A review of dementia and acute care mental health services in Bolton

Transcription

1 Tony Ryan Associates A review of dementia and acute care mental health services in Bolton Dr Tony Ryan and Paul Rooney December 2011

2 Contents Executive summary 4 Background 13 Scope of the review 13 Objectives 14 Process for the review 14 A review of dementia services in Bolton 15 Introduction 16 Key themes 16 Developmental issues and recommendations 27 Conclusions and next steps 34 Appendix 1 Policy background and key documents 35 A review of acute care mental health services in Bolton 39 Acute care 40 Key themes 44 Current pattern of acute care delivery 47 Review findings 53 Developmental issues and recommendations 54 Conclusions and next steps 65 Acknowledgements 67 Appendix 2 Policy background and key documents 68 Appendix 3 Data analysis 70 Appendix 4 Notional Acute Care Pathway 89 Appendix 5 Recommendations of the Academy of the 91 Royal Colleges Appendix 6 About the reviewers 93 Appendix 7 Contact details 94 "

3 It will be equally important that, as more decision making is taken locally to reflect the needs of patients and the clinicians who support them, the NHS does more to integrate service delivery, not only across primary and secondary care between mental and physical health but also with social care organisations. NHS Operating Framework, 2012/13 #

4 Executive summary NHS Bolton and Bolton Council commissioned an independent review of dementia services and functional mental health services in Bolton. This work was undertaken by Tony Ryan Associates; Dr Tony Ryan undertook both elements of the review and was joined for the functional services review by Paul Rooney. The review was undertaken between June and November The areas covered by the review have been: Secondary care services for people with mental health problems (functional illness and dementia) including in-patient and community services. The developing integrated (health and social care) Community Dementia Service and how this inter-relates with the wider social care environment in the independent and voluntary sectors. 24/7 access to mental health services for both urgent and non-urgent needs. Examining the access to acute care services for people of 16 years and upwards. In addition we have commented upon the location of the Psychological Therapies Service within the service system in Bolton. Whilst this was not part of our original remit it would be remiss of us not to highlight risks that appear to be present in respect of the care pathway between this service and the secondary care mental health services. In undertaking this review we have spoken to people who use, or have used, the dementia and mental health services in Bolton, carers, front line clinicians and practitioners, service managers, senior managers, commissioners and politicians from a wide range of statutory and non-statutory organisations. We have analysed data on service usage and considered documentation provided about the services and how they operate. The critical factor to future development of dementia and mental health services in Bolton will be two Stakeholder Boards: one for dementia and one for mental health. These have been agreed between participants in this review as high-level strategic Boards that will oversee the dementia and mental health agendas set out in this report, and also other issues that lie outside the remit of this report. The Stakeholder Boards will consist of Board Level personnel from NHS Bolton, Bolton Clinical Commissioning Group, Bolton Council, Greater Manchester West NHS Foundation Trust and Bolton NHS Foundation Trust. These Boards will report directly to the Bolton Health and Wellbeing Board and will feature as a standing item on its agenda. The Terms of Reference for the Stakeholder Boards will be signed off at the Health and Wellbeing Board. In respect of the dementia services in Bolton 13 areas were highlighted for development in one way or another and recommendations are made in respect of these areas. (1) Recommendations on support for carers The development of support to carers in Bolton should be seen as a major area of priority. $

5 All future service developments and service changes should consider the question how does this help carers to support people with dementia? Carers should be actively engaged in service development across Bolton. Carers and people with dementia should be represented on the Dementia Stakeholder Board. (2) Recommendations on whole system working Any opportunity for cross agency / cross organisation working should be maximised, particularly joint training and developmental opportunities. A cross agency strategy for education and staff development should be established. Discussions are required between GMWFT and primary care practices (with the support of the PCT and CCG) to facilitate access to space to deliver services in primary care settings. A plan to improve data intelligence on the prevalence and needs of people with dementia and their carers should be agreed between key stakeholders. Commissioners should consider agreeing to a pooled budget for dementia, in order to have greater future flexibility in respect of how monies are spent. (3) Recommendation on reduced dementia assessment in-patent beds in GMWFT An Impact Assessment should be undertaken at a point agreed by the Dementia Stakeholder Board on the effects of the planned reduction in dementia assessment beds in Bolton. (4) Recommendations on Firwood The role and function of Firwood requires urgent agreement between the key stakeholders, and should be considered in the context of the wider service system. The future service should operate within a single line management structure, operating to single policies and procedures and a single system of case recording. Commissioners should give consideration to the future service being commissioned using a single joint budget. Equal and consistent financial access to services in Firwood should be implemented as soon as possible. (5) Recommendations on care and nursing homes The Bolton Council Provider Framework should be used to drive up standards of %

6 care for people with dementia in care and nursing homes by regularly reviewing expectations of providers on the Framework. Bolton Council and other key stakeholders should consider developing a market management strategy that encourages providers in Bolton to develop services based on local need. Intelligence on the prevalence of dementia in care and nursing homes should be gathered in a consistent manner, in order to inform future service planning. Support from general practice to care and nursing homes should be reviewed and Local Enhanced Services implemented, where appropriate, in order to better support people with dementia. (6) Recommendations on home support Agreement should be reached between home support providers and BFT and GMWFT in relation to implementing minimum standards of communication about service user needs when moving home. Commissioners should consider the opportunity to develop night-time home support services. A system needs to be agreed whereby providers can communicate more effectively in an increasingly fragmented provider market. (7) Recommendations on Memory Assessment Service The Bolton Memory Assessment Service should be established as soon as possible. Consideration should be given to Firwood providing the main base for the service. (8) Recommendations on BFT beds and liaison The Dementia Stakeholder Board should agree a strategy to develop a liaison service akin to the Birmingham RAID model that meets the needs of people with dementia, substance misuse, alcohol misuse, and mental health needs in the A&E Department at Bolton and also on the BFT in-patient wards. The impact of reduced dementia assessment beds in GMWFT need to be monitored through an Impact Assessment to identify any unintended consequences for BFT in-patient services. (9) Recommendations on supporting primary care Good practice established in respect of screening, assessing and dementia registers should be rolled out across all GP practices in Bolton. &

7 The Working Group on the use of anti-psychotic medication for people with dementia should have active GP representation. A strategy to develop primary care professionals in respect of dementia should be agreed at the Dementia Stakeholder Board. Guidelines should be agreed between primary and secondary care professionals about the most effective and efficient way to utilise each other s expertise and advice. There needs to be clarity and agreement about the strategic intentions for property management across the Bolton health and social care economy, and how this can support capacity and capability-building in primary care. (10) Recommendations on end of life care A time-limited Task and Finish Group should be set up to review and agree how to ensure end of life care for people with dementia maximises the resources and expertise that exists across the service system. (11) Recommendations on BME and other minority groups BME services should be fully engaged in all service development in Bolton. Health promotion and anti-stigma initiatives in Bolton should involve BME and other minority groups in their design and implementation. (12) Recommendations on vascular dementia Clear literature to support carers and people with vascular dementia should be available that informs people about (i) the condition and (ii) support mechanisms available during the course of life with the condition. The Memory Assessment Service should develop guidance about how people diagnosed with vascular dementia are linked into other forms of support after discharge from secondary care services. Integrated working between GMWFT and BFT should be explored for areas such as stroke assessment and vascular clinics. (13) Recommendations on early onset dementia A time-limited Task and Finish Group should consider the current situation in Bolton with regards to the identification and support available to people with early onset dementia and their carers. '

8 In relation to the functional mental health services 14 areas were highlighted for development and associated recommendations in connection with these are provided below. (1) Recommendations on defining the model of care and redesigning the care pathway services to deliver that model A high-level Task and Finish Project Group should be established to determine the model of care and preferred service structure. The focus of this work should include: A clear definition for acute care Reducing health inequalities Risk management rather than risk aversion ( risk dumping ) Clearly defined thresholds for access to service components Secondary care SPoA Referral and management arrangements between primary and secondary care This work should be time limited and the resulting model should be signed off by the Mental Health Stakeholder Board (2) Recommendations on access and triage There should be a single point of access at the point of referral to secondary mental health care, and it should be managed by GMWFT. There should be better alignment of the current CMHT and CRHT triage, assessment and urgent care arrangements, with the introduction of a common point of access/referral and triage and duty system. This could be provided by a duty system, comprised of a rota of senior experienced clinical staff to ensure expert triage and a prompt response to urgent /acute care referrals. The CRHT should gate-keep access to in-patient beds on a face-to-face basis. Consideration should be given to developing an out of hours duty night assessor service (delivered outside any A&E Liaison Service). Current multiple referral routes into the service should be addressed and streamlined. (3) Recommendations on primary care/secondary care interface There is a need to achieve a consensus view regarding thresholds for access to secondary and primary care services. These should be agreed between primary and secondary care. People on the secondary care caseload who experience stable long term mental health problems should be transferred to primary care services with (

9 arrangements for prompt access to re-engage the mental health service if required e.g. the Somerset Orange Card system1. There should be an agreed joint approach between primary and secondary care to respond to disagreements about referrals. There is a need to agree a shared approach to arbitration with GPs about referrals that are received from primary care and that are deemed inappropriate. Clear standards on providing prompt feedback to referring GPs should be developed; this could build upon local pilot work in this area by one consultant. (4) Recommendations on acute care service capacity CRHT service should be enabled to effectively gatekeep all admissions face-toface, and should have the capacity to provide home treatment to all potential admissions who would benefit. Consider additional resourcing of CRHT function to maximise its capacity to provide home treatment for service users who are currently admitted/readmitted. Planned levels of in-patient provision are adequate but should be kept under regular review in the light of improved community acute care pathway performance. With effective whole system working there should be future opportunities to improve the nurse / service user ratios through reducing beds. Further analysis should be undertaken of the data that is available for people who have regular repeat and lengthy admissions, in order better to understand this service user group and to develop strategies to reduce their dependence on in-patient provision. Consider further development of crisis/respite house provision as alternatives to in-patient admission, for example for those with a personality disorder diagnosis. There is currently only one bed that serves as a crisis bed in the community. (5) Recommendations on A&E liaison service A dedicated service is required in line with the recommendations of the Academy of the Royal Colleges report (2008) (see Appendix 5 for recommendations from this report). We recommend the development of a mental health A&E liaison is prioritised and explicitly recognised as a core component of both the mental health and the general hospital care pathways. There is a pressing need to expedite the development of this service. (6) Recommendations on the balance of care pathway services and care pathway management arrangements 1 _co.aspx )

10 The sector consultant psychiatrists and their outpatient clinics should be based in the community, along with their clinical teams. The Trust should consider the strengths and weaknesses of continuing to have separate management arrangements for hospital and community services (i.e. hospital service managers and community team managers, as opposed to sector managers with some in-patient beds). The Trust should also consider the advantages and disadvantages of developing dedicated acute care lead consultant arrangements as emerged from New Ways of Working2. This often takes the form of having consultant psychiatrists who specialise in acute care (in-patient and CRHT) along with other colleagues who operate in non-acute community teams. (7) Recommendations on review and discharge arrangements Daily Acute Care Team meetings should take place to review the current acute care caseload (in-patients and CRHT). This group should have the power to discharge/transfer service users. Use of teleconferencing should be considered to support this, if required. Consider new ways of working and roles to bridge hospital / community gap, including rotational posts. (8) Recommendation on care coordinator involvement We recommend standards are set to ensure minimum levels of care coordinator contact with service users and in-patients staff, these should include: o The care co-ordinator will continue to provide face-to-face contact with the service user for a minimum of x times per week. o The care co-ordinator will review the service user s progress with the service user s key worker/named nurse at least weekly, to co-ordinate care planning and resolution of any issues that may delay discharge. o The care co-ordinator will meet with the key worker/named nurse and service user for a pre-discharge meeting within one week of the discharge date. o Where there is no existing care co-ordinator for an acute care service user, one is appointed by the respective team manager within x days. A system of auditing the contact of CPA care coordinators with their service users whilst they are in-patients should be implemented. (NB = x to be agreed) ",--./ , :;5<=7>:3,04957.=03,:3?4?-@A@==B-=0C3,0CB<035;7>B<-=03?4?-@ A@==B-03,:$*""#$#2.3D *+

11 (9) Recommendations on service for people diagnosed with personality disorders (PD) An options paper should be produced to develop greater clarity on how best to develop targeted provision to meet the needs of people diagnosed with personality disorders, including their needs for in-patient care. Development of alternatives to traditional in-patient admission and/or development of crisis/respite house provision, to include a more specific and specialist personality disorder component. (10) Recommendations on in-patient service GMWFT should consider the merits of developing a specific focus on relapse prevention, with particular attention paid initially to in-patients with high readmission rates. Identify people who have repeat admissions and establish a targeted recovery programme for these service users that could commence on the ward and continue in the community after discharge. GMWFT should consider how dual diagnosis expertise within Bolton could support such a recovery programme. Health and social care commissioners should review arrangements for access to supported accommodation care packages for those at risk of becoming long stay in-patients, and reconsider the high number of in-patients being discharged to temporary accommodation. Assess whether the current separate arrangements and interface for dual diagnosis/drug and alcohol services needs revisiting, in order to ensure consensus on thresholds for referral and admission. (11) Recommendations on the community and voluntary sector Ensure the active participation of service users and carers in taking forward this review, and in the planning and development of future services. Pay particular attention to how best to involve those from black and minority ethnic communities. Work with local voluntary organisations to develop practical links, such as CPN advice sessions. (12) Recommendations on improving acute care access for young people An audit of transfer arrangements for people moving from the Early Intervention team into the CMHTs could usefully clarify any transition problems and inform future solutions. **

12 Consider further alternatives to acute hospital admission for young people in crisis between commissioners, providers and other stakeholders, including access to the CRHT for people between 16 and 18 years of age. A review of the needs of young people who are placed out of area could usefully take place to determine how alternatives to hospital might be developed locally. (13) Recommendations on improving communications Establish regular forums to discuss and review care pathway working. At a strategic level there needs to be a forum where people working in the acute care pathway, and closely connected to it, can regularly reflect on and review how it is operating, and recommend changes to the system and ways of improving effectiveness and efficiency. (14) Recommendation the role and location of the Psychological Therapies Service In order successfully to manage the variations in thresholds between primary and secondary care, mental health services and the associated risk the Psychological Therapies Service commissioners should consider how this service could be delivered through GMWFT. *"

