, shame, worthless hopeless

I can’t talk to

my parents/ hide

behind a smile

Triggers

Mum diagnosed with breast cancer Family experiencing physical health

problems. Finding collage challenging

Historical Factors

Trauma

I hide it

because I

don’t want

people to feel

sorry for me.

embarrassed

I’m not

important/burden

Try to avoid

feelings &

thoughts

Short term:

sleep/

Self-harm/isolate

myself at home

Works for 5 mins

I’m useless, I’m a

failure, I’m not good

enough, I can’t do

anything right, My thoughts go

round and round

in my head.

Short term: self

harm

People try to stop

me self-harming

Critical

Controlling

I

Criticises

Controlled

I want to

kill myself

Team becomes

anxious

Rescuing

Perfect care

I

Rescued

perfectly cared

for

Splits team

Lack of shared

understanding

between teams

Lack of

consistent

working with

the service user

Team feel

stressed worn

out

Developing Understanding

• “Because your clients are behaving in ways that elicits a response from you but when you have got that diagram you can see other avenues and you can see why.”

• “Having the team formulation and having like a diagram that explains your own responses so you know that sometimes the feelings that you are feeling are natural … you know where it’s coming from.”

• “It helps because you feel like you have understood the problem a bit more ... that gives us confidence in what we are doing .. .its easier to give our service users confidence.”

The Main Risks

• It doesn’t work and people are readmitted to the acute care system.

• It doesn’t work and there are many SUIs.

• It doesn’t work because people become institutionalised in the community and can’t move on.

Reducing Bed Nights

• Twenty-seven people had been using 9855 bed nights per year.

• In the last 27 months, a 99% reduction.

Incidents

• Approximately 70% related to self harm.

• Approximately 30% related to threatening behaviour.

Next Steps

• Some people are now moving on.

• We want to link this with our development of personality disorder / trauma-focussed / formulation-led services more widely in the City.

Not the Cutting Edge

www.england.nhs.uk

Crisis and Acute Mental Health

National Update

Bobby Pratap, NHS England

Adult Mental Health Crisis and Acute

Care: NHS England’s national

programme

Bobby Pratap, Senior Programme Manager

Adult Mental Health

Mental Health Clinical Policy and Strategy Team

NHS England

Email: [email protected]

Twitter: @bobbypratapMH

mailto:[email protected]

103

Contents

1. Background and policy context: why is NHS England

investing in the acute care pathway

2. Crisis Resolution & Home Treatment Teams

3. Acute mental health care, including out of area

placements 4. Liaison Mental Health

5. Mental Health Act

6. Community Mental Health Services

1. Background and policy context:

Why is NHS England investing in

mental health crisis & acute care?

www.england.nhs.uk

Two key documents published in February last year which have shaped the

National Crisis and Acute Care programme:

Policy Context

Old Problems, New Solutions: Improving

Acute Psychiatric Care for Adults in England

A report from the independent Commission on

Acute Adult Psychiatric Care

The Five Year Forward View for Mental Health

A report from the independent Mental Health Taskforce

to the NHS in England

106

CAAPC – what did it say? Some of the top recommendations

• End the practice of sending acutely ill patients

long distances for treatment by October 2017

• Strengthening CR/HTs, with a particular focus on

ensuring that home treatment teams are

adequately resourced to provide a safe and

effective alternative to acute inpatient care where

this is appropriate

• A single set of measurable quality standards

needs to be created spanning the acute care

pathway, including a maximum four-hour wait

for admission to an acute psychiatric ward for

adults or acceptance for home-based treatment

following assessment

www.england.nhs.uk

Recommendation 17:

• By 2020/21 24/7 community crisis response across all areas

that are adequately resourced to offer intensive home

treatment, backed by investment in CRHTTs.

Recommendation 18:

• By 2020/21, no acute hospital is without all-age mental

health liaison services in emergency departments and

inpatient wards, and at least 50 per cent of acute hospitals

are meeting the ‘core 24’ service standard as a minimum.

Recommendation 22:

• Introduce standards for acute mental health care, with the

expectation that care is provided in the least restrictive way

and as close to home as possible.

• Eliminate the practice of sending people out of area for

acute inpatient care as a result of local acute bed pressures by

no later than 2020/21.

107

Mental Health Task Force – acute mental health

www.england.nhs.uk

“By 2020, there should be 24-hour access to mental

health crisis care, 7 days a week, 365 days a year –

a ‘7 Day NHS for people’s mental health’.”

108

Spending Review – Headlines for Crisis & Acute Care

• over £400m for crisis resolution and home

treatment teams (CRHTTs) to deliver 24/7

treatment in communities and homes as a safe

and effective alternative to hospitals (over 4

years from 2017/18);

• £247m for liaison mental health services in every hospital emergency

department (over 4 years from 2017/18);

• £15m capital funding for Health Based Places of Safety in 2016-18 (non-

recurrent)

109

National programme – crisis & acute mental health

Phase 1: 2016/17:

• National policy development

• Embed crisis & acute care into as many national levers and

incentives, infrastructure to drive local delivery from 2017/18:

Phase 2: 2017/18

Investment begins:

• £43m uplift to CCG baselines for CRHTTs in 2017/18

• £15m transformation funding for liaison in 2017/18

• Shift from national policy to driving regional implementation

preparedness and supporting local delivery

110

Development of national policy

During 2016 /17 multi-agency expert reference groups – service

managers, clinicians, experts by experience, commissioners, social care,

policy managers, police, academics have followed a NICE-guideline type

process to develop national policy guidelines for crisis & acute care :

Referral to treatment pathway, quality benchmarks / standards,

including response times, interventions, NICE recommended

care

Implementation guidance & helpful resource pack – e.g. service

examples

CCQI England-wide quality assessment and improvement

scheme

Specify england-wide baseline audits & gap analysis

Articulate key national metrics to measure pathways

Year long CCQI implementation support scheme following publication of new suite of

national quality benchmarks and resources

CCG Improvement and Assessment Framework – including transformation indicators for

U&E MH in 2016/17, crisis & acute indicators prioritised in 2017/18;

NHS Planning guidance – U&E MH explicit in 2 of the 9 NHS ‘must dos’ (UEC, MH)

