The Future Delivery of Functional In patient Mental Health Services in the Lancaster and Morecambe district of North Lancashire

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1 NCAT Review Lancashire Care NHS FT The Future Delivery of Functional In patient Mental Health Services in the Lancaster and Morecambe district of North Lancashire Reviewer: Dr Pete Sudbury MRCPsych, MBA, Medical Director, Barnet, Enfield and Haringey MHT Schedule of the Visit. Information provided: V2 Lancashire care OBC proofed North Lancs briefing paper development of Oaklands Pathfinders project board minutes: 28/7/9, 7/9/9, 5/10/9 Project map Sept 09 Presentations: LCC OSC Steering 9 Sept 09; Consultation OSC Site Visits: Ridge Lea Oaklands / Derby Home Interviews: Project Overview: Shirley Saunders, Deputy Chief Executive and Director of Operations, Ian Huitson, Network Director Older Adults, Emma Foster, Assistant Network Director Adults and Kevin McGee, Director of Commissioning, NHS North Lancashire CEO: Prof. Heather Tierney-Moore Public Governors: John Macleod and Moira Mondesire Clinicians: Dr Alison Napier, Consultant Older Adult Psychiatrist, Karen Bowman and Yvonne Twigg, Modern Matrons Medical Director: Prof Max Marshall Context: Mental health in-patient care is in a period of very rapid change in the UK. The NSF services and other best practice initiatives have been introduced and are continuing to be developed, including: 1

2 Crisis and Home treatment teams (integrated with in-patient units) Assertive outreach and assertive community treatment Early intervention Functionalised working for consultants (i.e. in-patient /home treatment specialists, as opposed to general psychiatrists each doing a small proportion of their jobs in the in-patient arena). These have resulted in very large reductions in demand and usage of in-patient services, and a change in the nature of in-patient work. Admission to hospital is no longer a default option, or part of the standard care pathway for acute mental illness, but a specialised intervention involving intensive nursing care, which can only be provided in hospital: all other care is context-independent. Partly as a result of this, there is currently very large variation in use of adult inpatient beds across England and Wales. "best in class" performance is around 1000 occupied bed days (obd) / 100k weighted adult population (WAP) 1, with a continuous variation from there to the top of the third quartile, at 3000 obd/100k WAP, and outliers up to 5000 obd/100k WAP. In older people's services, the picture is less clear, and even more variable. Despite standard 1 of the NSF for older people stating that there should be no discrimination on the grounds of age, there is great inconsistency in the availability of crisis teams, home treatment and other assertive community treatment for older people. There are also local variations in the use of intermediate care beds for people with dementia, and in availability and quality of nursing homes. This is compounded by demographic changes which will lead to large increases in the over-65, and more importantly, the over-80 age group, in the latter group of which around a quarter of people suffer from dementia. This leads to a very significant lack of clarity over the likely current and future needs for in-patient provision. With PICU, there is a general trend towards very much lower bed usage. As acute wards become more intensive, and adapt to dealing with higher levels of disturbance, there is less demand for PICU, which has resulted in an increasing oversupply in both public and private sector. The NSF promoted the move towards functionalised services (i.e. services aimed at groups of patients with specific sets of needs, rather than, for example, specific age groups). This has been further advanced by the InPAC system, which has been confirmed by the DH as the basis for MH PbR for adults and older people, and which is based on 21 functionalised care groups, with no age boundaries. Alongside these developments have been changes in workforce roles, including those initially badged New Ways of Working, but recently renamed Creating Capable, Flexible Teams, and including: The concept of distributed responsibility within teams, where all team members are accountable for their caseload, and work to the limits of their skills. 1 Audit Commission benchmarking club These figures are indicative, and there is some confusion over the denominator: it appears some Trusts may have submitted beds per weighted whole population, others weighted adult. A further set of benchmarking data, using WAP, should be available mid-november 09. 2