13 A review of dementia and acute mental health care services in Bolton 1 Background NHS Bolton (on behalf of the Bolton Health Consortia the Clinical Commissioning Group) and Bolton Council jointly commission the majority of the adult integrated mental health acute care services from Greater Manchester West NHS Foundation Trust (GMWFT). There are agreed service specifications for all elements of service and these are embodied as part of the new standard mental health contract, which runs till 31 March Acute care services in this context include in-patient wards, psychiatric intensive care beds (PICU) and the outpatient clinics. NHS Bolton also commissions secondary care community services including the Crisis and Home Treatment Team, Community Mental Health Teams (CMHTs), Assertive Outreach Team (AOT), and the Psychological Therapies and Early Intervention Team (EIT). The primary care Psychological Therapy service is delivered through the Bolton NHS Foundation Trust. In relation to acute functional mental health care, commissioners in Bolton (NHS Bolton and Bolton Council) are keen to understand how the acute care pathway functions, how entry and exit occurs, who uses these services, and ways in which they can be developed to improve quality, effectiveness and efficiency. NHS Bolton and Bolton Council also commission mental health and social care services for adults with dementia. As part of their response to the National Dementia Strategy NHS Bolton, the GP Consortia and Bolton Council are keen to develop a model for future services that best fits the needs the local population (as defined by detailed needs assessments and the Joint Strategic needs assessment) and which will do so in the future as demand for services increases and changes. Within this there is a requirement to determine the number of inpatient beds required as well as the capacity/size of community teams as part of integrated care pathways, which will also include support needs of general hospital acute sector and how mental health services can offer support. The independent sector will also be factored into this review in relation to its role as part of the dementia care pathways. This review has been resourced primarily by the Greater Manchester Mental Health Network in addition to NHS Bolton and sponsored by the Bolton Health and Wellbeing Board. It has been commissioned by NHS Bolton as a project undertaken in partnership between NHS Bolton, Bolton Council, Bolton Health Consortia, GMWFT, Bolton Hospital NHS Foundation Trust (BFT) and other key stakeholders. Ongoing governance for the review has been provided through the Integrated Mental Health Steering Group (IMHSG). There has also been governance through the Integrated Mental Health Implementation Group and a Task and Finish Group, the latter was established to ensure the review was undertaken smoothly and has reported to the IMHSG as necessary. 2 Scope of the review The areas for the review have been: Secondary care services for people with mental health problems (functional illness and dementia) including in-patient and community services. *#

14 The developing integrated (health and social care) Community Dementia Service and how this inter-relates with the wider social care environment in the independent and voluntary sectors. 24/7 access to mental health services for both urgent and non-urgent needs. Examining the access to acute care services for people of 16 years and upwards. 3 Objectives There are five key objectives for the review: 1. To define the acute care pathway for people with acute care mental health needs (functional and organic) including the age range for service eligibility. 2. To determine the number of adult acute beds required for the population of Bolton and the impact on the community teams. 3. To make related recommendations for future commissioning requirements and service configuration/models that seek to maximise the quality, effectiveness, efficiency and integration of these services for the population of Bolton. 4. To make recommendations in relation to 24/7 access to services, both urgent and nonurgent, including the role and function of the single point of access. 5. To describe areas of good practice identified during the review. The review will support the implementation of the mental health strategy in Bolton. The review has not examined the finances associated with the services in Bolton. 4 Process for the review A multi-method approach has been employed for this review that has been developed with the support of key stakeholders. The primary approach to this work has been to interview key informants across the service system, including people with dementia, their carers, front line practitioners and clinicians, managers and commissioners. Much of this was undertaken within the services that also provided helpful contextualisation and aided understanding. Interviews and services visits took place between June and November Data provided Greater Manchester West NHS Foundation Trust (GMWFT) has also been used to support the process. A wide range of documentary information has also been reviewed. The two key elements of the review (dementia services and acute care) are presented separately below in this report and by the very nature of the tasks required are also presented in different formats. *$

15 A review of dementia services in Bolton *%

16 Bolton dementia services 1 Introduction This element of the review was tasked with identifying the number of in-patient dementia assessment beds required in Bolton. As discussed below this work has been refocused somewhat from the original as only by improving the wider service system will effective and efficient bed usage be established. Consequently this element of the report focuses upon a range of areas where future commissioning and provider service development will need to be prioritised in order to minimise the need for more beds to be made available in Bolton. 2 Key themes A total of 86 people have provided information that has fed into the review of dementia services in Bolton. As a result of this information, along with quantitative data and a review of documentary evidence, a number of key themes have emerged. These are described below. They are not presented in priority order but will form a menu of areas that can drive individual service and whole system development. The conclusions describe how this should operate in practice and also be governed. 2.1 Carer support Although the themes below are not in a priority order, the importance of supporting carers of people with dementia is essential to the whole of the service system. Their support therefore is a vital facet of ensuring the proposed reduction in beds in Bolton is successful. Service users and carers would like people to stay in the own homes as long as they possibly can, and in order to achieve this the support that carers receive is vital it should not be lost in any service redesign. It will be essential to build on the previous good work of the carers demonstration site work in GMWFT. The current carers groups clearly provide a great source of support to both carers and people with dementia. This support should be built upon through developing more carers groups, peer support groups, flexible day support, out-of-hours home support, and respite opportunities. There should also be a clear carer voice within service planning and development. The planned changes to supporting carers by the Older People Mental Health Team (OPMHT) have been contested in some quarters. Therefore it will be important to evidence the interventions and functions delivered by the Admiral Nurses, and to ensure they are still taking place in the new service model. The Bolton Carers Strategy, which is being developed early in 2012, should provide a significant opportunity to ensure the needs of carers who support people with dementia are considered and that this strategy is dementia friendly. *&

17 The access criteria for respite services needs to be clear and freely available to all who may have an interest in using this provision. There will be a need to enhance GP recognition of the need for support to carers as they are often the first point of contact when a relative begins to show signs of dementia. They may also be the only professional involved with the service user and carer for lengthy periods of the course of the condition. Carers also require advice and information early on in the journey. One ideal place for this would be within the Memory Assessment Service. This is a key point in the pathway and is also an early point for most people on the dementia journey. As a result, the provision of information about the condition and its course, services and support (in both the immediate and long term), and advice on managing agitation, disruptive behaviours, sexually inappropriate behaviours, not eating and so forth could be provided at this point in the pathway. Use of existing literature and other informational resources should be explored, rather than designing new information. Primary care is often the first point of contact for carers of people with dementia and is therefore crucial to the recognition of carer needs, ensuring they receive carer assessments, physical and mental health checks, and other ongoing support to assist them in their role. 2.2 Integration, collaboration and communication There is a wide range of services available within Bolton to support people with dementia and their carers. The way these services fit within a whole system will determine their effectiveness and efficiency as a system. Collaboration and good communication will be essential to gain the maximum benefit from the financial and human resources available. In part, this can be achieved through integrated approaches to learning and staff development. 2.3 Mainstreaming of dementia service developments Service provision to people with dementia should not be seen as something that occurs separate to how older adults or people with long-term conditions are treated. All opportunities to ensure service provision is dementia friendly should be seized across the health and social care systems. In respect of the way in which dementia care is mainstreamed and services are integrated, the Bolton AQuA/King s Fund Project should provide a useful vehicle for this, although it should not be seen as the only tool available to stakeholders. 2.4 GMWFT in-patient dementia assessment beds GMWFT is proposing to reduce the number of dementia assessment beds from 35 down to 20 beds. The rationale is based on a combination of current service utilisation and benchmarking against peers in the North West and through the Audit Commission Benchmarking Club. At this moment in time there are not precise and accurate formulae for determining the exact number of beds required. Such formulae would need to take account of other services *'

18 components in the wider system, the available estate, morbidity, deprivation, demography and future population trends. In addition to this they would also need to take account of the highly variable, and difficult to measure, variations in clinical tolerances to risk between practitioners in the area, in particular between psychiatrists. The rationale Greater Manchester West NHS Foundation Trust (GMWFT) has presented would appear logical enough, and time will tell if any of the other above mentioned factors affect the future bed requirements. The most important aspect of the bed reduction plan will be to undertake this in a safe manner, especially if the bed base is to be reduced further in the following years. The phasing of any reduction is a sensible approach to take. However, it would be prudent to have an agreed plan of action in the event that the bed base of 20 proves insufficient at any point of time, and this should be managed by GMWFT. There are some concerns in Bolton NHS Foundation Trust (BFT) that there may be knock-on effects for its services by the bed closures by GMWFT. These will need to be discussed further between the two organisations as part of the consultation exercise for the reduction of dementia beds. There is a need to improve closer working between GMWFT, Bolton Council Adults Social Care and the care and nursing homes and home care services, particularly in respect of discharge arrangements. There are differing opinions between the various parties on the effectiveness of current discharge arrangements. Regular dialogue between stakeholders on this issue should reduce the differences in perceptions that exist. In order to maximise efficient bed usage it will be important to have plans to: Understand the reasons for delayed discharges (Monitor defined or otherwise) and respond to these reasons. Seek to continuously improve the links between hospital and community services, including services not managed by GMWFT - e.g. Bolton Council Adults Social Care Teams, care and nursing homes, intermediate care, home care, carer groups. Develop and support the staff in in-patient services to meet the needs of service users as effectively as possible. Maintain a constant and effective dialogue between GMWFT and BFT on their respective need for support from each other, and in service development. 2.5 The quality of the environment This issue is relevant to all provider organisations and there may be differences in the way quality is delivered dependent upon the remit of the provider and the associated regulatory measures. The Department of Health Commissioning Pack states that health care premises design should be consistent with the Dementia Design Checklist (NHS Scotland, 2007) 3 and should ensure that care environments are consistent with the principles set out in Enhancing the Healing Environment (King s Fund, 2007) *(

19 Consideration should be given to environmental improvements in the physical layout and signage in hospitals including dementia sign-off for environmental or building changes to address the needs of people with dementia. 2.6 Firwood Clarity about future direction, role and function of Firwood is required. Given the desire to reduce the number of in-patient dementia assessment beds Firwood will play a crucial role in the wider system. Currently, it provides respite, day care, intermediate care and a base for the community teams. A future service model should focus work towards providing an alternative to hospital admission; a place for step-down from hospital as well as respite; day support and assessment 5 ; and a location for Memory Assessment Service clinics. The Memory Assessment Service should have a base at Firwood although would need to operate outside this facility too, in order to ensure best access for all people across Bolton. This will require support from primary care colleagues to maximise accessibility through utilising primary care settings where possible. The services in the facility could usefully be managed by a single organisation and utilise a single suite of policies and procedures along with a single recording keeping system. Undertaking these actions would significantly improve practice, effectiveness and efficiency. Greater integration between all the service components in Firwood, including the community teams, would improve efficiency for the future service model in Firwood and the wider service system. This may require staff to be seconded or transferred into GMWFT in order to operate to a single set of policies and procedures. As part of rethinking the service model, the registration status with the Care Quality Commission should also be reconsidered. If the service functioned as a care home with nursing it would be able to meet higher levels of needs than it currently does if registered as a care home. It could therefore also assist with the wider system in terms of keeping people out of hospital who could be supported elsewhere (on-site in Firwood and externally through outreach opportunities by the Bolton Community Dementia Service). Any future model will need to clearly integrate all the various aspects of service provision. At present there are considerable areas where health and social care staff roles, functions and practice jar against each other. Single management of all the staff in the facility would be helpful, especially if they were all then able to work to a single set of policies and use one electronic record system in the building. An integrated single managed service could also resolve the issues associated with utilising two record keeping systems (ICIS and Care First) which, along with operating to two sets of policies, can increase risks for service users. Currently there are differential costs to people with dementia and their carers, based on access routes into the services these inequalities need to be examined and resolved. The intermediate care beds have been considered as part of a review driven by BFT and there is an action plan that suggests the withdrawal of beds at Firwood. This requires the use of these six beds at Firwood to be reconsidered, along with the use of the other 21 respite beds as 5 It would be useful to have agreed and definitions of respite, day care and day support. *)

20 part of the review of the service model referred to here. Firwood could then offer specialist intermediate care for people with dementia, distinct from the other intermediate care services as well as respite care. 2.7 Day support and assessment The future service at Firwood requires a clear joint commissioning approach to agree the service model and also to involve the existing service providers (Bolton Council and GMWFT) in the service redesign as well as other key stakeholders, including people with dementia and their carers. There is the potential for intermediate care services for people with dementia by providing outreach to support people at home and in care homes. This should be examined as part of the wider approach to preventing people moving up the service system wherever possible. 2.8 Interfaces between GMW specialist services and other services There are a number of areas where interfaces between services could be further developed to the benefit of all. For example, through improved communication, understanding of each other s services, joint working arrangements and shared care opportunities. A number of key relationships were highlighted as areas where there could be improvement: Firwood and other forms of day care and the Bolton Community Dementia Service Generic Social Workers (non-specialist) and the Bolton Community Dementia Service General community nursing and specialist mental health services Secondary care and primary care Dementia services and end of life services 2.9 Care and nursing homes Care and nursing homes are a large and key part of the wider service system for people with dementia. They will require support and development, connectedness to the system beyond their walls and ongoing scrutiny of their practice. Central to all of these issues will be the Bolton Community Dementia Service and In-reach service functions. Their role and function in respect of the care and nursing homes should be clearly articulated. Their ability to engage with providers should be reinforced through the Provider Framework that should ensure that the Bolton Community Dementia Service and Inreach service has right of access into services, and that providers are expected to engage with the Bolton Community Dementia Service in order to maintain their status on the Framework. Psychology support via the In-reach team would significantly help develop the skills and abilities of care and nursing home staff. The role of primary care in supporting people in care homes through domiciliary visits from dentists /opticians/chiropodists / physiotherapy and other services requires improvement. Currently this is highly variable with some providers reporting they are unable to access and engage with some of these service providers. NHS Bolton (PCT) and Bolton Health "+

21 Consortium (CCG) will have important parts to play in achieving this goal. There is also a lack of access to re-ablement services within care and nursing homes. Some care and nursing homes report variable experiences in working with general practice. This should be examined further with the option of a Local Enhanced Service (LES) being developed where appropriate. Currently, the way in which data is recorded in Bolton Council means that true analysis of the prevalence of people with dementia and their use of care and nursing homes cannot be undertaken. A system is required whereby people who enter care and nursing homes for other needs but then develop a dementia are identified, in order that (i) they can be appropriately supported and (ii) accurate prevalence rates can inform further service planning. This will require medical professionals to make the diagnosis and recording systems to gather such diagnoses effectively. A rolling programme of training and development of provider services and their staff should be considered in order to examine some of the key issues they deal with, amongst other things (i) use of anti-psychotics, (ii) behaviour management, and (iii) age and ethno-sensitive appropriate activities. Currently there are reported to be poor transfer experiences between hospital services and care homes (and to home support providers too) from both GMWFT and BFT in-patient services. Both care homes and home support report examples of limited information being provided upon discharge, and times where discharges are sudden and do not give the receiving care provider time to prepare for the transfer. Systems to improve these transfers require examination across the wider service system and need to engage the providers actively in these discussions. There is a need for specialist facilities for men only and women only. This will require proactive commissioning with providers. Currently the market does not provide male-only facilities, and the number of men who display sexually inappropriate behaviours as a result of their dementia challenges the system. This results in (i) some people being inappropriately placed in GMWFT beds for longer than they should be, (ii) the placing of people at risk in services that are unable to cope with such behaviours, and (iii) some people being placed out of area and away from their families and friends which can add to the stress of placement, particularly where relatives and friends are also elderly. There is a need for work on market management of care homes leading to improved quality through a performance framework. The application of the Dementia Premium needs clarification, and service standards and expectations can assist in driving up quality. Furthermore, this is likely to dovetail with a strategy that ensures quality data about the prevalence of dementia in Bolton. At this point there are no clearly agreed protocols between community nurses, GPs, and the care and nursing homes on how they collectively work together on managing end of life for people with dementia. These agreed protocols are required in order that end of life support to the person with dementia and their carers is effectively coordinated. "*