NHSI Oversight Framework and CQC ratings to be based on new pathways;

Aides memoires and assurances of STPs include U&E and acute MH;

MH Dashboard, CCG financial tracker – specific returns and transparency on UE Liaison

and CRHTT spend and provision of services;

Changes to national datasets – MHSDS and ECDS; establishment of new national

statistics

CQUINs (Frequent attenders to A&E), CCG Quality Premium (out of area placements);

New payment models for UEC and MH – work in development;

NHS England assurance and performance functions

111

Crisis & acute now hard-wired and prioritised in many of

the national levers - this has not been the case until now

2. Crisis Resolution & Home

Treatment Teams

FYFV Deliverable: By 2020/21, NHS England should expand Crisis

Resolution and Home Treatment Teams (CRHTTs) across England to

ensure that:

- a 24/7 community-based mental health crisis response is

available in all areas

- these teams are adequately resourced to offer intensive home

treatment as an alternative to an acute inpatient admission.

Intensive home treatment:

• Short term intensive care spell: aims to transfer

patients according to an ongoing plan of care

• As many visits as necessary, 24/7, likely to

need visits of up to three times per day initially,

with frequency reducing as patient recovers

• Visit duration that meets the person’s needs

and allows for therapeutic care

• Multi-professional team approach with effective

handover (at a minimum, daily), which allows

case-load sharing and the offer of a range of

interventions

• Partnership working with other community services

to facilitate ongoing care

• Facilitate early discharge from inpatient settings.

• Subject to similar ‘bed management’ approaches

as inpatient care

113

CRHTTs – what are their key functions?

Community crisis assessment:

• Accessible 24/7

• Rapid assessment to the

community and people’s homes for

urgent and emergency referrals

• Gate-keeping function (managing

access to local acute inpatient beds)

• Initial treatment package (medical

and brief psychological intervention)

• Management of immediate risk

The UCL Core study has a 39 point

fidelity scale for teams to assess

themselves against

https://www.ucl.ac.uk/core-resource-pack/fidelity-scale

https://www.ucl.ac.uk/core-resource-pack/fidelity-scale

24/7 access to mental health crisis services

Timely assessment in an appropriate place

Avoids unnecessary admission when home treatment may be more suitable

Therapeutic care to support recovery: in people’s home environment, social triggers to

crisis, and barriers to independent living can be more visible, and therefore assessed and

acted upon in situ, providing potential for more sustainable coping skills - including for

instance family relationships, shopping, banking etc. As such, teams should be multi-

disciplinary, not just doctors, nurses but psychology, pharmacist, social work, OT input in the

skill mix

Usually people report a more positive experience of care than for inpatient care

Facilitate early discharge / supports people to go home on leave from the ward

Avoid A&E attendances, free up acute hospital liaison service for ward in-reach

When part of tight bed management process and acute care pathway, can help reduce out

of area placement

Where teams implemented with high fidelity, that incorporates gatekeeping and has 24-hour

community-facing provision have been associated with reduced admission rates with an

associated reduction in costs

Published evidence of impact (1) ; Evidence (2) ; Evidence (3) ; Evidence (4)

114

Benefits of CRHTTs when implemented in line with

evidence base

https://www.ncbi.nlm.nih.gov/pubmed/15994574



http://pb.rcpsych.org/content/33/1/17

http://eprints.lse.ac.uk/56773/1/Knapp_etal_Investing_in_recovery_2014.pdf

https://www.centreformentalhealth.org.uk/priorities-for-mental-health-economic-report

Response time targets

• 45.4 % have target to commence an assessment in under 4 hours

• 20.0 % have target to complete an assessment in under 4 hours

115

What do we know about CRHTTs – selected stats from

UCL survey, 2016 (1/2)

PR PSCSUANRNH

SANRH VCSAH

Adults 92.6 91.1 84.7 67.4 69.5

0102030405060708090

100

% t

eam

s

CRHTT 24/7 offers PR Phone referral

PSCSU

Phone Support to current CRHTT Service Users

ANRNHS

Assessment of New Referrals on NHS premises

ANRH

Assessment of new referrals at home

VCSAT

Visit current CRHTT Service users At Home

116

Eligible Referrer Adult CRHTTs n/N (%)

Psych Liaison 180/184 (97.8)

GPs 148/184 (80.4)

NHS 111 108/184 (58.7)

Police 132/184 (71.7)

Self referral (known patient)

127/184 (67.4)

Self-referral (new patient)

79/184 (42.9)

Staffing and caseloads

• 35.4 – mean caseload of CRHTTS

• Around 55-65% of teams have staffing: caseload ratio in line with 2000 policy

implementation guidance

What do we know about CRHTTs – selected stats from UCL

survey, 2016 (2/2)

117

Early considerations from the ERGs on quality benchmarks:

response times and interventions for emergency referrals

• 24/7 UEMHC/crisis lines - calls should be answered within a maximum of 2

minutes

• Within a maximum of 1 hour of contact, the urgent and emergency mental

health service should provide the person who contacted the service with an

update/feedback on care and support to be provided;

• Within 4 hours of a request for help, the person in crisis should have been

provided with an assessment and have an urgent and emergency mental

health care plan in place (the assessment should be biopsychosocial, but if

this is not possible, an initial face-face crisis assessment should be

undertaken as a minimum), and

- been accepted and scheduled for follow-up care by an appropriate

service (this could include support provided at home),

or

- been discharged because the crisis has resolved; or

- started an assessment under the Mental Health Act.

118

Early considerations from the ERGs on quality benchmarks:

response times and interventions for emergency referrals

• As well as the initial emergency response to a crisis within 4 hours, services

should ensure continuity of ongoing care outside of the 4-hour response

(this could include further assessment if necessary, for example to complete a

biopsychosocial assessment if this was not possible within 4 hours)

• Advice should be sought from an appropriately trained and competent mental

health professional immediately in the event of a mental health crisis. Each

professional should ensure that they:

• provide a kind, compassionate and empathetic response

• plan for the short-term safety of the person, if necessary

• undertake an initial risk assessment

• plan appropriate observations for both mental and physical health

• access any existing mental health Plan, where available

• notify the local authority if the person is an ‘at risk’ adult or older adult.

