Agenda Item 9 Meeting: Shetland NHS Board Date: 21 st August 2018 Report Title: Proposal to reduce agency locum costs for consultant psychiatry Reference Number: Board Paper 2018/19/29 Author / Job Title: Decisions / Action required: Simon Bokor-Ingram, Director of Community Health and Social Care Karen Smith, Interim Head of Mental Health Service That the Board approves the recommendation to increase the medical staffing in the Adult Community Mental Health Team to reduce the reliance on agency locums. High Level Summary: The Adult Community Mental Health Team has made significant progress over the last year and has made a good number of completions on its action plan. There has been ongoing fragility within the clinical team due gaps in current staffing. CPN recruitment has been successful. A substantive Consultant Psychiatrist has been in post for 6 months and a Locum Consultant Psychiatrist has been required for 12 months. The reliance on a locum consultant psychiatrist has proven to be extremely costly in 2017/18, and the continuation of locum usage will inevitably contribute significantly to the cost pressures in 2018/19. The demand on the psychiatrists is very high for a small population, both from the community and the Gilbert Bain Hospital; for scheduled, unscheduled and crisis work. Out of hours cover is currently being delivered solely by a locum and this is not sustainable. Discussions are taking place with the other island Boards who are agreeing in principle that a shared out of hours rota would be the most sustainable way forward. In order to develop an efficient model of psychiatric care for Shetland it is proposed to recruit a third psychiatric consultant post (appendix 1). Corporate Priorities and Strategic Aims: The Joint Strategic Commissioning Plan describes how health and care services can be delivered, jointly, across the services described in the Shetland Islands Health and Social Care Partnership s Integration Scheme. The Plan is a significant part of public sector delivery in Shetland and supports the Shetland Community Partnership s Local Outcome Improvement Plan, Shetland Islands Council s Corporate Plan and NHS Shetland s 2020 Vision and Local Delivery Plan. Delivery of the Strategic Commissioning Plan relies on partnership working between Shetland Islands Council, NHS Shetland, Shetland Charitable Trust, other regional and
national organisations (such as the Scottish Ambulance Service, NHS Grampian and other specialist Health Boards) and voluntary sector providers. For Mental Health Services, there is a Service Level Agreement in place with NHS Grampian for specialist services. Mental Health Services for adults in Shetland are supported by a range of partnerships. There is in place a Mental Health Partnership and a Mental Health Forum. There are connections to a range of related services and initiatives, including: unpaid carers; domestic abuse; adults with disabilities; the Criminal Justice service; and substance misuse/ addictions. There is a dedicated Child and Adolescent Mental Health Service, provided by NHS Shetland. A formal needs assessment has been undertaken by NHS Shetland s Public Health Department to support the development of these services and this is nearing completion. Key Issues: Sustainability across the service would be created at a much reduced cost, although this requires a budget to be created for permanent recruitment. This would result in no longer having to rely on locum provision, which is costly and uncertain regarding continuity. Implications : Identify any issues or aspects of the report that have implications under the following headings Service Users, Patients and Communities: Human Resources and Organisational Development: Equality, Diversity and Human Rights: Partnership Working Legal: Consistent Psychiatric support for patients through a period of development. Current service performance, as measured predominantly through access to treatment times, is variable. There is in place an improvement plan to address waiting times targets. Substantive Psychiatrist and Community Psychiatric Nurses will be supported to implement team models i.e. Liaison Psychiatry will be shared across team for day time unscheduled/crisis work There are no specific issues to address with regard to equality, diversity and human rights. Improvements with GBH, Community i.e. Social Work/Mental Health Officers, Royal Cornhill Hospital There are no specific legal issues to consider. Finance: Locum Agency costs for a full year would amount to 625,000, whereas the budget cost of a Consultant Psychiatrist would equate to 166,000 per anum. Action 15 Mental Health Strategy government ring fenced funding will increasingly feed into the mental health budget over a 4 year period, but the funding levels in years 1 to 3 would not equate to the cost of an additional post, and the Action 15 money is also needed to part fund the Consultant Psychologist post and address the identified gap in the offer for psychological therapies. Assets and Property: There are no specific asset and property issues to consider.