22 2.10 Home support Home support services are vital to ensuring people with dementia do not enter care and nursing homes or hospital services unnecessarily. They also provide indirect support to carers through their support for people with dementia. Consequently, they are a key part of the wider service system, especially given the continued implementation of self-directed support. There is a need to improve linkage between home support providers and other parts of the system (i.e. GMWFT services, BFT services, general social care, GPs and primary care). They play a key role as part of the multidisciplinary team (MDT) and need to be effectively engaged by other services to get maximum benefit from their efforts. At present, the people they support may move from home and into bed-based service for a period of time, and when returning home they are unlikely to receive appropriate information to enable to them to pick up the reins of support. There is more fragmentation in Bolton now than there has been previously in respect of home support. This is due to a recent competitive tender and the ongoing implementation of self directed support. A system needs to be developed locally that allows the range of home support providers to effectively communicate with other parts of the service system. Home support service providers should be included in any system wide approaches to training and development. Service commissioners should consider commissioning night-time support to people in their own homes, i.e. home support out of hours, as a means of preventing some people moving into care and nursing homes and intermediate care. Rigorous data collection on the needs of people who enter care and nursing homes or respite would assist in identifying the levels of need that might be met through this approach. It would then be possible to determine any cost savings that might occur as a result, as well as the personal saving to the people with dementia who do not therefore have to experience the upheaval of moving to a different environment Memory Assessment Service (MAS) This service should be established as quickly as possible. Ideally, it should be provided directly through GMWFT as they manage the other key elements of the pathway, have the knowledge of local services and provision, and have skills in place on the ground at this point in time. Introducing a new service provider would be likely to create problems of integration across the secondary care pathway. As part of the development of the MAS there will be a need to clarify its role and function in the wider care pathway. MAS could provide a key point in the service user and carer journey for the provision of information about dementia and support services as described earlier. There is approximately 53,000 non-recurrent monies available from the Department of Health to support Councils in relation to social care aspects of Memory Assessment Services. One option for this would be the Dementia Advisor / Navigator role. Ideally, this would be provided through the third sector through the employment of two part-time workers or a job share (this reduces the risks associated with a single worker taking extended leave for a period). This role could be effectively co-located within the MAS service, even if delivered ""

23 by a third sector provider. In the longer term the PCT / CCG could work with the third sector provider to bid for money from charitable funding sources to fund the posts on a recurrent basis Bolton NHS Foundation Trust (BFT) beds A cross-agency approach to supporting people in BFT beds with dementia and suspected dementia is required. These people account for a considerable proportion of those in acute hospital beds. The existing Liaison Service is well regarded but is not large enough to provide the support required. Alternative methods of supporting BFT will need to be developed. There is a need to explore how services such as the Birmingham Rapid Assessment Interface and Discharge model (RAID) 6 (or elements of it) might be applied in Bolton and how this may be resourced through a QIPP or an Invest to Save initiative locally. Carer support services within BFT could also be usefully developed as part of a wider programme of support to carers across Bolton taking into account the GMWFT carer demonstration site work. There is a need to improve discharge arrangements and closer working between BFT and the care and nursing homes and home care services. BFT is currently operating a project in conjunction with Manchester University to improve awareness and education relating to dementia, and has been supported with input to training by GMWFT mental health liaison nurses. This could usefully be rolled out further and shared with the whole health care system Intermediate care There is a need to clarify the future role and function of intermediate care across the Bolton system and how this links to the Firwood beds in the future. This will require consideration in respect of how Darley Court and Firwood can best complement each other in the provision of intermediate care and working with people with dementia. Consideration should be given to how best to provide specialist support to people with dementia in Darley Court and other intermediate care services. As with care and nursing homes, there is a need to develop robust data collection about the use of intermediate care services for people with dementia, in order that this can inform future service planning and staff development Primary care There is a need to build on the positive working relationships that currently exist between secondary care services and primary care. The Consultant Psychiatrists in Bolton are valued by their GP colleagues for their knowledge, experience and accessibility. This interface is 6 "#

24 crucial to early and effective diagnosis and support to service users and carers through primary care. There would be significant benefit from agreeing clear guidance about when and how primary care could access the expertise in secondary care to best effect for all parties. In many places it is acknowledged that GPs expertise in relation to working with dementia requires support and development. This will need to be undertaken strategically, as well as through day-to-day contact between general practice and secondary care. There is a need to develop good practice between primary care and home care / care homes in a manner that improves the services on offer within these providers and which minimises variability in quality. There is need for clarity about the role of GPs in dementia care and the support they can provide and also will need to receive. In part, this could take place when agreeing the criteria for inclusion on Dementia Registers in Bolton. The PCT / CCG will need to lead strategically on these issues. The inclusion of dementia in the Triple Aim programme will provide the vehicle for this and assist in making significant progress in this area. Regular physical health care checks are needed for people with dementia (and their carers) and could usefully be linked to the development of Dementia Registers in practices. One area of identified good practice is the dementia screening and assessment work undertaken in one GP practice. Strategies to spread this further across primary care the Triple Aim programme will be invaluable in supporting this BME groups Many BME communities have well established support networks in Bolton. However, they also struggle to seek support for people with conditions such as dementia, due to the perceived stigma associated with the condition. Support is needed to enable BME services to challenge this stigma and would assist in the early identification of dementia amongst BME groups. There is a clear need to improved integration between BME services for people with dementia or who are working with people with dementia and the wider service system. Such services also require improved access to support from the wider health and social care economy Medication Progress has been made across the services in Bolton in respect of the use and abuse of various medications prescribed for people with dementia. However, this requires further action, partly to improve appropriate prescribing and administration, and also to identify possible cost reductions. This applies not only to the use of anti-psychotics. A strategy to improve understanding of use of anti-psychotics and analgesics (amongst other medicines) could usefully assist, particularly if led by NHS Bolton and the CCG. Any such strategy will "$

25 need to include education and the sharing of practice with respect to alternative ways of managing dementia related behaviours. An earlier NHS Operating Framework sets a target of a two-third reduction of anti-psychotic prescribing for people with dementia by End of life There has been a significant amount of joint working between GMWFT and the End of Life Care Team, particularly focused on people with dementia. This work has included: Support in the implementation of the Liverpool Care Pathway and associated prescribing algorithms in the in-patient service. Supporting the clinical team in delivering care at the end of life in the in-patient unit, including providing weekend support to ensure all the person s needs were met. Providing a range of training across both services. The planning and delivery of a successful joint conference (opened by Professor Alistair Burns) in Bolton, entitled Dying with Dementia Matters. However, there is a need to ensure that end of life services are dementia-friendly. In part, this could be done by closer working between end of life services, specialist mental health teams, and other providers working with people with dementia. End of life planning for people with dementia in care and nursing homes should involve district nursing and GPs Whole system Training and staff development across all agencies could be better coordinated in order to improve value from the training that takes place, and also to enable staff from across agencies to have time together and to build up their working relationships. There is a need to improve cross agency multidisciplinary team (MDT) working. Intelligent data and information about use of services by people with dementia is required to inform future service planning and to detect accurate prevalence rates for dementia in Bolton Day support services Exploration is required into ways in which day and sessional support can be provided more flexibly. The staff of Firwood Day Service will need to be involved actively in this. The use of adult placement needs to be further examined by commissioners in order to explore the potential this service offers in order to provide a flexible and responsive respite option. A number of carers raised this as an approach they would value. This service is reported as currently being under review. "%

26 2.20 Telecare Telecare systems are in operation in Bolton for a wide range of service users, including older adults and people with mental health needs. Improved use of telecare, such as just checking, could enable more people with dementia to be supported at home for longer periods of time, and a case could probably made for this to pay for itself. There is evidence from the recently published report on the early findings of the Department of Health Whole System Demonstrator projects that indicate both quality and financial benefits 7. Where utilised properly, the findings suggest telecare can support people with longterm conditions to enable people to live independently. It can also reduce A&E visits by 15%, emergency admissions by 20%, bed usage by 14% and, most importantly, mortality rates by 45% People with a diagnosis of vascular dementia There is a need for a particular focus on support to people with vascular dementia, and their carers, after diagnosis. Currently very little is offered to this service user group between diagnosis and end of life care, other than access to respite care Early onset dementia There is a need to consider how the needs of people with early onset dementia accords with the development of services, in particular recognition and access to the MAS once it is developed. There is a need to develop closer and more integrated working between BFT and GMWFT services to ensure the development of care and treatment pathways across other services, where people with early onset dementia are likely to present. There have been previous attempts to develop a pathway with neurology services (which would also be beneficial for people who present with more complex needs, such as Lewy Body) although these have not been successful to date Good practice A number of examples of good practice were identified during this review, including: Shared GP trainee post between primary and secondary care Dementia screening and dementia register in one GP practice Support groups for people with dementia and their carers In-reach Team Standard letter for GP feedback developed for adult mental health (could be utilised in older adults) 100 voices project in Bolton Foundation Trust, to ensure staff are better aware of the needs of carers It was also apparent that there were many motivated staff working across the service system. 7 "&

27 3 Developmental issues and recommendations 3.1 Overview of developmental issues/recommendations These fall into 13 key areas: 1. Carers 2. Whole system working 3. In-patient dementia assessment beds in GMWFT 4. Firwood 5. Care and nursing homes 6. Home support 7. Memory Assessment Services 8. BFT beds and liaison 9. Supporting primary care 10. End of life care 11. BME and other minority groups 12. Vascular dementia 13. Early onset dementia Below is greater detail of each of these areas. It should be noted that some of the suggested ways forward are applicable to more than one area. It should also be noted that the continued implementation of the personalisation agenda through self-directed support is likely to have an impact on the way services are developed and delivered in the future in Bolton. 1 Carers Carers are the bedrock of maintaining people in their own homes and out of services. Therefore support to carers will need to be prioritised and further developed as much as possible. Carers have stated they would like support in a range of areas, including information about the condition, the course of the condition, how to manage challenging behaviours and not eating, where and how to access practical support ranging from support to the person they care for through to support for them as carers, information about financial support and how to obtain this, peer support groups, and so forth. (1) Recommendations on support for carers The development of support to carers in Bolton should be seen as a major area of priority. All future service developments and service changes should consider the question how does this help carers to support people with dementia? Carers should be actively engaged in service development across Bolton. Carers and people with dementia should be represented on the Dementia Stakeholder Board. "'

28 2 Whole system working Integration, collaboration, and effective communication can bring about substantial gains without requiring additional resources. Opportunities for shared staff learning and development need to be maximised. There are multiple points across the service system where connections could be improved and better MDT working could take place. This will require proactive management. Greater collaboration between primary care and GMWFT is required in order to facilitate access to space to deliver services in primary care settings by GMWFT. A coordinated approach to awareness raising and education across all parts of the services system is needed, which would have the added benefit of helping front line staff engage with peers and see a larger picture. The AQuA / King s Fund project to develop integrated care approaches for people with dementia is welcomed and should also provide some useful baseline information in prevalence rates in Bolton. Intelligent data and information about use of services by people with dementia is required to inform future service planning and to detect accurate prevalence rates for dementia in Bolton. (2) Recommendations on whole system working Any opportunity for cross agency / cross organisation working should be maximised, particularly joint training and developmental opportunities. A cross agency strategy for education and staff development should be established. Discussions are required between GMWFT and primary care practices (with the support of the PCT and CCG) to facilitate access to space to deliver services in primary care settings. A plan to improve data intelligence on the prevalence and needs of people with dementia and their carers should be agreed between key stakeholders. Commissioners should consider agreeing to a pooled budget for dementia, in order to have greater future flexibility in respect of how monies are spent. 3 In-patient dementia assessment beds in GMWFT The in-patient bed based reductions being proposed by GMWFT are appropriate but the transition needs careful management. Reduced in-patient dementia assessment beds will require other elements of the service system to function more efficiently and effectively. "(

29 GMWFT and its commissioners will need to be vigilant regarding currently unforeseen consequences of bed closures, and must have a system of response in place to address any such issues. (3) Recommendation on reduced dementia assessment in-patent beds in GMWFT An Impact Assessment should be undertaken at a point agreed by the Dementia Stakeholder Board on the effects of the planned reduction in dementia assessment beds in Bolton. 4 Firwood Firwood requires a commissioner-led, provider-informed review of the service model, with a view to clarifying its future role and function, improving integration between service components (including community services based at Firwood, with provision on site) and single line management that leads to a single record keeping system, and an operational policy that reduces risk. The future role of Darley Court, other intermediate care providers and Firwood requires consideration, particularly in respect of where intermediate care is best provided for people with dementia. In part, this will be determined by the future service model for Firwood, but this needs to be developed alongside the future role and function for Darley Court. (4) Recommendations on Firwood The role and function of Firwood requires urgent agreement between the key stakeholders, and should be considered in the context of the wider service system. The future service should operate within a single line management structure, operating to single policies and procedures and a single system of case recording. Commissioners should give consideration to the future service being commissioned using a single joint budget. Equal and consistent financial access to services in Firwood should be implemented as soon as possible. 5 Care and nursing homes Care and nursing home providers are essential to ensuring people do not need to move into hospital unnecessarily. Support, staff development, and integration into the wider system is essential in terms of maximising their ability to support people without moving them into hospital. ")

30 The Framework operated by Bolton Council for care and nursing homes could usefully be employed to drive up quality standards and ensure access by the OPMHT, with providers being required to engage with other parts of the service system, including the In-reach Service. The development of single sex services should be encouraged through active market management, in particular the development of local male-only services. (5) Recommendations on care and nursing homes The Bolton Council Provider Framework should be used to drive up standards of care for people with dementia in care and nursing homes by regularly reviewing expectations of providers on the Framework. Bolton Council and other key stakeholders should consider developing a market management strategy that encourages providers in Bolton to develop services based on local need. Intelligence on the prevalence of dementia in care and nursing homes should be gathered in a consistent manner, in order to inform future service planning. Support from general practice to care and nursing homes should be reviewed and Local Enhanced Services implemented, where appropriate, in order to better support people with dementia. 6 Home support Home support providers need to be better integrated within the service system, especially in respect of the provision of information from hospital and primary care services that enable them to continue to support effective planned care. An agreed format for discharge letters to care / nursing homes and Home Support providers could usefully be established between the two Foundation Trusts and these providers. Commissioners should consider the opportunity to develop night-time home support services. There may be opportunities to maintain people at home who otherwise may go into a care or nursing home, or into hospital. (6) Recommendations on home support Agreement should be reached between home support providers and BFT and GMWFT in relation to implementing minimum standards of communication about service user needs when moving home. Commissioners should consider the opportunity to develop night-time home support services. A system needs to be agreed whereby providers can communicate more effectively in an increasingly fragmented provider market. #+