Profession Grade WTE

Consultant Psychiatrist Medic 2

Team Manager (CRHT & IRS) Band 7 1

Clinical Lead Band 7 1

Crisis Clinicians Band 6 20

Home Based Treatment Nurses Band 5 3

Support Workers Band 3 3

IRS Clinicians (Urgent telephone & face to face triage) Band 6 9

AHPs (pharmacists, social work, OT) Band 6 3

Call Handlers Band 3 11

Total 53 119

Example staffing from IRS & CRHT with high fidelity

• Funding uplift in CCG baselines secured over 4 years to support similar resourcing

everywhere! Spend / resourcing now being tracked nationally - £43m uplift in 2017/18

• Savings generated (e.g. reduced OAPs, ward closures) have been reinvested in CRHTTs

and community MH services where transformation has worked well

C £2.2m for initial response service, crisis response, HTT for c300,000 population

120

Case study: example staffing cover over 24/7 spell from a high performing

home treatment team (below does not include crisis assessment function)

• Bradford First Response service, Haven – whole system approach including acute,

community, social care and police services

• Cambridge & Peterborough has replicated Bradford crisis model, including Sanctuary -

mental health attendances at all three EDs in the area have reduced by 20%

• Sunderland Initial response service with big focus on reducing clinician admin including

digital dictation service that clinicians credit as key enabler of successful service

• Central and North West London NHS Foundation Trust: Westminster Older Adults

Integrated Community Mental Health and Home Treatment Team

• Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH): CRHTTs

• 2gether NHS Foundation Trust: Hereford Crisis Assessment and Home Treatment Team

121

Case studies: community urgent & emergency response and

HTTs

http://positivepracticemhdirectory.org/adults/bradford-airedale-whole-system-crisis-care-redesign/



http://positivepracticemhdirectory.org/adults/haven-crisis-service/

http://positivepracticemhdirectory.org/adults/cambridgeshire-peterborough-mh-uec-vanguard/

http://positivepracticemhdirectory.org/adults/self-help-sanctuary-24-hour-mental-health-crisis-support/

http://positivepracticemhdirectory.org/adults/initial-response-service-ntw/

http://positivepracticemhdirectory.org/nccmh/westminster-older-adults-integrated-community-mental-health-home-treatment-team-central-north-west-london-nhs-foundation-trust/



http://positivepracticemhdirectory.org/nccmh/crisis-resolution-treatment-teams-crhtts-rotherham-doncaster-south-humber-nhs-foundation-trust-rdash/

http://positivepracticemhdirectory.org/nccmh/hereford-crisis-assessment-home-treatment-team-2gether-nhs-foundation-trust/

Reporting requests submitted to NHSD, likely to include:

• No / rates of referrals to CRHTTs

• Response times from referral to contact by CRHTTs

• NICE-recommended interventions

• Total number / rates of ‘admissions’ (i.e. accepted referrals) for

home treatment

• For patients admitted to HTT number of care contacts broken

down by week in care episode (eg how many contacts in

week, 1,2,3,4 etc)

• Median duration of care contact by HTT

Regular (annual tbc) national survey of CRHTTs

122

Data: new national reports coming in 2017 for CRHTTs,

including response times - transparency at last!!

3. Acute mental health care, inc.

out of area placements FYFV Deliverables:

- the practice of sending people out of area for acute inpatient care

due to local acute bed pressures eliminated entirely by no later

than 2020/21

- standards for acute care introduced

- full response to the Independent Commission on Acute Adult

Psychiatric Care, established and supported by the Royal College

of Psychiatrists

124

Early considerations from acute care ERG – quality

benchmarks: time from referral to admission

• Any person requiring acute mental health care in an inpatient setting

should receive orientation onto the ward as well as verbal and written

information about who their named care team will be within 4 hours of

referral.

• Any person requiring acute mental health care in a community-based setting

should be accepted for care within 4 hours of referral and receive their

first face-to-face NICE Concordant treatment contact within 24 hours of

referral.

1. A comprehensive physical health assessment made within 24 hours of the start of treatment;

2. A care plan to be initiated within 72 hours of the start of treatment

3. A Care Act-compliant assessment to be completed within 72 hours of the start of treatment to identify any social care issues

4. The discharge destination to be considered within the first 72 hours of care for those who have housing needs

5. Access to daily meaningful and recovery-focused activities while receiving care

6. One-to-one face-to-face time with a care professional that the person knows, every day

7. Feedback on service experience to be sought to improve the delivery of care

8. Follow-up after discharge from an acute mental health inpatient setting to be made within 48 hours.

125

Early considerations from acute care ERG - what is NICE

recommended acute mental health care? (inpatient and community)

Inpatient activity – split by bed type for the first time:

For inpatient and HTT

• Referrals / referral rates

• Gatekeeping

• Admission / admission rates

• Readmission

• NICE-recommended interventions

• Average length of stay

• Follow up post-discharge

• Time from decision to admit to admission

Delayed Transfers of Care - by bed type

• With new categories for mental health

Out of area placements – MHSDS to replace special interim collection

• Numbers, bed days, reasons, distance, duration

Mental Health Act

• Including waiting times

126

Data: new national reports coming in 2017-2019 for acute care

127 www.england.nhs.uk

• In their reports published last year, both the Commission on Acute

Adult Psychiatric Care and the Mental Health Task Force called

for an end to the practice of sending acutely ill people long

distances for treatment, which leads to poor patient experience,

outcomes and unnecessary costs to the NHS.

• We have committed to eliminating the practice completely by

2021 for those requiring non-specialist acute care.

Eliminating acute mental health out of area placements (OAPs)

Broader impact:

OAPs are a sentinel indicator of

a mental health system under

pressure, not simply the result of

too few acute mental health beds

nationally. System-wide

solutions are therefore required

with a focus on alternatives to

admission, community mental

health services and interfaces

with key partners such as

housing and social care.


An OAP occurs when an adult assessed as requiring acute mental health inpatient

care, is admitted to a unit that does not form part of their usual local network of

mental health services. This includes inpatient units that:

• are not run by the person’s usual provider;

• are not intended to admit people living in the catchment of the person’s local

community mental health service;

• are located in a place where the person cannot be visited regularly by their care

coordinator to ensure continuity of care and effective discharge planning; or

• are located in a place where the person cannot be visited regularly by their

family, friends or support networks.