3 The widespread introduction of unregistered staff trained in specific competencies, often to high levels of skill, taking on sections of roles traditionally performed by professionally registered staff, including care co-ordination, delivery of psychological therapies, and support and recovery roles. This area is rapidly evolving, and will have a very significant impact on workforce profiles over the next few years. Diffusion of traditional medical roles: Non-medical prescribing, and Responsible Clinician roles under the mental health act are specific examples of this, as are hospital at night schemes, where specialised nurses fill roles traditionally performed by junior doctors. There are many other specialist practitioner roles where staff of 1 professional group perform roles traditionally performed by other professions, especially in psychological therapies. Multiprofessional consultant leadership. The traditional team was by default led by a consultant psychiatrist, but, alongside the changes above, consultant leadership is much more open to being performed by other professionals, whose core training may be much better suited to providing leadership of teams in some speciality areas. All of this occurs against the backdrop of an impending restriction in healthcare spending, which is likely to be more prolonged and severe than any previously experienced by the NHS. Cost-effective use of resources has always been important within the NHS, but new capital schemes, with fixed costs set for decades, require especially high levels of scrutiny. More generally, the consensus is that closer collaboration between commissioners and providers is extremely important, and that this needs to replace antagonistic and competitive models of working. Background to the Project. The reconfiguration of services in Lancaster has been consulted on in a number of different forms over several years, and its development has largely tracked the changes outlined above. The initial consultation was for a new build in-patient unit with a total of 150 beds, and met with strong local opposition. The current option involves the closure of a single adult ward in an old asylum building (Ridge Lea), conversion of a mixed-use older people's unit (Oaklands) into an acute unit with beds, for adults with functional illness, and other changes to accommodate residual services from Ridge Lea, the non in-patient services currently in Oaklands, and provide flexibility for the accommodation of frail elderly patients. Opinion. Stakeholder involvement and Consultation: The close working relationship of the Trust with its commissioners is exemplary, as is the way in which both sides have reset their relationship in the recent past to be much more collaborative, leading to an agreement about both the Lancaster service changes and the wider strategic direction. There has been well-conducted consultation with governors, patients and the public and staff around this reconfiguration, and it has broadly met with support for the favoured option. The main concerns seem to relate to a view among some staff and service users that the beautiful setting of the Ridge Lee unit was an asset, and this compensated for its lack of modernity, compromised privacy and dignity, isolation 3

4 and the excessive running costs of keeping a single unit open in an otherwise almost empty building. Culture and Approach It is clear that the Trust is well-run and governed. It's leaders are well aware of the difficulties of future-proofing service models involving capital assets, have already demonstrated flexibility and a willingness to change, and have intelligent mitigation strategies in place. Very significant progress has been made even in the short time since the OBC was written. All of those interviewed gave a clear and consistent message about the development in question, and their overall strategic direction, were open in admitting and discussing areas of difficulty and uncertainty, and showed genuine interest in new or divergent ideas when they were introduced. The governors and senior clinicians interviewed were clear that their views were respected and listened to. Overall there was a strong impression of an open, creative and respectful culture, orientated to producing results, conducive to the generation or adoption of new ideas, and justifiably confident in its ability to set stretch targets and to deliver against them. The following should therefore be read as a commentary on the current state of the project, and suggestions as to how it might make further progress, rather than in any sense negatively critical. Modelling bed numbers The Trust is aiming for best quartile performance in terms of obd/100k, but this is still 50% higher than best in class, and a more ambitious target would be appropriate. Although the trimmed LoS figures (between 20 and 30 days) are more in line with good performance nationally than those quoted in the OBC, this could still be improved further. In addition, there are significant numbers of patients with extended LoS, a significant proportion of whom are probably misplaced in acute settings. The Trust currently has no consistent rehabilitation model, and should actively explore the creation of an intensive rehabilitation in-patient and community team with a strong "recovery" orientation, aimed at patients who are not responding to assertive outreach, have numbers of "revolving door" admissions with failure to maintain stability outside hospital, or are difficult to discharge or place due to poor skills. These patients have often responded poorly to standard medication regimes, and are also demoralised and have lost hope of the possibility of being in control of their lives. Such a service can also act as a "step down" from forensic services, and following the Bradley report, may also provide a pathway for institutionalised but lower risk prisoners with mental health problems. Such a service should have input from a consultant team, possibly headed by a consultant occupational therapist, with strong psychological therapies input, expert pharmacy, medical and nursing support. Such a service should further reduce the requirement for acute in-patient care. Ridge Lea It is clear that the Ridge Lea unit is not fit for purpose as a modern in-patient unit, despite it having been excellently refurbished to as high a standard as reasonably practicable, and having staff who are of high quality. In the ward itself, observation is problematic, it has no direct access to the open air, the bedrooms are adequate but lack en-suite facilities, there is no flexibility around the ratio of male and female beds, and inadequate numbers of toilets and bathing facilities. Once other wards move from the site, it will be isolated and unsafe. Its position, whilst idyllic for a "retreat", 4