31 7 Memory Assessment Service Memory Assessment Service needs to be established as quickly as possible, ideally delivered through GMWFT 8, and with a clear remit for (i) how it functions, (ii) how it interfaces with other services in the Bolton system, and (iii) how it provides service users and carers with information about dementia, the care pathway, and support. (7) Recommendations on Memory Assessment Service The Bolton Memory Assessment Service should be established as soon as possible. Consideration should be given to Firwood providing the main base for the service. 8 BFT beds and liaison Support to BFT requires further development with consideration of how the RAID model (or aspects of it) might be applied within Bolton. This will require strategic partnership working between commissioners and both Foundation Trusts. (8) Recommendations on BFT beds and liaison The Dementia Stakeholder Board should agree a strategy to develop a liaison service akin to the Birmingham RAID model that meets the needs of people with dementia, substance misuse, alcohol misuse, and mental health needs in the A&E Department at Bolton and also on the BFT in-patient wards. The impact of reduced dementia assessment beds in GMWFT need to be monitored through an Impact Assessment to identify any unintended consequences for BFT in-patient services. 9 Supporting primary care There is a need to strategically develop the expertise of GPs in working with people with dementia and supporting their carers effectively. The good practice developed by one GP practice in screening and assessing for dementia could usefully be spread across the rest of primary care in Bolton. (E--,B-?>B5D19?-?<4?-1@=9B.59-B3-,@--,?=,@=<51FBB<@49BB32 #*

32 A screening tool for general practice will be developed in 2012 as part of the Triple Aim programme. 9 Reduction in the use of anti-psychotic medication for people with dementia is an area NHS Bolton and the CCG could usefully lead upon. The current Working Group needs to be developed further to ensure full engagement by GPs. (9) Recommendations on supporting primary care Good practice established in respect of screening, assessing and dementia registers should be rolled out across all GP practices in Bolton. The Working Group on the use of anti-psychotic medication for people with dementia should have active GP representation. A strategy to develop primary care professionals in respect of dementia should be agreed at the Dementia Stakeholder Board. Guidelines should be agreed between primary and secondary care professionals about the most effective and efficient way to utilise each other s expertise and advice. There needs to be clarity and agreement about the strategic intentions for property management across the Bolton health and social care economy, and how this can support capacity and capability-building in primary care. 10 End of life care There has been a significant amount of joint working between GMWFT and the End of Life Care Team, particularly focused on people with dementia. However, there is a need to build on this collaboration between all dementia service providers and end of life services, including district nursing and general practice, including the approach to advanced care planning and advanced directives. (10) Recommendations on end of life care A time-limited Task and Finish Group should be set up to review and agree how to ensure end of life care for people with dementia maximises the resources and expertise that exists across the service system. 9 For more information about the Triple Aim Programme see: #"

33 11 BME and other minority groups Support is required to BME services in order that they can tackle the issue of stigma associated with dementia in their communities, in order to improve early detection, intervention and support to families and carers. There is a need to link all dementia work with minority group needs that exist or may emerge in the near future, for example people with learning disabilities. (11) Recommendations on BME and other minority groups BME services should be fully engaged in all service development in Bolton. Health promotion and anti-stigma initiatives in Bolton should involve BME and other minority groups in their design and implementation. 12 Vascular dementia Support to people with vascular dementia and their carers, between diagnosis and end of life care, should be improved. The development of the Memory Assessment Service will be particularly helpful for this service user group. There will also need to be stronger links developed between GMWFT and BFT in relation to integrated working across service areas, such as vascular clinics, stroke assessment, etc. (12) Recommendations on vascular dementia Clear literature to support carers and people with vascular dementia should be available that informs people about (i) the condition and (ii) support mechanisms available during the course of life with the condition. The Memory Assessment Service should develop guidance about how people diagnosed with vascular dementia are linked into other forms of support after discharge from secondary care services. Integrated working between GMWFT and BFT should be explored for areas such as stroke assessment and vascular clinics. 13 Early onset dementia Access and subsequent response to people with early onset dementia requires consideration in respect of the implementation of the issues highlighted in this report. ##

34 (13) Recommendations on early onset dementia A time-limited Task and Finish Group should consider the current situation in Bolton with regards to the identification and support available to people with early onset dementia and their carers. 4 Conclusions and next steps The National Dementia Strategy was published in 2009 and, along with Operating Framework 2012/13, it provides the blueprint for the way forward for services and commissioners in this field. The above represents a menu of activity required to improve services and whole-system working for the benefit of people with dementia and their carers in Bolton. Importantly, much of this accords with the direction of travel described in the National Dementia Strategy. The process of moving from where the services are now to where they should be will be enhanced by two critical factors. Firstly, the appointment of the Dementia Lead for Bolton until the end of March 2013 is crucial and needs to continue throughout this period in order to draw together all the strands of work that link to the above. Importantly, it should be acknowledged that a vast swathe of the above does not require additional investment but improved connections and coordination. A Dementia Partnership has been established across the service system and an action plan is being drafted to coordinate future developmental work. The second critical factor to future success will be the development of the Bolton Dementia Stakeholder Board. This has been agreed as a high level strategic Board that will oversee the dementia agenda as described here and in other areas that lie outside the remit of this report. The Dementia Stakeholder Board will consist of Board Level personnel from NHS Bolton, Bolton Clinical Commissioning Group, Bolton Council, Greater Manchester West NHS Foundation Trust and Bolton NHS Foundation Trust. This Board will report directly to the Bolton Health and Wellbeing Board and will feature as a standing item on its agenda. The Terms of Reference for the Dementia Board will need to be signed off at the Health and Wellbeing Board. The Dementia Partnership should report to the Dementia Stakeholder Board as its operational arm. #$

35 Appendix 1 Policy background and key documents Significant guidance has been developed over the past 11 years through a number of key policy documents that relate to services for people with dementia and their carers. These include: Department of Health (2011) Dementia commissioning pack Department of Health (2011) National strategy for carers Department of Health (2011) Transparency in outcomes: a framework for adult social care Department of Health (2011) No health without mental health: a cross-government mental health outcomes strategy for people of all ages Department of Health, Skills for Health, Skills for Care (2011) Common core principles for supporting people with dementia: a guide to training the social care and health workforce Department of Health (2010) Nothing ventured, nothing gained: risk guidance for people with dementia Department of Health (2010) Quality outcomes for people with dementia: Building on the work of the National Dementia Strategy Department of Health (2010) NHS Outcomes Framework Department of Health (2010) Dignity in care Department of Health (2010) A vision for adult social care: Capable communities and active citizens Department of Health (2009) Joint commissioning framework for dementia Department of Health (2009) The use of antipsychotic medication for people with dementia: Time for action Department of Health (2009) National Dementia Strategy Care Quality Commission (2011) The state of health care and adult social care in England. An overview of key themes in care in 2009/10 Department of Health (2011) Service specification for dementia: better care at home, and in care homes Healthcare at Home (2011) Understanding out of hospital dementia care Mental Health Foundation (2011) Personalisation and Dementia: A practitioner s guide #%

36 Mental Health Foundation (2011) Personalisation and dementia: a resource for trainers on self-directed support for people living with dementia Skills for Care (2011) Meeting the workforce regulations: Skills for Care advice on CQC s workforce-specific outcomes; 14 and 25 Social Care Institute for Excellence (2011) Black and minority ethnic people with dementia Research briefing 35 Think Local Act Personal Partnership. Available from All-Party Parliamentary Group on Dementia (2010) A misspent opportunity?: inquiry into the funding of the National Dementia Strategy Alzheimer's Society (2010) My name is not dementia: people with dementia discuss quality of life indicators Audit Commission (2010) Under pressure: Tackling the financial challenge for councils of an ageing population Dementia Action Alliance (2010) National dementia declaration House of Commons Committee of Public Accounts (2010) Improving dementia services in England: an interim report Joseph Rowntree Foundation (2010) Equality and Diversity and Older People with High Support Needs National Audit Office (2010) Improving dementia services in England - an interim report National End of Life Care Programme (2010) Care towards the end of life for people with dementia: an online resource guide Personal Social Services Research Unit (2010) Measuring the outcomes of care homes: final report Personal Social Services Research Unit, Age UK (2010) The impact of a tightening fiscal situation on social care for older people Personal Social Services Unit Research (2010) Projections of demand for residential care for older people in England - Report for BUPA Royal College of Psychiatrists (2010) The need to tackle age discrimination in mental health. A compendium of evidence Social Care Institute for Excellence (2010) Dignity in care, SCIE guide 15 Social Care Institute for Excellence (2010) Personalisation briefing: Personalisation and mental capacity, At a glance 33 #&

37 Social Care Institute for Excellence (2010) Personalisation briefing: Implications for nursing homes Care Quality Commission (2009) Review of healthcare for people living in care homes Centre for Policy on Ageing (2009) Ageism and age discrimination in mental health care in the United Kingdom. A review from the literature Healthcare Commission (2009) Equality in later life: a national study of older people s mental health services Joseph Rowntree Foundation (2009) Inquiry into the dementia care skills of social care staff supporting people with dementia in care homes and their own homes Mental Health Foundation (2009) All things being equal: Age equality in mental health care for older people in England Royal College of Psychiatrists Faculty of Old Age Psychiatry (2009) Links Not Boundaries: Service Transitions for People Growing Older with Enduring or Relapsing Mental Illness Social Care Institute for Excellence (2009) Personalisation briefing: Implications for residential care homes All Party Parliamentary Group on Dementia and Alzheimer's Society (2008) Always a last resort: inquiry into the prescription of antipsychotic drugs to people with dementia living in care homes Commission for Social Care Inspection (2008) See me, not just the dementia: understanding people s experiences of living in a care home House of Commons Committee of Public Accounts (2008) Improving services and support for people with dementia Institute for Public Policy Research (2008) Older People and Wellbeing Joseph Rowntree Foundation (2008) Supporting older people in care homes at night Personal Social Services Research Unit (2008) Age Discrimination in Mental Health Services Age Concern England, Mental Health Foundation (2007) Improving services and support for older people with mental health problems: the second report from the UK Inquiry into Mental Health and Well-Being in Later Life Alzheimer s Society (2007) Home from home: a report highlighting opportunities for improving standards of dementia care in care homes Care Services Improvement Partnership (2007) Integrated mental health services for older adults: a service development guide #'

38 Help the Aged, National Care Homes Research and Development Forum (2007) My home life: quality of life in care homes - a review of the literature National Audit Office (2007) Improving Services and Support for People with Dementia Personal Social Services Research Unit (2007) Dementia: international comparisons (see p13 for a table on care home provision in several countries) Social Care Institute for Excellence (2007) The participation of adult service users, including older people, in developing social care, SCIE Guide 17 Age Concern England, Mental Health Foundation (2006) Promoting mental health and wellbeing in later life: a first report from the UK Inquiry into Mental Health and Wellbeing Age Concern England (2006) The whole of me: meeting the needs of older lesbians, gay men and bisexuals living in care homes and extra care housing: a resource pack for professionals British Geriatrics Society (2006) Hospital discharge of older people with cognitive impairment to care homes Royal College of Psychiatrists Faculty of Old Age Psychiatry (2006) Raising the Standard: specialist Services for Older People with Mental Illness Social care Institute for Excellence (2006) Assessing the mental health needs of older people, SCIE guide 3 Care Services Improvement Partnership (2005) Everybody s business. integrated mental health services for older adults: a service development guide Social Care Institute for Excellence (2004) Aiding communication with people with dementia, Research briefing 3 Office for National Statistics, Department (2003) The mental health of older people: report based on the analysis of the ONS Survey of Psychiatric Morbidity among Adults in Great Britain carried out in 2000 Audit Commission (2002) Forget me not Developing mental health services for older people in England Joseph Rowntree Foundation (2002) Designing and managing care homes for people with dementia Audit Commission (2000) Forget me not. Developing mental health services for older people in England #(

39 A review of acute care mental health services in Bolton #)

40 A review of acute care mental health services in Bolton 1 Acute Care In respect of this review, acute care relates to acute adult in-patient wards, Psychiatric Intensive Care Units (PICUs), and Crisis Resolution Home Treatment Teams (CRHTs). 1.1 Acute care and the mental health system The role and function of the acute care service is inextricably linked with the wider mental health system. The effectiveness of whole system functioning will have a direct relationship with the acute care system. Where community services operate well, there will be less reliance upon acute in-patient beds and Psychiatric Intensive Care Units (PICUs). Where the community services do not operate effectively, or all the components are not in place, there will be a greater need for hospital beds. 1.2 The central role of acute care Acute mental illness is characterised by significant and distressing symptoms of a mental illness requiring a rapid treatment response. This may be the person's first experience of mental illness, a repeat episode, or the worsening of symptoms of an ongoing mental illness. Depending on the person's needs, acute treatment can be offered in the person's own home, in a community setting, or in a psychiatric in-patient service. The symptoms usually respond to intensive treatment. Acute care services are core and essential to the effective overall working of any local mental health service system. They play the major role in supporting people and keeping them safe at times of crisis and relapse. Where they are not functioning well they will compromise the effectiveness and quality of care of much of the rest of the secondary mental health care provision. There is strong evidence that many local acute care services, including both CRHT and in-patient services, need to be better integrated with the community-based components of local mental health service provision, in a more whole-systems approach to care pathway planning and management. As evidenced by a range of reports, including the recent MIND independent inquiry into acute and crisis health care Listening to Experience (MIND, 2011), improving acute care services remains a service user and carer top priority. How acute care services are provided needs to be better recognised as a key dimension to promoting an individual s social inclusion and recovery. Times of crisis can be catalysts for change and recovery. How well acute care is provided powerfully influences service user, carer, GP, and public perceptions of local mental health services and their confidence in them. Improving acute care mental health services also remains a national priority. Variability in the quality of provision has been highlighted in a range of reports such as the 2008 CQC national review of acute in-patient services and the 2010 benchmarking exercises undertaken by the Audit Commission. The acute care pathway has been identified by the Department of Health $+