Given the varying sizes and geographical footprints of mental health providers, the

definition necessarily places the onus on local sending providers to determine

whether the placement is out of area, based on the key principles above.

Out of area placements: new national definition

This definition was developed following considerable engagement with commissioners, providers and users of mental health services.


OAP decision tree

1. ‘Internal’ OAPs – where the patient remains within their home organisation, but the location of the

receiving unit disrupts their continuity of care.

2. ‘External’ OAPs – where the sending organisation is paying another provider to care for their patient,

usually because they do not have an available bed.

Deciding whether an admission is an OAP

The patient is being admitted by their home provider to an inpatient unit that usually receives

admissions for people living in the catchment

area of the person’s CMHT

Not an OAP (Best

Practice)

The patient is being admitted to an inpatient unit within the person’s

home provider, but not in the catchment area of the

person’s CMHT

The patient’s care coordinator is able to visit them as often as stated in the Trust’s

policy for patients who are admitted locally AND

they can be visited regularly by their

friends, family, carers or support networks

Not an OAP (But not best

practice)

The patient’s care coordinator is not able

to visit them as often as stated in Trust’s policy for patients who are

admitted locally AND/ OR they cannot be

visited regularly by their friends, family, carers or

support networks

1. OAP

The patient is being admitted to an inpatient

unit in any provider other than their home provider. This includes

other NHS and independent sector

providers.

2. OAP


Out of area placements: new national definition

It is important that the decision to place someone out of area is documented at

the time of admission by the admissions team (e.g. CRHTTs who ‘gatekeep’

admissions). Their responsibility for assessing the person’s needs and their

involvement in the placement process means they are best able to decide whether the

placement is out of area in accordance with the definition. The information team within

your organisation should not be relied upon to identify which placements are out of

area based on retrospective analysis of notes or records.

Key Considerations when applying the definition locally:

Are you paying another provider to place your patient?

Is the person being placed outside the catchment area of their usual CMHT, or the

CMHT that serves their home area if they are not previously known to services?

Is the person’s care coordinator able to ensure continuity of care and effective

discharge planning and visit as often as stated in the Trust’s policy?

Can their friends/family/carers/support networks visit regularly - or is this made

difficult because the person is admitted too far away? We know that in more rural

areas some distances are unavoidable, but it’s important to apply local knowledge

and check that the person has been admitted to their most local unit.


Headline Data Q4 2016/17

Inappropriate

OAPs started in

period

Total no. of OAP

days over the

period

Total recorded

costs over the

period

No. of OAPs that

ended in the

period with a

length of 31 or

more nights (1)

No. of OAPs

active during the

period with a

distance of

100km or greater

Average

recorded daily

cost over the

period (2)

England 1,853 52,577 £18,792,900 316 790 £530

North 530 13,476 £2,466,090 90 115 £505

Mids & East

420 15,113 £6,298,090 90 345 £525

London 305 7,462 £3,847,700 40 25 £525

South 565 14,375 £5,582,340 85 250 £580

Unknown 30 2,145 £598,653 10 25 £530

• The regional data in this table for ‘Inappropriate OAPs started in period’ is subject to NHS Digital’s suppression rules -

counts have been rounded to the nearest five.

• (1) Only includes OAPs that ended during February and that started on or after the 17th October 2016. This means

that the current maximum duration for an OAP included in the March report is 166 nights. It is not yet known what

percentage of OAPs last longer than this, but it will become clearer collection runs for more time.

• (2) Recorded Cost – since January cost has only been recorded where a provider has been charged by a different

organisation for making the placement. (There are some scenarios where an OAP may take place within a provider

organisation where the provider covers a very large geographical patch). As such the costs reported for 2017 should

not be compared with those in 2016.


OAPs to NHS and Independent Sector Providers (Feb, Mar, Apr 2017)

• February’s report enabled us to clearly distinguish between OAPs to NHS and Independent Sector providers

(ISPs) for the first time.

• The table shows that almost two-thirds of all OAPs are to ISPs and that these placements account for 80% of

the total recorded costs. They also tend to have longer lengths of stay and require people to travel further from

their homes (6 times more likely to travel over 100km).

• We have requested that NHS Digital provide a further breakdown of the independent sector providers at

organisational level.

Receiving organisation

New OAPs received in period

Total number of OAP days over the period

Total recorded costs over the period

Number of OAPs that ended in the period with a length of 31 or more nights

Number of OAPs active during the period with a distance of 100km or greater

Feb Mar Apr Feb Mar Apr Feb Mar Apr Feb Mar Apr Feb Mar Apr

England 611 616 582 16,912 21,678 21,882 £5,763,700 £7,320,180 £7,704,460 96 120 108 271 313 283

NHS providers

221 202 209 5,739 7,277 7,372 £1,004,870 £1,259,680 £1,224,000 20 40 27 38 44 45

Private providers

390 414 373 11,173 14,401 14,510 £4,758,840 £6,060,500 £6,480,460 76 80 81 233 269 238


From the Q4 data (Jan-Mar 16/17), people from the North region spent 13,476 bed days out of area at a

cost of £2,466,090 (lowest cost across all regions, despite large geography).

Possible priority areas for improvement:

Greater Manchester STP, has the highest no. of OAP bed days of all STP areas.

Tees, Esk and Wear Valleys FT, Greater Manchester Mental Health FT and South West Yorkshire

Partnership FT reported the highest OAP bed days over the period across the North region. In these

cases, most people were remaining within the organisation, but the distance travelled to inpatient unit

disrupted their continuity of care.

A number of CRHTTs in Greater Manchester appear to be poorly resourced. This is also the case

for Lancashire Care NHS Foundation Trust, where CRHTTs aren’t able to visit people 24/7 and

reportedly spent more than £750K on OAPs during the quarter.

Positive:

Four Trusts in the North (Cheshire And Wirral FT, Rotherham Doncaster And South Humber FT,

Bradford District Care FT and Sheffield Health & Social Care FT) have reported no OAPs YTD.

Many of the CRHTTs across these Trusts deliver the key functions.