5 isolates patients from access to their homes and community, and is inconsistent with "recovery" oriented models of care. Oaklands / Derby Home project The proposed development at Oaklands is exciting and innovative, with the move to a functionalised as opposed to age-related service delivery well thought through, including the potential for the use of other underutilised units at Altham Meadows or Moss View to accommodate very frail elderly people. The degree to which they will actually need segregating may be exaggerated, as the proposed in-patient development has a variety of areas for patients, and nursing staff already have experience of nursing highly vulnerable patients on adult acute in-patient wards. Nevertheless, the plans for frail elderly functional patients need to be finalised and costed as part of the project. Extra care and PICU utilisation The extra care model, minimising the need for use of PICU, is a good solution to the lack of an on-site PICU. Alongside the higher nursing standards and ability to cope with disturbance that are necessary in modern acute units, it is likely to have a very significant effect on the use of PICU, which the Trust will need to model when deciding its need for PICU beds in the new unit in Whyndyke Farm. Simple calculations, using the figures given by the Trust, of 8 patients a year needing to go to PICU, with the current Trust ALoS of 100 days, suggests that an average of 2 beds will be in use from Lancaster, and that the Trust as a whole will need around beds in total. These figures are probably an overestimate, as it is stated, with high face validity, that the extra care model should allow repatriation of patients from PICU earlier, thereby reducing the number of OBD required. If possible, the project plan for Whyndyke farm should leave flexibility on the final decision as to the size of PICU provided until after the Lancaster reconfiguration has opened. Other estates issues. Education and Training The OBC mentions medical education and training, but only to state they are excluded from financial modelling. As traditional medical roles are taken by other professions, the lines between medical and non-medical postgraduate education will become increasingly blurred, and facilities will need to be available that are of sufficient size and flexibility to accommodate possibly quite large numbers of professionals attending postgraduate training on a regular basis. The Trust will therefore need to ensure that there are easily available resources (either owned or leased) that can be used for both regular and ad hoc training. The Trust is exploring options with Lancaster university, and the option of out-sourcing all or part of the administration and delivery of training may be worth considering. Office space Provision of office space will need to be subject to the same level of scrutiny as clinical space, and subject to the same rigorous assessment of utilisation. Open plan working or shared offices should be the norm, with single-occupant offices only allocated to clinicians or managers who are expected to spend 80% or more of their time in them. Of equal or greater importance is flexible use of space, with "hot desk" 5

6 facilities, and mobile working wherever possible, as both of these reduce unnecessary returns to base and overall utilisation of space. Staffing and workforce. This is the least developed area of the OBC, but there is good awareness of the work needed to design safe, effective staffing for a relatively isolated unit. The clinicians are positive about their role and influence in ensuring this does happen, and it is clear that work is progressing on this. The critical question revolves around maximising the resilience of a relatively isolated in-patient unit, performing a number of functions including seclusion and enhanced care. Rather than focus on the ratio of qualified to unqualified staff, the Trust should review the training and competencies required, and if necessary work with a HFE provider to design bespoke courses in specialist acute care, suitable for both registered and skilled unregistered staff. It is also recommended that the Trust actively consider combining the CHT and in-patient teams for both adult and elderly patient to create a single acute care team. This will maximise the pool of available staff who can be called upon or deployed to where their presence is most needed. The professional mix of this team should include psychology, OT and pharmacy. To ensure maximum clinical focus, the team should be led and managed by a senior clinician at consultant or specialist practitioner level. Within this team, traditional medical roles can be provided in a multiprofessional medical care team. This should be led by a consultant psychiatrist, who should be responsible for ensuring proper governance of a team of NMPs, specialist practitioners and nonmedical responsible clinicians. Recommendation The scheme should be fully supported. Dr Pete Sudbury 22/10/9 6