41 as one of three nationally QIPP mental health target areas for quality improvement and efficiency savings. Acute Care Pathway redesign, in line with national best practice, is a key element of Bolton s Mental Health Commissioning Intentions (2012/13). It is also the necessary underpinning of the GMW Trust s business case for the Redesign of In-patient Services in Bolton, including a reduction of 14 beds that is currently in progress. 1.3 Recommended foundations of an effective acute care service Most local acute care services comprise two essential core components: (i) the in-patient wards, including Psychiatric Intensive Care Unit provision (PICU), and (ii) the Crisis Resolution/Home Treatment Team (CRHT). It is increasingly clear that this provision should be supplemented by a dedicated A&E psychiatric liaison service with clear joint working arrangements with local general hospital A&E services. Service elements which may be added to the range of acute care options available include respite/crisis house provision, acute day treatment services, place of safety provision, and step-down of various forms, including supported housing accommodation. 1.3 In-patient wards The Healthcare Commission s Pathway to Recovery review, which represents the most comprehensive benchmarking of NHS acute in-patient services ever undertaken, identified four criteria for an effective acute in-patient service: There is an effective care pathway that ensures admission to hospital is appropriate and that discharge from hospital is timely. In-patient services provide individualised whole person care that promotes recovery and inclusion. Service users and carers are involved in care planning, in how the ward is run, and in operational and strategic planning, evaluation and development. The ward has systems, processes, and facilities in place to ensure the safety of service users, staff and visitors. It is this first criterion looking at the care pathway context of acute in-patient care that is the principal focus of our review. 1.4 Crisis Resolution Home Treatment (CRHT) CRHTs should provide intensive home treatment for people whose mental health crisis is so severe that they would otherwise have to be admitted to an in-patient ward, but who can, with adequate support, be managed in the community. The main aim is to provide service users with the most appropriate and beneficial treatment possible in the least restrictive environment. But the CRHT is also intended to reduce in-patient admissions and bed occupancy, support earlier discharge from in-patient wards, and reduce out-of-area treatments. A core, nationally performance managed, function of the CRHT is that they $*

42 should gate-keep (carry out a face-to-face clinical assessment) all requests for admission to an acute in-patient bed. 1.5 A&E liaison Working relationships between mental health services and general hospital A&E departments need special attention. The vast majority of service users presenting at emergency departments have different needs from those requiring CRHT. Dedicated psychiatric liaison services should co-ordinate the front line response for psychiatric support to the Accident and Emergency Department and the general hospital acute wards. Only 40 per cent of general hospitals have a psychiatric liaison service. This is a very significant gap in provision, as many people in general hospital care with mental health needs and increasing demands have been placed on both mental health services and A&E departments in recent years. Where no A&E liaison service is available there is a danger that CRHT services will be sucked into the hospital. A 2005 unpublished survey at the Norwich and Norfolk Hospital revealed that around 90% of service users of whom A&E requested a mental health assessment did not require CRHT input. The mental health assessment and collaboration needs presenting at A&E are far greater than can be provided by a CRHT service and require a separate dedicated A&E liaison service to deal with requests for mental health assessment that only pass on to the CRHT cases at risk of admission. A Liaison Mental Health Team based in the acute trust, working with crisis teams, is likely to provide the best and most sustainable solution for first line response. (Academy of Royal Medical Colleges, 2008) Evaluations of specialist liaison services, such as the RAID service in Birmingham, provide increasing evidence that focused liaison mental health input can both improve the quality of care and reduce bed stays and admission rates in the general hospital. An effective liaison psychiatry service offers the prospect of saving money as well as improving health. 1.6 Alternatives to admission As well as home treatment from the CRHT, other alternatives e.g. crisis houses, respite housing, acute day units, etc. provide valued options in the provision of acute services. 1.7 Whole system working National policy is that a whole system approach to acute care pathway services is essential to ensure that there are shared values, principles and processes across all components of the care pathway, and that these are consistent with the values, operational policies and processes used in the wider secondary care mental health pathway. While no single care pathway configuration of services for acute care will be appropriate in all communities and settings, a number of Trusts have successfully developed locally tailored integrated acute care service models that focus on providing an expert streamlined acute assessment, triage and gate-keeping function, via a single point of referral that also delivers a rapid treatment response to referrals. Successful variations on this theme include: $"

43 Those with both CRHT and acute in-patient services under single clinical and management arrangements. Those that have integrated CRHT and the short-term treatment function of community mental health teams (CMHT) under single clinical and management arrangements. In this variation the duty/assessment and short-term treatment functions of the traditional CMHT are separated from the more long term interventions of the CMHT for those with severe and persistent mental health problems, and for those who are difficult to engage. 1.8 Defining the acute care pathway The Acute Care pathway can be defined as: The journey a service user makes from initial referral to discharge from acute services. This pathway needs to run from early identification of need, through assessment and implementation of care plans, ending with safe and effective discharge /transfer. Effective care pathways need to be explicit about service connections, i.e. the who, what, where and when specifics. An effectively integrated care pathway aims to have: the right people, doing the right things, in the right order, at the right time, in the right place. The primary outcome of these aims is to ensure the quality of service user and carer experience is as good as it possibly can be. In order to achieve these aims, all acute care pathway services should adhere to a number of shared principles and policies to ensure integrated service delivery in practice: Single assessment at point of entry including risk assessment that is consistently revised Clear purpose for each admission to the pathway Consistent gate-keeping procedures Consistent care planning arrangements across the pathway Discharge planning from the start Clear management arrangements, with unambiguous lines of responsibility Effective and consistent communication mechanisms between clinicians, teams, and agencies For the purposes of this review the starting point of the acute care pathway has been defined as when an individual first seeks help from or is first referred to the service. The end of the care pathway is defined as when responsibility for the individual s care is transferred to another team or service outside the pathway, or when the individual is discharged from specialist mental health care services after the acute episode. $#

44 However, it needs to be borne in mind that acute mental health care does not exist in a vacuum; it can only be effective as part of a wider system of services in which all the involved services work together. Recognising and understanding the interdependency of how the different component parts of the wider local mental health services work together, including where there are differences in clinical thresholds, inputs, practice and performance, may be critical in developing appropriate service development plans, and in determining the effectiveness of acute care service delivery. For effective acute care service delivery, critical care pathway factors include: The primary care / specialist mental health care interface, and the extent to which there are clearly defined and agreed thresholds of care for primary care and secondary care. The ability of the mental health service overall to prioritise effectively between acute short term needs, and longer term recovery and rehabilitation needs. Acute in-patient and CRHT interfaces and working relationships with local Community Mental Health Teams. An effective balance of CRHT workload regarding its capacity to carry out assessments and provide intensive home treatment. Liaison arrangements with local A&E departments. 2 Key themes This section of the report describes the key themes that have emerged from interviews, visits to services, feedback from service users, carers and staff, and also from examining documents provided by participants in the review. One year of data was provided by GMWFT in relation to people who used their services between 1 st September 2010 and 31 st August High-level data on referrals and referral outcomes were provided by Bolton FT in respect of the single point of access function that is currently located within the Psychological Therapies Service. The primary focus of our review was the Bolton acute care pathway services for the catchment area for which the population is approximately 266,500 people. In gathering our evidence we interviewed 203 people and reviewed 97 documents. We also observed a number of team and review meetings in practice, as well as visiting all the inpatient wards involved. We spoke to current service users and their carers and families, front line clinicians and practitioners in acute care and other related services, service managers, commissioners and members of the management teams. We also spoke to former service users, primarily via third and community sector networks. 2.1 Current service model and composition The two main components of the Bolton acute care service CRHT and the in-patient and PICU wards are based in the Rivington Unit at the Royal Bolton General hospital. This is also where the adult consultant psychiatrists and outpatient clinics are located. $$

45 There are two Community Mental Health Teams (CMHT) based in community health centre premises. 2.2 Community Until recently, the composition of the Bolton service following guidance on implementation of the National Service Framework for Mental Health (NSF) was comprised of distinct and separate CRHT and AOT services and three traditional CMHTs. 2.3 Community Mental Health Teams (CMHTs) While not specifically an integral part of the acute care pathway, the capacity, organisation and throughput of Community Mental Health Team services, including sector consultant psychiatrist caseloads, fundamentally underpins acute care pathway effectiveness. A new community service model is being developed and implemented in Bolton to provide a more all-age needs-led service, to address shortcomings apparent in operating the previous model, and to achieve savings. The primary focus of the CMHTs is service users with serious mental illness (SMI), defined in accordance with HoNOS PbR criteria. They do not provide for service users with mild psychiatric illness, those with a primary diagnosis of substance or alcohol misuse, or service users with a serious mental illness who are in remission or recovery. This new model is currently in the process of being rolled out across the Directorate. It involves: The creation of two sector Community Mental Health teams for people aged 16 and above with functional mental health problems serving two groups of GP practices in the North and South of the catchment area. There were until recently three CMHTs. Integration of the Assertive Outreach team role into these two CMHTs and some transfer of resources from Older Adult Community teams to facilitate provision of this service for people aged over 65. The CMHTs provide a Monday to Friday 9am 5pm service, with some provision for an extended service available to those whose have been identified as needing this, such as AOT service users. The teams operate a duty officer system to receive and allocate referrals to their service. 2.4 Single Point of Access Service (SPoA) There is a designated Single Point of Access (SPoA) service in Bolton for adults (this does not include people requiring access to older adult mental health services). The aim of this service is to provide a facility which can signpost all new, non-emergency adult mental health referrals in Bolton. This does not include services for service users requiring Crisis Resolution. $%

46 This service is provided through Royal Bolton NHS Foundation Trust, and is part of their Psychological Therapies Service based at Breightmet Health Centre where they are co-located with the North sector CMHT. 2.5 Crisis Resolution Home Treatment Team (CRHT) The Bolton CRHT is a multidisciplinary team, based at the Rivington Unit, comprising of team manager, designated consultant psychiatrist, nurses, social workers, occupational therapy, and support time and recovery workers. Its remit is: To provide home based treatment for service users 365 days a year 24 hours a day, with access to a qualified practitioner at all times. To gate-keep all admissions to the acute in-patient wards. To facilitate early discharge from the acute in-patient wards. To offer assessment for individuals experiencing mental health problems in the A&E Department. To operate an out-of-hours telephone helpline for service users and carers under secondary mental health services. 2.6 Consultant outpatient clinics There are 12.5 whole time equivalent (wte) consultants 10 comprising six sector consultants plus one consultant for the CRHT, one for dual diagnosis and 0.5 wte for the Early Intervention Team. There are also four older adult consultants within the 12.5 wtes. These are all based at the Rivington Unit where their outpatient clinics are held. There are approximately 64 outpatient clinics held in the Rivington unit each week. 2.7 The Acute In-patient Service Acute admission beds The acute in-patient assessment and treatment beds for the Bolton catchment area are provided on three mixed sex wards (K1, K2 and K3) for those aged at the Rivington Unit at Royal Bolton Hospital. The Trust is moving to an ageless service within in-patient service. These wards are currently subject to an ongoing refurbishment and upgrading programme to improve the physical environment (improved observation, privacy and dignity on the wards with single rooms for all adult mental health service users, improved access to bathing and toilet facilities, better accommodation for activities, carers visiting, etc), and more efficient, effective use of beds. In order to achieve this, overall acute beds will be reduced from 71 to 57. K1 currently has 24 beds but will be reduced to 18 beds after refurbishment K2 currently 23/22 beds going down to 15 beds 10 There is also one consultant specialising in learning disabilities, not included here. $&

47 K3 has 24 beds and will remain the same as single rooms are already provided There is no dedicated Section 136 Assessment Suite provision within the Rivington Unit a small room is utilised in the A&E Department for such assessments, although this is not designed for this purpose Psychiatric intensive care beds (PICU) There is also a 6-bed PICU service provided on a Trust wide basis based at the Rivington Unit, Maple House, which is not directly affected by the capital redevelopment programme. GNWFT is investing in this resource to provide seclusion facilities which will be available from March 2012, although this will not increase the capacity of the unit Community accommodation as alternative to hospital admission There is one crisis bed available through Bolton Council, which supports people in respect of social crises that may link to a mental health issue, but this does not function as an alternative to hospital admission as the threshold is much lower A&E liaison service There is no specialist A&E liaison service with dedicated staff available at the Royal Bolton A&E Department. The CRHT provide an A&E assessment service as an integral function. 3 Current pattern of acute care pathway service delivery 3.1 The wider referral and triage process The gateway to secondary care mental health services is notionally via the Single Point of Access (SPoA) service, which is provided from within the Primary Care Psychological Therapies service, managed by BFT. The intention was that this should be the single point of contact for the catchment area for all new referrals, bar crisis/emergency referrals, providing effective screening and triage to enter secondary mental health services. In part, the rationale is that this service should help define and manage thresholds of care for primary care and secondary care, by providing prompt triage, advice and guidance, through an integrated care pathway approach, on the appropriateness of referral to secondary mental health services. In practice this arrangement does not work. The SPoA service operates as a psychological therapies service for mild to moderate mental health problems, routinely screening out nearly all service users with any past use of secondary mental health services who are redirected to the CMHTs. The current SPoA arrangements cause a good deal of confusion regarding eligibility and access to services. They are unpopular with both the GPs making the referrals and the secondary care services and clinicians to whom they are redirected. One GP stated that when $'

48 he has a (new) service user who needs to be seen urgently they will likely get bounced between the SPoA and the CMHT or CRHT and noted the risk that while this was going on an urgent situation can easily escalate into a crisis. There are no agreed integrated service access and eligibility criteria, and working relationships between the SPoA service and the CMHTs are poor. In some cases the criteria being applied by these services are contradictory and disputes as to which is the responsible team are common. GPs now increasingly bypass this system and continue to refer directly to sector consultant psychiatrists, to the CMHTs, and for urgent/crisis cases, direct to the CRHT team, or wherever they are most confident of getting a response. In practice, there are multiple points of access into the service for new referrals outside the SPoA service. 3.2 The community acute care pathway Acute care referrals of service users who are seen to be in crisis or at risk of admission are all directed to the Crisis Resolution Home Treatment team. The CRHT service should carry out a face-to-face assessment as to whether admission is appropriate (gatekeeping) and ensure intensive home treatment is offered without delay to those who can be managed in the community. CRHT pick up all urgent out-of-hours acute referrals, most commonly from A&E but also via the out of hours telephone helpline (see data analysis in Appendix 3). While the CMHTs do try to provide a rapid response for emergency referrals of known service users it is reported that the capacity of the CMHTs to respond to urgent situations is limited by high caseload size, low throughput, and the operating hours of the service. In most cases, if there is a need for a service user to be seen urgently by a consultant psychiatrist, they will need to be brought to the hospital unit. It was reported that obtaining a consultant or other medical member of staff to undertake a home visit at the request of a CMHT was extremely difficult to achieve. A consistent approach is lacking amongst the CMHTs and the sector consultant psychiatrists regarding which service users need to be retained on their caseloads and who could be discharged back to primary care. There are examples amongst some consultant psychiatrists of reviewing caseloads and moving people back to primary care, whilst others have the view that people would be at greater risk of relapse if this occurred, and therefore retain high caseloads. This in some cases means that significant numbers of stable long-term service users who could be managed in primary care services are retained while the service is not able to provide a prompt community response to acute needs. Several consultants have undertaken individual initiatives to discharge people from their caseloads that do not need a secondary care service, although this has not been undertaken systematically across all of the Bolton secondary care caseloads. A number of those interviewed expressed concern at the extent to which the service is drawn into the hospital, and argued that the sector consultant psychiatrists and outpatient clinics, which are hospital-based, should be based with the sector CMHT. We need a more community-based mental health service, offering ready inreach to acute beds/expertise so the vast majority of patient contact takes place in the community, not the hospital. (GP) $(