Northumberland Tyne and Wear FT has some of the best resourced CRHTTs in the country,

delivering the key functions.

Selected headlines – North Region

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?*

Can the CRHTT assess new referrals at home 24/7?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

Sou

ther

n H

ealt

h N

HS

Fou

nd

atio

n T

rust

Southampton Acute Mental Health Team

N Y N N 55 28.50 0.52

3020 £1,778,750 North Hants Acute Mental Health Team

Y Y Y Y 38 24.00 0.63

East Acute Mental Health Team

N N N N 70 25.70 0.37











Bra

dfo

rd D

istr

ict

Car

e N

HS

Fou

nd

atio

n T

rust

IHTT Airedale Y Y Y Y 80 16.50 0.21

* *

IHTT Bradford

Y Y Y Y 120 20.50 0.17











Do

nca

ster

Ro

ther

ham

an

d

Sou

th H

um

be

r N

hS

Fou

nd

atio

n T

rust

Doncaster Access Team

Y Y N Y 30 20.60 0.69 * *











Hu

mb

er N

HS

Fou

nd

atio

n T

rust

CRHTT (HULL?)

Y Y N Y 85 27.00 0.32

600 £240,668

East Riding of Yorkshire CRHTT

Y Y Y Y No data 21.60 No data











Leed

s an

d Y

ork

Par

tner

ship

Fo

un

dat

ion

Tru

st

South Intensive Community Service

N N N N 45 25.10 0.56

126 £61,321

West/North West Intensive Community Service (ICS)

N N N N 70 45.80 0.65











Lee

ds

and

Yo

rk P

artn

ers

hip

N

HS

Fou

nd

atio

n T

rust

East North East (ENE) Intensive Community Service

N Y N N 55 33.50 0.61 126 £61,321











Ro

the

rham

Do

nca

ster

an

d S

ou

th H

um

be

r N

HS

Fou

nd

atio

n T

rust

North Lincs Access Team

N Y N Y No data 26.00 No data

* *

Rotherham Access Team












Shef

fiel

d H

ealt

h a

nd

So

cial

Car

e N

HS

Tru

st

West HTT N Y N Y 27 13.20 0.49

* *

South West HTT

N Y N N 25 13.80 0.55

HTT Y N N Y 20 10.50 0.53

North HTT N N N Y 24 10.00 0.42











Sou

th W

est

York

shir

e P

artn

ersh

ip N

HS

Fou

nd

atio

n T

rust

Crisis / Home Based Treatment Team

Y N N Y No data 25.00 No data

4383 £351,009

Kirklees Intensive Home Based Treatment Team


Barnsley Intensive Home Based Treatment Team

Y Y Y Y 46 24.70 0.54











Tees

Esk

& W

ear

Val

ley

Fou

nd

atio

n T

rust

Harrogate N N Y N 20 18.50 0.93

2204 *

Hambleton & Richmondshire

Y Y Y Y 20 17.20 0.86

The Scarborough, Whitby, Ryedale

N Y Y Y 30 16.00 0.53

Hartlepool Y Y Y Y 18 18.00 1.00



Is there a 24/7 crisis line in this CRHTT area?








Tees

Esk

& W

ear

Val

ley

Fou

nd

atio

n T

rust

Stockton Y N Y Y 25 15.00 0.60

2204 *

Crisis & Access Service

Y Y Y Y 35 38.60 1.10

Middlesbrough Crisis Team

Y N Y Y 30 15.10 0.50

North Durham

Y N Y Y 29 9.00 0.31











Tees

Esk

& W

ear

Val

ley

Fou

nd

atio

n T

rust

South Durham and Darlington

Y Y Y Y 40 26.94 0.67 2204 *

146

Case study: Sheffield (1/2) – headlines

In 2011 bed occupancy 120%, 142 beds, almost 3000 bed days out of area

Wards now reduced in size, (69 beds) staffing has stayed the same, so patient-to-

staff ratios have improved, zero out of area .

Because of the reduction of wards, SHSC has been able to significantly reduce the

use of agency staff,

£2 million was invested in community services to ensure its sustainability. This

included investment in IHTTs and new services for people with highly complex

problems often associated with a diagnosis of personality disorder. In addition to

this reinvestment, cost savings of over £1.5 million were made

No increase in incidents, close monitoring of quality markers – which have improved.

147

Case study: Sheffield (2/2) – how did they do this?

Risk-sharing agreement between SHSC and the Sheffield CCG. SHSC took responsibility for the budget for out-of-area placements.

Efficiency programmes reduction in average length of stay from 56 to 31 days. Work focused on improving time spent with patients on the wards, discharge facilitators on every ward, planning for discharge on admission, particularly in relation to social factors and daily bed management meetings with consultants.

Quality initiatives : included: psychology posts on wards; reflective practice supervision for staff; reduction in seclusion and restraint; service user-led, all-staff training programme to improve the management of violence and aggression.

Bed management weekly bed-management meetings chaired by the clinical director, and including all consultants, ward managers, discharge coordinators, partner services (crisis house, respite provision, community teams). Meetings use live data and focus on patient flow.

Investment in intensive home treatment bed-management processes were applied to manage the flow of people. Fewer people accessing home treatment, smaller team caseloads but more intensive treatment for those in HTT.

Whole system approach - vital. Rethink crisis house and helpline, Wainwright Crescent respite and step-down beds; joined-up management/governance between inpatient and community services, live data showing flow across the whole system; and engagement with service users, carers and staff throughout.


Common themes from other areas that have / are

attempting to reduce out of area placements

Intensive focus on OAPs as a priority – agreement of system priority at all levels

• Agreement at all levels that OAPs are a priority

• Principle that bed / HTT must always be available where that is the right

choice

• Board-level responsibility

• Clinical and/or Service Director who is personally responsible

• Strengthened community services, savings reinvested back into MH

• Financial risk/benefit sharing agreement between providers and

commissioners

• Whole system coming together in partnership to redesign pathways and

agree processes – inpatient staff, CRHTTs , social care, AMHPs, CMHTs,

vol sector, patients, IAPT, primary care

• Intensive focus on flow, bed management

• Community and inpatient teams attend regular MDT discharge meetings

• Use of real time data, including info on bed availability, capacity of HTTs,

community alternatives (e.g. crisis houses)

• Info on patients who have passed discharge dates, reviews / new

discharge dates


Sheffield – blog from clinical lead, Dr Mike Hunter – now associate national clinical director at NHS

Improvement. Further detail can be found here.