49 We could do with [the consultants] being based in the teams but some consultants rationalise why they need to be in hospital they wouldn t like to be in the community. (community team staff member) The impact of a lack of community service capacity to respond to urgent need is to increase the proportion of the CMHT and consultant caseload that are deemed to be at risk of crisis or admission referred to the CRHT. Demands on the CRHT and the size of their overall caseload mean it is very limited in two ways. Firstly, in its ability to respond to requests for face-toface assessments in the community, and then to work collaboratively with the CMHT care cocoordinators; and, secondly, in the number of potential admissions for whom it can offer the alternative of intensive home treatment. Service users and others we interviewed informed us that there is now an understanding amongst many of them that when they are in crisis and are seeking an admission, presenting at A&E, particularly out of hours, is the best way to guarantee access to a service and to get admitted to a bed. This of course increases demand on the A&E department, the ambulance and police services, and the high readmission rate of the in-patient psychiatric service. Now I go to A&E to get fast tracked onto K3... it s the quickest way to get a response. The reality is that the CRHT does not have the capacity to fulfil its remit, and it is not able to maintain an emphasis on working with those who would otherwise require admission to hospital, and on preventing avoidable admissions. In practice, this leads to many admissions being agreed by the sector consultants without consideration of home treatment as an alternative. Relatively few other admission requests are assessed/gate-kept face-to-face prior to admission by the CRHT, except for those coming via the A&E Department. In the absence of an effective screening and triage function at the point of entry to the secondary mental health service, the majority of consultant (and a proportion of CMHT) requests for in-patient admission are simply processed through without face-to-face assessment. The role of the CRHT is in many cases reduced to that of bed finding. This in itself leads to conflict between the CRHT service and the ward staff over bed availability and appropriateness of admissions. In the absence of dedicated A&E liaison service provision, the CRHT is drawn into undertaking many assessments, particularly via the A&E department. CRHT is under pressure from the A&E department to see people with mental health presentations in order to avoid breaches of A&E waiting/treatment time targets. The majority of these are people who they should not be seeing as part of their secondary care service user group (for example, those solely with alcohol misuse and substance misuse problems), who are not at risk of admission, and for whom they can offer relatively little. At night, CRHT cover consists of one CRHT practitioner who responds to requests from A&E for assessments, and who is also staffing the crisis helpline. It was reported that five referrals in one night is not unusual. This high A&E usage as a means of accessing mental health care is contributing to inappropriate and revolving door admissions. The CRHT staff we met are very committed, but feel besieged. They acknowledge that they are completely overwhelmed by the work: $)

50 We are pulled in all directions this is the team that cannot say no. We are having all this risk referred to us without the resources to manage it. Feedback from GPs, service users and carers on the CRHT was mixed. The above pressures lead to the CRHT service having a poor reputation with some service users and carers who have been denied a service or provided with a less intensive service, but others were very positive about the help received. 3.3 Admission in-patient wards While our principal focus has been on reviewing the effectiveness and capacity of the care pathway, rather than on the quality of the in-patient service, we recognise the interdependency of these issues. Overall, we found the culture on the wards and staff attitudes to be positive and not lacking in therapeutic optimism. In general, service user feedback was positive, in line with the recent CQC evaluation. Carer feedback was more variable, with mixed experiences. Progress is being made and there are some welcome initiatives underway, such as increased psychology input focussing on the training and in-service development of in-patient staff, and the development of service user involvement on the wards with the service user organisation BAND. In interviews with ward managers, clinical leads and many of the consultant psychiatrists, there was a general consensus that the planned reduction in bed numbers is appropriate and manageable with improved community services. There is agreement that with fewer beds and smaller wards, an improved physical environment and a better nurse / service user ratio will be helpful in developing a more purposeful, therapeutic, and recovery-orientated in-patient care milieu. There were a number of key issues raised in these interviews, including: Committed skilled in-patient staff but very stretched due to high bed occupancy. This presents difficulties in ensuring sufficient one-to-one time for staff engagement with service users, and for engagement with carers. Ward staff, consultants, CRHT and community staff reported many avoidable and inappropriate admissions that, with strengthened gatekeeping and availability of home treatment, could be managed in the community. Similarly, early discharge of more service users could be facilitated by a strengthened CRHT function. The wards and community teams are not as engaged as they should be in terms of informed care and collaborative risk planning to reduce length of stay. Protracted lengths of stay and delayed discharges mean service users get stuck in the system. Difficulties with the number of ward rounds and management styles for in-patient teams to work around. Difficulties in developing a genuine MDT approach. The need for better strategies with regards to how to manage high use by service users and people with personality disorders and those with substance misuse problems. %+

51 Well co-ordinated review and discharge arrangements are essential in ensuring optimal use is made of in-patient provision, and in maximising the therapeutic potential of the wards. Review of in-patients is by formal ward rounds, usually on a weekly basis. Early discharge is not routinely facilitated; there is no same-day review system in place. It was reported that service users sometimes remain on the ward for some days after they are ready to discharge. There are acknowledged difficulties in ensuring care co-ordinators attend ward rounds when their service users are being reviewed. There is a weekly review meeting (the Link Meeting) between the in-patient wards and community team staff to discuss CPA cases and potential/planned discharges, particularly in respect of housing issues. However, in general, care co-ordinator involvement with the wards is not robust. Both the wards and community services report difficulties in achieving effective dialogue and joint care planning, particularly regarding discharge arrangements with the involvement of the care co-ordinator. Lack of supported housing/care packages was cited as a regular reason for protracted delayed discharges. 3.4 Community and voluntary sector supports to the acute care pathway services Voluntary sector day and community support services in Bolton is a thriving sector of provision, including: Bolton Carers Support provides support for any carer over 18 and runs courses for carers. It also provides support through MhIST (see below). STEPS (Supported Training and Employment Programmes) run a number of projects working with people who have used mental health services, and try to get people into paid work; they work with about 50 people each week. BAND support drop-in centres throughout Bolton, with many open for 365 days a year, and in-reach into in-patient wards. They have developed additional services including 1:1 support project, working around recovery and helping people to achieve their recovery goals. They have identified small groups of people with shared interests who do things together and who support each other. Delivering Race Equality workers are also employed at BAND and they work on service user representation, as well as specific projects. St. George s Day Centre provides a four-day-a-week service for anyone with a mental health problem, and offers one day per week as a counselling service. It assists in getting people ready for employment opportunities, and also provides therapeutic activities and support to members outside the centre. The Centre works with 180 members, of whom only a few are in other services. BEST (Bolton Employment Support Team) Bolton Council staff seconded into GMWFT to work with secondary care service users to set up work placements and volunteering. Placements can vary from a few hours a week, as allowed through permitted work. They also support people in employment and volunteering, and work with around 80 people. MhIST independent support team that provides advocacy and self help groups, social groups, courses to build self-esteem, information and support to people in supported accommodation. %*

52 Active Choices an initiative where Bolton Council employees are seconded into GMWFT but are doing various 1:1 community-based initiatives with people to get them into mainstream social and leisure activities. Move Forward Bolton is an umbrella organisation that includes many of these services and helps to coordinate activity. Bolton Counselling Alliance another umbrella group that draws together a range of organisations providing talking therapies of various forms. These services are highly valued by their service users, who place significant emphasis on mutual support, meaningful activity, having a social life, and knowing there is someone they can turn to for support. We interviewed representatives of some of these organisations, who raised a number of concerns, including: The confusion in the referral route where they experience difficulty in making a referral to the mental health service while they report receiving the majority of their referrals from NHS sources. A sense they were making a contribution that significantly underpins statutory services while not being reciprocally valued. The need for a recognised way for relevant voluntary organisations to liaise with GMW trust, and for their involvement to be encouraged in planning and developing future services. Service users expressed: Their concerns about cutbacks in availability of drop-in and day services. A need for a better balance of hospital and community services, including a preference for having outpatient services available in the community. A wish for better practical support at their community centres. Would be even better if we had linked CPN or professional staff who came to centre. 3.5 Summary of data analysis (see Appendix 3 for greater detail) Data was provided by Greater Manchester West NHS Foundation Trust (GMW) for the period 01/09/10 and 31/08/11. Data was raw data extracted from the ICIS clinical record system and has been used to explore routes through services. This may contain differences to performance report data and will have been cleaned of errors at source. Nevertheless, differences between the two data sets are likely to be minimal. In essence, our work is intended to identify key themes across the care pathway that link to the qualitative data gathered through documentary and interview sources. The analysis presented here examines the referral pathway and those people who are high users of in-patient beds. General Practitioners made the largest number of referrals into secondary mental health services, accounting for almost one quarter of all referrals across the whole system. %"

53 The CRHT received 2,916 referrals during the year (an average of eight per day), which is over ten times more that are triaged through the single point of access (SPoA) to secondary care. This excludes helpline advice provided by the CRHT. The lack of an effective triage system, lack of an A&E Liaison service, and inappropriate expectations faced by the CRHT all contribute to this high number. A&E to CRHT was the most common referral route across the service system. In addition, virtually all referrals made by A&E are to the CRHT. This confirms the view of people working the services that the CRHT is being drawn away from its primary role of working with secondary care service users to reduce their in-patient usage, and is drawn into assessing people who are unlikely to require secondary care mental health services. In total, 41.0% of all referrals to the CRHT came through the A&E Department and a further 11.5% came from GPs. Only 56.4% of all CRHT service users have been given a primary mental health diagnosis at their last contact. This may suggest that the CRHT is assessing a significant number of service users who may not have a mental health problem. The majority of adult in-patient episodes record GPs and the CRHT as source of referral. The largest proportion of people admitted to adult in-patient wards go through A&E (31.4%). The majority of service users who have been subject to Section 136 have contacts with other mental health services (84.5%). However, this does mean that there are almost 100 individuals who have been the subject of Section 136, and have not ended up in a service. Section 136 service users show a very similar referral pathway to all service users and almost half have had an in-patient episode over the period. There are a small number of people who utilise a significant proportion of the in-patient bed days (n = 106). These people are likely to have experienced movement between three services over a two-day period. They are also likely to have had contact with the AOT, and had minimal contact with the CRHT. Finally, they are also likely to have complex needs as indicated by their lengths of stay, time on CPA, frequency of contact, and primary diagnosis of psychosis. The number of people who are admitted to adult acute wards from a temporary place of residence was nine, whereas the number discharged to a temporary residence is 65, an increase of 722%. This requires further investigation. 4 Review findings 4.1 Overview The overall impression gained is that while it has a number of examples of good practice service provision, with committed and expert staff, the Bolton acute care pathway lacks clear definition, and is poorly integrated with current arrangements not utilising its resources to best effect to ensure an effective community response to crisis referrals leading to regular avoidable admissions and protracted lengths of stay. %#

54 The Trust is currently considering how to redesign its service model and care pathway for both hospital and community services; some of this work was being undertaken during this review. The primary weaknesses of the current arrangements are: The lack of shared values, principles and processes across all components of the care pathway. There is a lack of an agreed, consistent approach to risk assessment and acute care pathway management. Tensions between care pathway services undermine mutual acceptance and confidence in inter-professional decision-making and clinical assessment. The care pathway is disjointed, with little evidence of integration from point of referral through assessment, care planning, and discharge. Numerous barriers to good communication and co-operation across the acute care pathway. Too much of the service is hospital-based and hospital-focused. There is no consensus regarding the appropriate model of care and the thresholds of care. Current arrangements fail to facilitate a focus on distinguishing between meeting the needs of those who require acute and short-term interventions and those who need a more long term recovery and rehabilitation focused service. Assessment, triage and gate-keeping arrangements do not provide an effective single point of access or expert triage to ensure clear routing of referrals from the start and a prompt response to crisis /acute care situations. An inability to achieve and maintain throughput and manageable caseloads. There needs to be a greater emphasis on purposeful, time limited interventions, and on targeting clinical expertise where and when it is most needed. Early/timely discharge from in-patients is not routinely facilitated, except when there is pressure on beds. The lack of a dedicated A&E mental health liaison provision. CRHT remit is beyond its capacity to deliver safely or effectively. The need to develop more alternatives to in-patient admission on the acute care pathway for high use service users. The lack of a service development forum for the involvement of key stakeholders. 5 Development issues and recommendations 5.1 Overview of development issues/recommendations These fall into 14 key areas: 1. Defining the model of care and redesigning the care pathway services to deliver that model 2. Access and triage arrangements 3. Primary care/secondary care interface 4. Acute care service capacity 5. Need for a dedicated liaison service 6. Care pathway management arrangements 7. Review and discharge arrangements 8. CPA Care Coordinator involvement %$

55 9. Personality disorder 10. In-patient services 11. Community and voluntary sector supports to the acute care pathway services 12. Acute care access for anyone over 16 years of age 13. Improving communication 14. The role and location of the Psychological Therapies Service Good practice examples are also highlighted at the end of this section. Below is greater detail of each of these areas. It should be noted that some of the suggested ways forward are applicable to more than one area. It should also be noted that the continued implementation of the personalisation agenda through self directed support is likely to have an impact on the way services are developed and delivered in the future in Bolton. 1 Defining the model of care and redesigning the care pathway services to deliver that model. An agreed service model for secondary care is needed. This requires the commissioners and providers to agree a clear model for the overall acute care pathway. This should also be described in the context of the wider mental health service system. An example is provided in Appendix 4, although this is purely for reference. (1) Recommendations on defining the model of care and redesigning the care pathway services to deliver that model A high-level Task and Finish Project Group should be established to determine the model of care and preferred service structure. The focus of this work should include: A clear definition for acute care Reducing health inequalities Risk management rather than risk aversion ( risk dumping ) Clearly defined thresholds for access to service components Secondary care SPoA Referral and management arrangements between primary and secondary care This work should be time limited and the resulting model should be signed off by the Mental Health Stakeholder Board 2 Access and triage arrangements There needs to be a 24/7 single point of access (SPoA) to triage urgent and non-urgent referrals, and to ensure consistently applied and managed gatekeeping. %%

56 Current single point of access arrangements and referral routes are confused and ineffective. While a single point of access to secondary care mental health services is essential to manage demand, we question whether this can best be managed by a primary care service that is not in a position to provide the expert triage or to promptly activate the service response required. The effectiveness of the GMWFT acute mental health services is not solely dependent upon the actions of the CRHT and in-patient services. Its performance is heavily influenced by how acute care is integrated within the operation of the wider secondary mental health care system. (2) Recommendations on access and triage There should be a single point of access at the point of referral to secondary mental health care, and it should be managed by GMWFT. There should be better alignment of the current CMHT and CRHT triage, assessment and urgent care arrangements, with the introduction of a common point of access/referral and triage and duty system. This could be provided by a duty system, comprised of a rota of senior experienced clinical staff to ensure expert triage and a prompt response to urgent /acute care referrals. The CRHT should gate-keep access to in-patient beds on a face-to-face basis. Consideration should be given to developing an out of hours duty night assessor service (delivered outside any A&E Liaison Service). Current multiple referral routes into the service should be addressed and streamlined. 3 Primary care /secondary care interface Mental health services cannot take on everyone without diluting the acute care service response. The absence of effective and co-ordinated access and triage arrangements, with agreed and operationalised care pathway eligibility criteria, undermines determining appropriate primary care and secondary care mental health thresholds. This limits the ability of the secondary mental health service to concentrate specialist expertise when and where it is most needed. It also hampers the development of provision of mental health treatment services in the primary care setting to improve access and choice of treatments in line with relevant NICE clinical guidance (anxiety; depression; psychotic illness; obsessive-compulsive disorders), and it will not help in developing the necessary consistency required amongst GP practices as to who should be on the practice registers of severe mental illness service users. It is clear from developments elsewhere in the country, and our discussions locally, that most GPs would be willing to take back and improve care arrangements in primary care for long term but stable service users, as a trade off for a more guaranteed prompt community response to urgent acute care situations. Keeping such service users on long term CMHT and consultants caseloads can be seen as counterproductive to their recovery, social inclusion and overall wellbeing. %&

57 Effective plans to address service user, carer and GP concerns, to ensure a prompt response if such service users relapse, can be addressed by the introduction of fast track quick access arrangements. There is a need to ensure GPs are kept aware of local acute care service issues, and how services operate and can be further developed to support primary care. Their early involvement should be sought in any plans to reconfigure the service model, which they will be increasingly responsible for commissioning. (3) Recommendations on primary care/secondary care interface There is a need to achieve a consensus view regarding thresholds for access to secondary and primary care services. These should be agreed between primary and secondary care. People on the secondary care caseload who experience stable long term mental health problems should be transferred to primary care services with arrangements for prompt access to re-engage the mental health service if required e.g. the Somerset Orange Card system 11. There should be an agreed joint approach between primary and secondary care to respond to disagreements about referrals. There is a need to agree a shared approach to arbitration with GPs about referrals that are received from primary care and that are deemed inappropriate. Clear standards on providing prompt feedback to referring GPs should be developed; this could build upon local pilot work in this area by one consultant. 4 Acute care service capacity: CRHT and current and planned levels of in-patient provision Acute home treatment is a proven safe and clinically beneficial alternative to admission when it is well delivered. Clearly, current care pathway arrangements mean that the ability of the current CMHT to provide this service is severely compromised. There is a need to introduce much more robust face-to-face gatekeeping arrangements, and to boost home treatment capacity to maximise both the availability of this alternative for all potential admissions, and also the quality and efficiency of the in-patient services. There is also a need to develop community-based alternatives for those who otherwise would not need to be in hospital. We want to see everyone who needs help receiving it in a timely way and the crisis (or pre-crisis ) response becoming the start of recovery. There should be more options for people in crisis more gateways into help and more kinds of help so that the requirements of all groups and communities can be satisfied. People should be understood in the context of their own lives, and friends and family members be supported. (Listening to Experience, MIND 2011) 11 e_co.aspx %'

58 On the balance of hospital/community resources we consider the planned acute in-patient bed capacity to be adequate but capable of further reductions once our recommendations are fully implemented. Despite current pressures on the acute admission wards, bed numbers are not the core issue. It should be noted that: Better gatekeeping and integration between community and hospital acute care would reduce the number of avoidable admissions and protracted lengths of stay. A dedicated A&E liaison service would reduce the number of admissions and free the CRHT service to fulfil its remit of reducing dependence on in-patient beds. The threshold of confidence about who can be effectively managed in the community can steadily improve with the implementation of a more focused acute care pathway. There is a lack of community alternatives to admission and a lack of supported housing to avoid delayed discharge. Many of the service users who make high use of in-patient beds, such as people diagnosed with a personality disorder, could be more effectively managed to reduce their reliance on in-patient services, which is not the best place for them. (4) Recommendations on acute care service capacity CRHT service should be enabled to effectively gatekeep all admissions face-toface, and should have the capacity to provide home treatment to all potential admissions who would benefit. Consider additional resourcing of CRHT function to maximise its capacity to provide home treatment for service users who are currently admitted/readmitted. Planned levels of in-patient provision are adequate but should be kept under regular review in the light of improved community acute care pathway performance. With effective whole system working there should be future opportunities to improve the nurse / service user ratios through reducing beds. Further analysis should be undertaken of the data that is available for people who have regular repeat and lengthy admissions, in order better to understand this service user group and to develop strategies to reduce their dependence on in-patient provision. Consider further development of crisis/respite house provision as alternatives to in-patient admission, for example for those with a personality disorder diagnosis. There is currently only one bed that serves as a crisis bed in the community. 5 The need for a dedicated liaison service Provision of an effective liaison service is an essential underpinning of any local acute mental health care pathway and should be a core component of mental health and general hospital care pathways. This service would need to cover both A&E and the BFT general hospital beds. Its focus should include dementia, mental health, substance misuse, and alcohol misuse. %(

59 The lack of a local service is disabling the CRHT service from fulfilling its function, and this has knock-on consequences for prompt risk assessment, identification and management, demand for beds, and the holistic effectiveness of the general hospital service. Notably, there is a very high number of people admitted who initially presented at A&E, and the high proportion of these have substance misuse problems. Greater understanding is needed of people who regularly present at A&E. This should inform the skill set required to effectively work with these people. A combination of professional skills is likely to be required. There is increasingly clear evidence that such a service can cost-effectively improve the physical and mental health of patients of all ages, with A&E liaison services being considered for funding under QIPP in many areas. (5) Recommendations on A&E liaison service A dedicated service is required in line with the recommendations of the Academy of the Royal Colleges report (2008) (see Appendix 5 for recommendations from this report). We recommend the development of a mental health A&E liaison is prioritised and explicitly recognised as a core component of both the mental health and the general hospital care pathways. There is a pressing need to expedite the development of this service. 6 The balance of care pathway services and care pathway management arrangements There remains considerable work to be done on the balance between hospital and community based services and cultures in Bolton. As stated above, a number of those interviewed expressed concern at the extent to which the service is drawn into the hospital and argued that the sector consultant psychiatrists and outpatient clinics, which are hospital-based, should be based with the sector CMHT. We agree that the sector consultants need to be with their teams, engaging in a clinical leadership role within the CMHT structure and involved in the development of CMHT and sector catchment area services. Furthermore, sector outpatient clinics should be moved to the community where readily accessible arrangements for seeing urgent cases should be ensured. Current key acute care pathway management arrangements should now be reconsidered. Acute care pathway positive collaboration needs to be more evident. There is a lack of an agreed, consistent approach and of an overall clinical consensus between community and inpatient care pathway services. Differing hospital and community cultures were frequently cited, by both parties, as being problematic. This lack of consensus and dialogue compromises consistency of assessment, care planning, risk management and throughput. It further %)

60 diminishes the opportunities to develop collaborative care planning and delivery, multidisciplinary input to the wards, or to promote community engagement initiatives. 6. Recommendations on the balance of care pathway services and care pathway management arrangements The sector consultant psychiatrists and their outpatient clinics should be based in the community, along with their clinical teams. The Trust should consider the strengths and weaknesses of continuing to have separate management arrangements for hospital and community services (i.e. hospital service managers and community team managers, as opposed to sector managers with some in-patient beds). The Trust should also consider the advantages and disadvantages of developing dedicated acute care lead consultant arrangements as emerged from New Ways of Working 12. This often takes the form of having consultant psychiatrists who specialise in acute care (in-patient and CRHT) along with other colleagues who operate in non-acute community teams. 7 Review and discharge arrangements Current acute care review and discharge arrangements need improving. We suggest the piloting of a system which looks at replacing ward rounds and facilitates the development of multidisciplinary practice on both ward and community teams. The Trust should investigate the establishment of a system (joint meeting, or similar, of key CRHT and in-patient clinicians) to clinically review the current acute care caseload (in-patient and CRHT) on a daily (weekday) basis, with the power to agree discharge/transfer of service users. A number of other Trusts acute care services (in-patients and community) have successfully implemented a daily review meeting (for one hour a day, in the morning) to review the acute care caseload, identify barriers and solutions to smooth movement through the pathway, and to make discharge decisions. This arrangement can replace over-reliance on the traditional ward rounds and may help to guarantee CPA Care Coordinator attendance. 7. Recommendations on review and discharge arrangements Daily Acute Care Team meetings should take place to review the current acute care caseload (in-patients and CRHT). This group should have the power to discharge/transfer service users. Use of teleconferencing should be considered to support this, if required. Consider new ways of working and roles to bridge hospital / community gap, *",--./ , :;5<=7>:3,04957.=03,:3?4?-@A@==B-=0C3,0CB<035;7>B<-=03?4?-@ A@==B-03,:$*""#$#2.3D &+

61 including rotational posts. 8 Acute service care co-ordinator involvement Care co-ordinators need to be more proactively involved with their service users whilst they are admitted to the wards. We recognise that some are highly involved. However, this should be the norm. If the service user is so unwell as to require admission, then they should be receiving a more, not less, intensive input from their care co-ordinator. As part of the development of the care pathway protocols recommended above, agreed standards for ensuring care co-ordinator involvement with the ward should be developed. These should define levels of involvement in care and discharge planning, from point of admission onwards. Service users and their carers / families should also be involved in the development of these standards. 8. Recommendation on care coordinator involvement We recommend standards are set to ensure minimum levels of care coordinator contact with service users and in-patients staff, these should include: o The care co-ordinator will continue to provide face-to-face contact with the service user for a minimum of x times per week. o The care co-ordinator will review the service user s progress with the service user s key worker/named nurse at least weekly, to co-ordinate care planning and resolution of any issues that may delay discharge. o The care co-ordinator will meet with the key worker/named nurse and service user for a pre-discharge meeting within one week of the discharge date. o Where there is no existing care co-ordinator for an acute care service user, one is appointed by the respective team manager within x days. A system of auditing the contact of CPA care coordinators with their service users whilst they are in-patients should be implemented. (NB = x to be agreed) 9 The service for people diagnosed with personality disorders (PD) Developing more specific provision for people diagnosed with personality disorders would be desirable, as in-patient care is rarely the best option for these service users. Over-reliance on hospital admissions is likely to be counter-therapeutic. National evidence indicates that many service users with personality disorder see in-patient admission as highly desirable and can gain admission through increasing their risk behaviours. An options paper is required for how to best meet the needs of this service user group and should include: Review of research and best practice. &*

62 Education options for service users to change views about in-patient admission as a desired goal. Role of A&E liaison in dealing with personality disorder presentations. Models of working between alcohol / substance misuse services and secondary mental health care. Specialist practitioners in CMHTs. Primary care liaison for people with personality disorders. Alternatives to hospital admission. 9. Recommendations on service for people diagnosed with personality disorders (PD) An options paper should be produced to develop greater clarity on how best to develop targeted provision to meet the needs of people diagnosed with personality disorders, including their needs for in-patient care. Development of alternatives to traditional in-patient admission and/or development of crisis/respite house provision, to include a more specific and specialist personality disorder component. 10 In-patient service The review of the length of stay data indicates that there are a number of groups within the inpatient population who might be targeted in relation to their interventions. For example, some people are admitted for very short periods, likely in crisis, which may be supported outside hospital. There are also a number of people who have very lengthy stays, who may also require specific targeted intervention, and a smaller group of people, mainly with personality disorder diagnoses, that have a high number of repeat admissions. Also, from the data it is apparent that more people leave hospital and move into temporary accommodation than are admitted from temporary housing. This requires further exploration to determine if this is a data recording issue or if it is something that requires intervention. If people are becoming homeless as a result of their contact with acute in-patient services this would be extremely counter-therapeutic. There should be a review of supported accommodation options available to provide short-stay home support packages or longer term supported housing that facilitates a step down from inpatient provision for delayed discharges. While we acknowledge that funding for home support and supported housing is at risk in many parts of the country, such provision should reduce admissions and delayed discharges for people with long-term illnesses, and should provide them with more appropriate and cost-effective care. &"

63 10. Recommendations on in-patient service GMWFT should consider the merits of developing a specific focus on relapse prevention, with particular attention paid initially to in-patients with high readmission rates. Identify people who have repeat admissions and establish a targeted recovery programme for these service users that could commence on the ward and continue in the community after discharge. GMWFT should consider how dual diagnosis expertise within Bolton could support such a recovery programme. Health and social care commissioners should review arrangements for access to supported accommodation care packages for those at risk of becoming long stay in-patients, and reconsider the high number of in-patients being discharged to temporary accommodation. Assess whether the current separate arrangements and interface for dual diagnosis/drug and alcohol services needs revisiting, in order to ensure consensus on thresholds for referral and admission. 11 Community and voluntary sector supports to the acute care pathway services Local voluntary sector, community organisations and service user and carer organisations provide key supports that contribute to the effectiveness of the acute care pathway, and in providing the support that service users and carers need to avoid crisis and hospitalisation. The services involved can be first point of call for those seeking help. There are some very good initiatives in encouraging improved service user feedback, such as those with BAND, but more could be done. Better links are needed between secondary care mental health services and the rich mix of local voluntary sector carer and service user organisations, to strengthen their voice in the planning and development of services. Several of the interviewees we saw from these organisations felt that tangible practical partnership working could be improved. Potential practical partnerships suggested included: CPN advice sessions in day services / drop ins. Development of carer groups. Advice pathways (i.e. how these services obtain advice from secondary care). Referral pathways (i.e. confirm eligibility for these services to be able to refer into secondary care (via the SPoA) and into the Psychological Therapies Service). 11. Recommendations on the community and voluntary sector Ensure the active participation of service users and carers in taking forward this review, and in the planning and development of future services. Pay particular attention to how best to involve those from black and minority ethnic communities. &#