North East London Foundation Trust – highlighted in RCPsych Commission on adult acute psychiatric

care (p27) – NELFT has eliminated out of area placements for many years, with one of the lowest bed

bases in the country - through investment in community services and intensive focus on acute pathway

management.

Leeds and York Partnership NHS FT: Efforts underway in ‘Leeds mental health flow’ project with write

up of the how the whole system is coming together to reduce out of area placements to save £1.5m for

the local health economy.

Bradford: adopted an approach with similar principles to Sheffield. Highlights include:

Vital partnership working with social care and local authority services to reduce delayed transfers of

care, mental health act detentions, admissions and recovery in the community – see next slide!

Whole system approach to eliminating out of area placements in Bradford.

Focus on acute inpatient ward flow, DTOCs, including a 10 point discharge tracker (below):

Further OAPs case studies and resources

https://www.england.nhs.uk/mental-health/case-studies/sheffield/

http://positivepracticemhdirectory.org/nccmh/sheffield-health-social-care-nhs-foundation-trust/

http://positivepracticemhdirectory.org/adults/north-east-london-nhs-foundation-trust/



http://media.wix.com/ugd/0e662e_aaca63ae4737410e9e2873dfde849841.pdf




https://www.leedsandyorkpft.nhs.uk/corporate/our-current-work/leeds-mental-health-flow/

https://www.centreformentalhealth.org.uk/social-care-and-the-mental-health-forward-view-ending-out-of-area-placements

http://positivepracticemhdirectory.org/nccmh/whole-system-acute-mental-health-services-bradford-district-care-nhs-foundation-trust/

https://www.england.nhs.uk/mental-health/case-studies/mh-bradford/


Take a look at Mark Trewin’s (Mental Health, Service Manager at Bradford Council and

Social Care Advisor to the NHSE Adult Mental Health Team) blog on the importance of

partnership working with social care and local authority services to reduce DToC, MHA

detentions, admissions, OAPs and support recovery in the community.

In Bradford, social care is integrated across a range of acute and community mental

health services and people are supported at home wherever possible using collaborative

work between health, social care and voluntary services to achieve the least restrictive

and most appropriate care through a single point of access.

Mental health social workers are based or involved in: The 24/7 First Response crisis

service ; The Haven (non-clinical community alternative to A&E); the Intensive Home

Treatment (IHT) team; the Police Hub; the AMHP service; Specialist housing social

worker; Community mental health teams, Early Intervention teams, Assertive Outreach

teams and community support services; Supported Accommodation. There are also joint

commissioning arrangements in place and increasingly joint decisions are being made

between NHS and LAs around funding (e.g. s117).

Key advice for any CCG, Trust or LA struggling with OAPs or private sector bed usage -

join together all NHS, local authority, VCS, police, housing and service user groups, and

review how integrated working and joint commissioning together might change the way that

people are cared for locally.

Role of social care and the voluntary sector in managing

the acute MH system

https://www.centreformentalhealth.org.uk/social-care-and-the-mental-health-forward-view-ending-out-of-area-placements-

https://www.centreformentalhealth.org.uk/social-care-and-the-mental-health-forward-view-ending-out-of-area-placements-


East London NHS Foundation Trust Tower Hamlets acute mental health service

Camden and Islington NHS FT, Drayton Park Women’s Crisis House

Mersey Care NHS FT has introduced No Force First, an award-winning restraint

reduction initiative.

South London and Maudsley NHS FT Gresham Unit Carers’ initiative

Addressing inequalities in acute mental health

Resources from Joint Commissioning Panel on mental health for people from:

• BAME backgrounds,

• older people

• learning disabilities

• physical health needs

Case study: African Caribbean Community Initiative, Wolverhampton

Further positive practice case studies: acute care

http://positivepracticemhdirectory.org/nccmh/tower-hamlets-adult-mental-health-east-london-nhs-foundation-trust/

http://positivepracticemhdirectory.org/nccmh/drayton-park-womens-crisis-house-camden-islington-nhs-foundation-trust/

http://positivepracticemhdirectory.org/nccmh/drayton-park-womens-crisis-house-camden-islington-nhs-foundation-trust/

http://positivepracticemhdirectory.org/nccmh/no-force-first-mersey-care-nhs-foundation-trust/

http://positivepracticemhdirectory.org/nccmh/gresham-unit-south-london-maudsley-nhs-foundation-trust/

http://www.jcpmh.info/wp-content/uploads/jcpmh-bme-guide.pdf

http://www.jcpmh.info/wp-content/uploads/jcpmh-bme-guide.pdf

http://www.jcpmh.info/wp-content/uploads/jcpmh-olderpeople-guide.pdf

http://www.jcpmh.info/wp-content/uploads/jcpmh-learningdisabilities-guide.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/11/cquin-2017-19-guidance.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/11/cquin-2017-19-guidance.pdf

http://positivepracticemhdirectory.org/nccmh/african-caribbean-community-initiative-wolverhampton/


Cheshire and Wirral Partnership NHS Foundation Trust, Complex Recovery

Assessment and Consultation service that has contributed to the elimination of out of

area placements

Cornwall Partnership NHS FT, Fettle House rehabilitation service

Northumberland Tyne & Wear NHS FT Rehabilitation and Recovery Services

Mental health supported housing examples

St Martin of Tours Housing Association, Islington

Living Well, South Yorkshire Housing Association

Mental health rehabilitation service examples

http://positivepracticemhdirectory.org/nccmh/complex-recovery-assessment-consultation-cheshire-wirral-partnership-nhs-foundation-trust/

http://positivepracticemhdirectory.org/nccmh/complex-recovery-assessment-consultation-cheshire-wirral-partnership-nhs-foundation-trust/

http://positivepracticemhdirectory.org/nccmh/fettle-house-cornwall-partnership-nhs-foundation-trust/

http://positivepracticemhdirectory.org/nccmh/rehabilitation-recovery-services-northumberland-tyne-wear-nhs-foundation-trust/

http://positivepracticemhdirectory.org/nccmh/st-martin-tours-housing-association-islington/

http://positivepracticemhdirectory.org/nccmh/living-well-south-yorkshire-housing-associatiobn/