64 Work with local voluntary organisations to develop practical links, such as CPN advice sessions. 12 Acute care access for 16+ Young people who develop acute mental health problems often face difficulties because of organisational, service and age-related boundaries. Interfaces between services are variable at present and some young people need to go outside Bolton to receive the service they require. Obviously, economies of scale mean that all forms of specialist services cannot be provided locally. Whilst unmet needs were not reported during the review, this interface has been one of the most challenging across the country, and therefore requires ongoing dialogue and monitoring. It is helpful that discussion at the local CAMHS transition group examines these areas regularly. 12. Recommendations on improving acute care access for young people An audit of transfer arrangements for people moving from the Early Intervention team into the CMHTs could usefully clarify any transition problems and inform future solutions. Consider further alternatives to acute hospital admission for young people in crisis between commissioners, providers and other stakeholders, including access to the CRHT for people between 16 and 18 years of age. A review of the needs of young people who are placed out of area could usefully take place to determine how alternatives to hospital might be developed locally. 13 Improving communication /Acute Care Forum Communication is a key factor in managing and delivering support through complex service systems. Any approaches that improve communication reduce risk, aid service and development, and also support efficient use of services. 13. Recommendations on improving communications Establish regular forums to discuss and review care pathway working. At a strategic level there needs to be a forum where people working in the acute care pathway, and closely connected to it, can regularly reflect on and review how it is operating, and recommend changes to the system and ways of improving effectiveness and efficiency. &$

65 14 The role and location of the Psychological Therapies Service The Psychological Therapies Service is managed by BFT and provides a range of psychological therapies to people in Bolton. It has been the location for the SPoA into secondary care, although it has not been able to fulfil this role due to multiple access routes into secondary care being in operation. There are variations between the thresholds for primary mental health care and secondary mental health care, and these create a risk across the service system. There is not the flexibility between primary and secondary mental health care at present to reduce this risk and have thresholds that serve the best interests of service users. Whilst some people working in the service disagree with us, our view is that this risk is better managed by one organisation rather than across two organisations. It has been suggested by BFT that prior to any changes in relation to the location of this service i.e. which organisation manages the service that commissioners review the evidence for locating it within GMWFT. 14. Recommendation the role and location of the Psychological Therapies Service In order successfully to manage the variations in thresholds between primary and secondary care, mental health services and the associated risk the Psychological Therapies Service commissioners should consider how this service could be delivered through GMWFT. 5.2 Good practice During our review we met many good clinicians, practitioners and managers. Their enthusiasm and motivation needs to be better harnessed in order to innovate and develop good practice further within Bolton. Amongst the examples of good practice we identified were: Dedicated psychology input to acute wards. Development of standard follow up letters to GPs from consultant psychiatrists. The implementation of reviews for in-patients with 50 and 100 day stays. A very active local third / community sector. Development of service user involvement through BAND. Achievement of key performance targets across all GMWFT provided services. Positive outcomes from GMWFT service user and the service user satisfaction survey A positive and motivated workforce across the care pathway. 6 Conclusions and next steps A wide range of policy and good practice has been written over the past 12 years that relates to both the acute care pathways and the system within which it operates. Much of the service system in Bolton accords with both the policy and good practice. However, there is a need to further develop the service system in order to maximise the benefits of the total resource in such a way that it works to best effect for service users and their carers. This requires the &%

66 acute care pathway to operate within the wider mental health system, and effectively to draw together both hospital and community services. The process of moving from where the services are right now to where they should be, will be enhanced by two key factors. Firstly, throughout the review, stakeholder organisations, and in particular GMWFT, have given strong indications that they are prepared to further develop the mental health services in Bolton, not just the acute care pathway. The key critical factor to future success will be the development of Bolton Mental Health Stakeholder Board. This has been agreed as a high level strategic Board that will oversee the dementia agenda as described here, and other areas that lie outside the remit of this report. The Mental Health Stakeholder Board will consist of Board Level personnel from NHS Bolton, Bolton Clinical Commissioning Group, Bolton Council, Greater Manchester West NHS Foundation Trust, and Bolton NHS Foundation Trust. This Board will report directly to the Bolton Health and Wellbeing Board and will feature as a standing item on its agenda. The Terms of Reference for the Mental Health Board will need to be signed off at the Health and Wellbeing Board. &&

67 7 Acknowledgements We would like to acknowledge the support of a wide range of stakeholders who participated in this review, or who facilitated access to information, or who coordinated aspects of the project. These have included service users, carers, clinicians and practitioners, service and organisational managers, commissioners, administrators, data analysts, third and independent sector colleagues, and local politicians. Without their support in the process this report would not have been possible. We are very grateful for the time they gave generously and openly to the review. We recommend that all participants in the review receive a copy of this report or the Executive Summary. &'

68 Appendix 2 Policy background and key documents Significant guidance has been developed over the past 12 years through a number of key policy documents that relate to the acute are pathway. These include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

69 E73?-P5>>?==?5<I"+*+J3"N$/$8$&F(+*8%?+-*8($&("7?'#(/*&#"'(5*"'#52L5<35<KE73?- :XB.59-:YW`MWY2.3D &)

70 Appendix 3 Data analysis Data analysis Data was provided by Greater Manchester West NHS Foundation Trust (GMW) for the period 01/09/10 and 31/08/11. The data was raw, extracted from the ICIS clinical record system, and it has been used to explore routes through services. This may contain differences to performance report data and will have been cleaned of errors at source. Nevertheless, differences between the two data sets are likely to be minimal. In essence, our work is intended to identify key themes across the care pathway that link to the qualitative data gathered through documentary and interview sources. The analysis presented here examines the referral pathway and those people who are high users of in-patient beds. All referrals Considering all referrals 13, including those within individual episodes, GPs make the most referrals into mental health services with 2,594, which accounts for 24.8% of all referrals over the 12-month period. Significant referrers behind GPs are consultants with GMW FT ( this Trust 14 ) (21.4%), consultants outside GMW ( other Trust 15 ) (12.2%), A&E ( not GMW 16 ) (12.1%), and the Community Mental Health Team (8.7%). The service receiving the most referrals was the Crisis Resolution Home Treatment Team with 2,916 referrals over the period, which accounts for 27.9% of all referrals. Following this are the various Elderly and Adult Sector services in Bolton: South Elderly (10.1%), North Elderly (8.8%), South Adult (7.0%), and North Adult (6.7%). The following table shows the most frequently used referral routes for all Bolton service users. The most common referral route is from A&E ( not GMW ) to the Crisis Resolution Home Treatment Team, followed by consultant ( other Trust ) to the Crisis Resolution Home Treatment Team. This confirms the views of staff in the services that the CRHT is extremely busy undertaking a large amount of assessment work. A&E and Consultant ( Other Trust ) make significant demands on the CRHT, which detract from its ability to undertake its role and to function as described in national guidance. The next highest referral route is then GP referrals to Elderly Sector services, which may be a key factor behind the positive view of older age Consultants held by the GP counterparts. ""#$%&%$$'"()#*+,$-%#'./#0%'1# # 2%&%$$'"(# 3%$-%.0# 456# 7$+1#89#:%;0#<#=+.#>?@#0+#A$B(B(#2%(+",0B+.#C+1%#D$%'01%.0#D%'1# ""#$ ""%& 7$+1#A+.(,"0'.0#4E0F%$#D$,(06#0+#A$B(B(#2%(+",0B+.#C+1%#D$%'01%.0#D%'1# $'( $%) 7$+1#>3#0+#=+$0F#9"/%$"G#*%-0+$## *#& *%+ 7$+1#>3#0+#*+,0F#9"/%$"G#*%-0+$# &+& &%* 7$+1#A+.(,"0'.0#4DFB(#D$,(06#0+#3FG(B+0F%$';G#D%'1#<#H.<;'0B%.0# &*' &%' 7$+1#A+.(,"0'.0#4E0F%$#D$,(06#0+#9"/%$"G#IB'B(+.#*%$JB-%# '+) '%* 13 Where ReferralID is unique. 14 Greater Manchester West NHS Foundation Trust. 15 Trust that is not Greater Manchester West NHS Foundation Trust. 16 Not GMW refers to services provided outside of Greater Manchester West NHS Foundation Trust. '+

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78 9+59)+ 8& ,2'**+, 0.52/ -4, %1:%+W1+4*)3,'%7&-.(+, *5/ - * ) %',+47+.'%+%0.524'4+*5@#/-4'47.+-%+50"AA^<F&+9'7*1.+,'00+.%05.5),+.-,1)* %+.>'7+ 1%+.%/ 8&+.+ 1%1-) 9) %',+47+ '% %*')) *&+ 25%* ,'%7&-.(+,+%*'4-*'54?-77514*'4(05.fD<"^505),+.-,1)*%'4C9-*'+4*+9'%5,+%8&+.+-,'%7&-.(+,+%*'4-*'54'%.+75.,+,B/:1*454CQRSTX-.+OQ1.%'4(R52+'%-)%5%'(4'0'7-4*?]E<]^50 -)).+75.,+,,'%7&-.(+,+%*'4-*'54%B< g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

79 4'31)5*()6(,)+005$%"07)*(28'0()5*(2*) ) F& DV@ %+.>'7+ 1%+.% 8'*& DVVh 754*-7*% AV 05. :+, / 25%*)3 5>+. - %'4()+%*-3'4&5%9'*-)?*&+.+-.+*&.++%+.>'7+1%+.%8&5&-,25.+*&-454+%*-3?'<+< 25.+ *& X-%+$454YZBBH '4 *5*-) *&+%+ %+.>'7+ 1%+.% * 05. 5>+. DE/VVV 754*-7*%8'*&'4*&+:+, ,-*-%+*?#V<V^50-)):+, *-7*%B<F&+ DV@%+.>'7+1%+.%-77514*05.DV[+9'%5,+%?'<+<DV[14'W1+X-%+$454YZL%B<Y4%12/*&+.+ %+.>'7+ 1%+.%.+%954%':)+ 05. ]"/f#v :+, *-7*%< F& / *&+ 9.+>'51%DV@%+.>'7+1%+.%-77514*05.-fE<D^50:+,,-3%<F&+05))58'4()55;%'4*5*&+ -7*'>'*350*&+%+%+.>'7+1%+.%-7.5%%*&+,'00+.+4*,-*-%+*%< F&+.+'%45,' (-.,'4(+*&4'7'*3:+*8++4*&+DV@&'(&1%+%+.>'7+1%+.%-4,-)) :+, %+.>'7+1%+.%/8&')%**&+.+'%-%2-))'47.+-%+'4*& *' '4*&+&'(&1%+%+.>'7+1%+.%/:1**&'%'%14)';+)3*5:+%'(4'0'7-4*/-4,*&5%+-(+,"VC"[ )';+)3*5:+-254(%**&+&'(&1%+(.519*&-4'%->+.-(+05.-)):+, %+.>'7+1%+.%< b-%+,54*&+'.)-%*.+75.,+,,'-(45%'%/*&+2-g5.'*350*&+%+&'(&1%+%+.>'7+1%+.%0-)) '4*5*&+%7&'e59&.+4'-/255,-00+7*'>+/-4,5.(-4'7,'-(45%'%(.519% AD <F&+*-:)+:+)58 %&58% *&+ 25%*.+7+4* 9.'2-.3,'-(45%'% 05. -)) %+.>'7+ 1%+.% AA < X529-.'4( *&+ *85 (.519%%&58%*&-*-,1)*&'(&1%+:+, %+.>'7+1%+.% )';+)3*5:+'4 *&+ %7&'e59&.+4'-/ %7&'e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`) P(A2+&'4Q)*&2(**#2(C%&(,)%",)*+/%&+D+2/),'*+2,(2*) " (&, +, ")&" [az#[a\) N(0%3'+A2%C)*.",2+/(*)%**+4'%&(,)R'&0)$0.*'+C+<'4%C),'*&A2-%"4(*I$0.*'4%C)D%4&+2*),,&, (,&# [bz#[b\) B'*+2,(2*)+D)%,AC&)$(2*+"%C'&.)%",)-(0%3'+A2) " (&, "# %&$ [cz#[c\) K(%2"'"<),'*%-'C'&.) ( '&" + "&) [`Z#[`\) B'*+2,(2*)+D)$*.40+C+<'4%C),(3(C+$/("&),,&, ",&% [\Z#[\`) N(0%3'+A2%C)%",)(/+&'+"%C),'*+2,(2*)R'&0)+"*(&)'") 40'C,0++,)I%,+C(*4("4(),,&,,,&, [\\) J"*$(4'D'(,)/("&%C),'*+2,(2),,&, ) '$ ",, %)+ ",, ) ) 20 That is, ClientAnonID occurs more than 100 times in bed occupancy file. 21 Primary diagnosis. 22 Where primary diagnosis is F00-F99. "[

80 17LMF71) 9(0&'+"):;<) [ZZ#[Z\)?2<%"'4Q)'"4CA,'"<)*./$&+/%&'4Q)/("&%C),'*+2,(2*) "$ #,&, $( #(&* [TZ#[T\) 6("&%C)%",)-(0%3'+A2%C),'*+2,(2*),A()&+)$*.40+%4&'3() *A-*&%"4()A*() ( #&% % "&+ [VZ#[V\) 140'X+$02("'%Q)*40'X+&.$%C)%",),(CA*'+"%C),'*+2,(2*) # "%&( ") ",&% [UZ#[U\) 6++,)]%DD(4&'3(^),'*+2,(2*) $ (%&+ ## %"&' [_Z#[_`) P(A2+&'4Q)*&2(**#2(C%&(,)%",)*+/%&+D+2/),'*+2,(2*) % +&$ # (&$ [az#[a\) N(0%3'+A2%C)*.",2+/(*)%**+4'%&(,)R'&0)$0.*'+C+<'4%C),'*&A2-%"4(*I$0.*'4%C)D%4&+2*),,&,,,&, [bz#[b\) B'*+2,(2*)+D)%,AC&)$(2*+"%C'&.)%",)-(0%3'+A2),,&, ",&* [cz#[c\) K(%2"'"<),'*%-'C'&.),,&,,,&, [`Z#[`\) B'*+2,(2*)+D)$*.40+C+<'4%C),(3(C+$/("&),,&,,,&, [\Z#[\`) N(0%3'+A2%C)%",)(/+&'+"%C),'*+2,(2*)R'&0)+"*(&)'") 40'C,0++,)I%,+C(*4("4(),,&,,,&, [\\) J"*$(4'D'(,)/("&%C),'*+2,(2),,&, ) %) ",, "+# ",, \+59)+ :.51(&* *5 %+.>'7+% *&.51(& S+7*'54 D]@ 50 *&+ N+4*-) R+-)*& $7* '295.*-4*( *&'%-4-)3%'%<R+.+/8+*-;+*&5%+%+.>'7+1%+.%8'*&-S+7*'54D]@ '4 *&+'. &'%*5.3?'<+< 0.52 i AVVf T $1(1%* AVDDB -4, %++ &58 *&'% %+.>'7+ 1%+. %+.>'7+1%+.%%&58-.+)-*'>+)3+W1-)(+4,+.%9)'*?#D<E^852+4HfE<A^2+4B/-%8+ %++05.-))%+.>'7+1%+.%-7.5%%*&+S+7*'54%<F&+.+8-%45,' (-.,'4(+*&4'7'*3/ -4,*&+-(+9.50')+-)%5>+.3%'2')-.*5-))S+7*'54%+.>'7+1%+.%< EV