3. Acute Hospital Urgent &

Emergency Liaison Mental Health FYFV Deliverables:

- introduce access and quality standards for crisis care

- 50% of acute hospitals at core 24 standard for adults by

2020/21


Proven clinical benefits: NICE-recommended care, expert, compassionate response,

better patient experience, care planning and links to community mental health services,

identify and treat (many) underlying mental health needs of physical health

presentations in acute hospitals

Proven financial / productivity benefits: reduced length of stay, reduced emergency

admissions via A&E, reduced A&E re-attendance rates

Core 24 acute hospital urgent & emergency liaison

mental health: the basics

National definition of ‘Core 24’ – minimum ambition for all acute hospitals with 24/7 A&E

departments:

24/7 hours of operation;

1hr response times to emergency referrals from ED, 24hr response to urgent ward

referrals;

Staffed in line with or close to recommended levels to cover 24/7 rota, including

access to older adult expertise;

Funded recurrently – this is now a minimum, no longer a ‘pilot’ service.


Liaison MH teams need to be close to or in the ED to achieve response times;

Much of their daily work should be in acute hospital wards;

Liaison MH is about much more than just urgent & emergency response – it is

about working alongside physical health pathways;

‘In-reach’ to acute hospitals from community crisis teams is not the same thing

as acute hospital liaison MH;

People should not need to be ‘medically cleared’ before referrals to liaison MH

teams – they are trained and expert in working alongside physical health

pathways;

On-site services help build relationships between liaison MH teams, ED staff

and other physical health pathways in the acute hospital as well as making it

easier to share IT systems, records, governance;

Busy crisis teams having to provide U&E MH care to acute hospitals is likely to

detract from their complementary core function to provide community crisis

response.

Importance of core 24 liaison as an on-site, distinct

specialty 1/2


Where local demand justifies a 24/7 A&E at an acute hospital, it therefore justifies a 24/7 expert

mental health response;

~5% of attendances for mental health as primary reason for attendance, many more will have

underlying MH needs. Estimated 75% of the most frequent attenders have secondary MH

needs;

Repeated evidence to show that there is high demand ‘out of hours’:

o most MH ED attendances between 5pm and midnight (Royal College of Emergency

Medicine);

o most mental health admissions via EDs are between 10pm and 7am (CQC);

o many 24/7 liaison services from rural and urban geographies have data about demand in

these hours.

Cannot meet response times if not 24/7;

Where services are not 24/7, it often results in backlogs and a mass of referrals when service

opens at 8/9am, with knock-on impacts to the service, 4hr A&E breaches;

Many testimonies about benefits of becoming 24/7 once it has happened – recently

Northumbria HCFT credited decision to move to 24/7 as one of key factors in ‘Outstanding’

CQC rating for hospital;

Does not necessarily need to be a full service – staff rotas can be flexed for times of lower

demand – e.g. 2:3:2 rota.

Importance of core 24 liaison as an on-site, distinct

specialty 2/2


London

Areas that have successfully bid in

Wave 1 to meet core 24 liaison

services by the end of 2017/18*

Areas that currently have access to

core 24 liaison services’

Areas that have successfully bid in

Wave 1 to meet core 24 liaison

services by the end of 2018/19*

Areas with liaison services that are

not yet at core 24 service level

*at the time of publication,

funding awards are

provisional

Wave 1 bidding process now

complete:

- 17 hospitals already at Core

24 (10%)

- £30m funding to 74 acute

hospital sites to achieve

‘Core 24’ from 2017-2019

- By 2019 – 81 aim to have

achieved Core 24 standard

Wave 1 transformation funding

for Core 24 U&E Liaison MH


Within a maximum of 1 hour of a liaison mental health service receiving an

emergency referral, any person experiencing a mental health crisis receives a

response from the liaison team (aka an ‘urgent and emergency mental health service’)

Response within 24 hours for urgent referrals from wards

Within four hours (NB works within existing 4hr A&E standard) from arriving at

ED/being referred from an acute general hospital ward, I should:

o have received a full biopsychosocial assessment and jointly created an urgent

and emergency care plan, or an assessment under the Mental Health Act should

have started;

o have been accepted and scheduled for follow-up care by a responding service;

o be en route to next location if geographically different; or

o have been discharged because the crisis has resolved.

Quality as important in terms of delivering evidence-based NICE-concordant care &

outcomes measurement

NHSE, NICE, NCCMH implementation guidance and helpful resources (right click to

open hyperlinks)

National quality benchmarks for urgent and emergency liaison

mental health – recommended response times and interventions

https://www.england.nhs.uk/wp-content/uploads/2016/11/lmhs-guidance.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/11/lmhs-helpful-resources.pdf


Outcome measurement tools

• Clinician reported outcome

measure - taken from RCPsych’s

FROM-LP: framework for routine

measurement of liaison psychiatry

• Patient reported experience

measure : taken from NICE

service user experience guideline

e.g. “During the treatment for my

crisis, I was treated with empathy,

dignity and respect.”

• If you score high on this PREM ,

you are delivering NICE-

recommended urgent &

emergency mental health care!

https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwjqm5XQ77XTAhURJ1AKHSQnBr8QFgguMAA&url=https://www.rcpsych.ac.uk/pdf/FRLP02.pdf&usg=AFQjCNF4UYrxcUrsAwwzs2NCXCGQXb36Lg&sig2=0-HeorsfQUmOY7AEUA3YjA

https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwjqm5XQ77XTAhURJ1AKHSQnBr8QFgguMAA&url=https://www.rcpsych.ac.uk/pdf/FRLP02.pdf&usg=AFQjCNF4UYrxcUrsAwwzs2NCXCGQXb36Lg&sig2=0-HeorsfQUmOY7AEUA3YjA


Requests submitted to NHS Digital for reports from MHSDS*, likely from this

financial year

Routine published reports likely to include a number of data items, including:

-Referrals,

-Response times

-Interventions

-Repeat referrals

*ECDS likely to be able to measure fuller pathways and from arrival at ED –

discharge

Data: new national reports coming in 2017 for U&E liaison

MH, including response times - transparency at last!!


4. Mental Health Act FYFV Deliverables:

- specific action should be taken to substantially reduce

Mental Health Act detentions and targeted work should

be undertaken to reduce the current significant

overrepresentation of BAME and any other

disadvantaged groups within detention rates

- police cells will be used only

in exceptional circumstances for people detained

under the Mental Health Act


What are recent trends in the SE in terms of overall uses of the MHA, and how is

this monitored by commissioners and providers? How is adherence to the MHA Code

of Practice monitored?

Are there particular issues in terms of demographics, diagnoses, ethnicity etc?

Is there a way to monitor repeat detentions of the same individual on a local footprint?

S135/6: what are recent trends in use of police cells vs use of HBPoS in the SE

police force areas? Is the overall use of s136 increasing in the SE?

S135/6: are partners aware of the new Policing & Crime Act 2017 amendments to the

MHA (implementation subject to the will of a new govt) and are CCGs ensuring NHS

system readiness? Changes include, e.g.

o Clarifying where s136 can be used;

o A requirement on police officers to consult with MH practitioners where practicable

before exercising a section 136 power;

o Reducing the maximum length of detention from 72 to 24 hours; and

o Prohibiting the use of police cells as places of safety for under 18 year olds and

significantly restricting their use in the case of adults.

Mental Health Act, including section 136

For further info see http://qna.files.parliament.uk/qna-attachments/714126/original/PQ69287%20attached%20letter.pdf

http://qna.files.parliament.uk/qna-attachments/714126/original/PQ69287 attached letter.pdf



www.england.nhs.uk

5. Community MH services FYFV Deliverables:

- various, including:

EIP

Physical health for people with SMI

Employment support for people with SMI


EIP: major programme already in full delivery phase

Improving physical health for people with SMI:

Guidance for CCGs in development

PH SMI CQUIN results for 16/17 to be published

Employment support (IPS) for people with SMI: baseline

audit results to be discussed in regional workshops, along with

next steps

Community mental health services: baseline audit in scoping

phase; scoping work with NCCMH also ongoing

Improving access to psychological therapies for SMI: work

also in scoping phase

Community MH services – not to be forgotten…

www.england.nhs.uk

Community MH Care

IAPT

Crisis Care

Acute Care

Rehab Care

Secure Care

Primary

Care

Recognition

& referral

PC treatment

Primary Care

Physical health, dental health

Primary

Care

Step-down

care

Sustaining

recovery

So

c C

are

+ H

ou

sin

g +

SM

S +

Vo

l S

ecto

r +

Leis

ure

So

c C

are

+ H

ou

sin

g +

SM

S +

Vo

l Secto

r + L

eis

ure

Social Care + Housing + SMS + Vol Sector + Leisure

Social Care + Housing + SMS + Vol Sector + Leisure

…. thank you and questions

Ruth Davies

Project Manager, Crisis & Acute Mental Health

Twitter: @RuthDaviesMH


Viral Kantaria

Programme Manager, Adult Mental Health Care

Twitter: @ViralKMH




www.england.nhs.uk

Group discussion 2: How can we improve acute care?






www.england.nhs.uk

The economic evidence on

recovery: employment, housing

and welfare advice

Andy Bell, Deputy Chief Executive, Centre

for Mental Health

The importance of recovery: employment, housing and welfare Andy Bell, 11 July 2017

Employment

At least 1m people out of work due to mental ill health

About 7% of people using mental health services are in employment

More than half would like to work

Work is a key part of recovery for many people

Individual Placement and Support

‘Place then train’ approach to employment support

17 international trials show 50-60% of participants achieve work outcomes

Higher rates of job retention than traditional vocational services

IPS principles

No exclusions

No compulsion

Rapid, assertive job search based on preference

Co-located with health support

Benefits advice

Time unlimited support in work

Current provision of IPS

Half of mental health service users want help with employment

About half of them are receiving any (CQC annual survey)

IPS currently offered by about half of NHS mental health trusts

Estimated 10,000-20,000 places each year

Economic evidence for IPS

Cost per person £2,700 a year (one off)

Reduced use of health services generates savings of at least £3,000 a year (recurring)

Extending provision of IPS

Economic and human case

‘Centres of excellence’

Fidelity reviews

‘Regional trainers’

Skills training

Extending to prisons, primary care, veterans and addiction services

Housing and mental health

80% of people with severe mental illness live in mainstream housing

35% of people on CPA do not have settled accommodation

Housing difficulties can be a major trigger for relapse of psychosis

Supported housing

Covers a wide range of housing types and forms of support, eg:

Crisis houses (to prevent admissions)

Step-down/transitional housing (eg from secure care or long-stay inpatient services)

‘Floating support’ in people’s own homes

Evidence of what works

Settled accommodation is an important part of recovery

Supported housing is preferred to sheltered accommodation

Preferences of service users (eg for autonomy) can be at odds with those of staff and carers (eg for safety)

Homelessness

62% of homeless people have a mental health condition

Homelessness 2.8 times more common among people with mental health problems

Homelessness a major barrier to getting work, eg for people leaving prison

Housing First has potential to offer better outcomes for same cost

Welfare advice

Multiple welfare rights issues affect people with severe mental illness

Sheffield CAB service located within (and funded by) mental health trust:

Cost per client £260

Cost of hospital admission £330 per day

Cost of a relapse of psychosis £18,000

Thank you

For more information:

[email protected]

@CentreforMH @MH_Challenge @Andy__Bell__

www.centreformentalhealth.org.uk

www.england.nhs.uk

Time for a break?

15 minutes only please!

www.england.nhs.uk

The value of welfare advice

Clare Lodder and Liz Skinner,

Citizens Advice, Sheffield

How we help

people – The

Value of Welfare

Advice

www.england.nhs.uk

Group discussion 3:

Supporting recovery for all






www.england.nhs.uk

Reflections and Final Thoughts

Andy Bell, Deputy Chief Executive, Centre

for Mental Health

www.england.nhs.uk

Thank you for Attending!

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evaluation forms!

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