Environmental: Risk Management: There are no specific environmental implications to highlight. The identified risks are the ongoing locum agency costs and the potential for lack of continuity when locums leave. Policy and Delegated Authority: Previously considered by: Exempt / private item NHS Shetland Board has the authority to approve additional consultant posts. Executive Management Team 09/08/18 N/A Appendix 1- Consultant Psychiatrist Capacity
Appendix 1: Consultant Psychiatrist Capacity Introduction The adult Community Mental Health Team (CMHT) consists of Psychiatry, Psychology, Substance Misuse Recovery Service (SMRS) and the Dementia Diagnostic Service The NHS Board previously agreed in June 2014 to a 2 Consultant Psychiatric model for the on-island service. Currently in post are one Consultant and one Speciality Doctor. A Locum Consultant Psychiatrist has been working alongside the permanent Consultant Psychiatrist due to a gap in staffing. The Locum has been providing the out of hours on call duties, unscheduled care, liaison with Gilbert Bain Hospital (GBH), Psychiatric input to SMRS and the general day-to-day psychiatrist reviews. Background The Adult Community Mental Health Team has made significant progress over the last year and has made a good number of completions on its action plan. There has been ongoing fragility within the clinical team due gaps in current staffing. CPN recruitment has been successful. A substantive Consultant Psychiatrist has been in post for 6 months and a Locum Consultant Psychiatrist has been required for 12 months. The current management and staffing arrangements have brought stability to the service, however the reliance on locum consultant psychiatry has proven to be extremely costly in 2017/18, and the continuation of locum usage will inevitably contribute significantly to the cost pressures of the IJB and the Health Board in 2018/19. Locum costs for a full year would amount to 625,000, whereas the budget cost of a 12 month Consultant Psychiatrist would equate to 166,000 (this would include 12 PA s and 3% availability). In addition to community psychiatric care, there is an ongoing demand for psychiatric input into the GBH with regards to advice on diagnosis, medication, risk and general clinical management, including whether a hospital admission is indicated, with or without application of the Mental Health Act. Psychiatric input is required mainly in A&E and Ward 3. Much of this work is unscheduled and includes both in hours low urgency work and semi-/urgent psychiatric care at any time of day, including weekends. In Shetland, we are very fortunate that the Consultant Physicians thus far have been willing to provide care and offer admission to psychiatric patients, lacking dedicated
psychiatric beds. Without this, all patients requiring more than routine psychiatric assessment and/or care would be transferred to the Royal Cornhill Hospital (RCH) in Aberdeen. These transfers would not be clinically indicated; would be disruptive to patients and those around them and costly to the Health Board. However, GBH Consultant Physicians and their ward staff rightly have made it clear that there are limitations to their ability to effectively and safely manage psychiatric patients; they have stated that without in- and out of hours specialist psychiatry input it would not be safe to provide care to this patient group. Specialist psychiatric input required by the GBH (and GPs) includes semi-/urgent referrals. These can occur at any time or day, including out of hours, and mostly involve psychiatric cases presenting to the GBH. The majority of these cases are mild to moderate in severity, presenting with suicidal ideation and/or deliberate self harm. Such cases tend to present out of hours. A&E assesses the urgency of the case and most are managed by A&E with either a referral back to the GP, or a referral for a next day assessment by the Duty Community Psychiatric Nurse (CPN). These are patients either sent home or admitted informally to ward 3 for physical care of their self harm. These mild to moderate semi-urgent cases occur some 2-3 times a week. They are managed by the CMHT mostly within working hours, assessing the patients over the phone, face to face in the mental health department, or if admitted, on Ward 3. Sometimes A&E requires more urgent advice, including out of hours, for example, if the patient expresses ongoing suicidal ideation or a patient at risk refuses care. Without access to this more immediate psychiatric advice, the default would be for physicians to admit all patients to Ward 3, except for the most obvious low risk cases. Again, in working hours, the first port of call is the duty CPN. In the absence of any other psychiatric service, out of hours the duty psychiatrist is contacted. A second, smaller group of cases requires an urgent psychiatric opinion which cannot wait until the next day. These include the more severe mental health problems and/or significant mental health related risks. These cases can present at any time of day. In all cases, a senior psychiatric opinion should be available, although in hours, the duty CPN or allocated CPN will be the first person dealing with the referral. The duty Consultant Physician can decide to informally admit these patients to Ward 3 or, if required, detain the patient under an Emergency Detention Certificate. Legally, this can be done without the advice of a psychiatrist, but considering the likely severity of the case, this would not be ideal and can lead to unnecessary admissions, unforeseen risks etc.
These cases occur approximately once a fortnight. For these cases, it is essential that there is access to psychiatric opinion at any time of day, whether or not a duty CPN is the first contact point. The advantage of a psychiatrist on island is the local knowledge he/she will have of services, relationships with patents and GBH staff, continuity of care, less need for Emergency Detentions and a reduced likelihood of transfers to RCH. However, this involves a 1:2 or 1:3 on call rota. Although not onerous in intensity of the out of hours work, the frequency of on call will have a significant impact on the work/life balance of the psychiatrist and may adversely impact on retention and recruitment of psychiatrists. On call provision is not stated officially as a requirement in the Service Level Agreement with NHS Grampian. However, there has for a long period of time been recognition that providing this via NHS Grampian prevents unnecessary admissions and/or Emergency Detention Certificates. Unfortunately, RCH recently highlighted their ongoing issues with staffing (there is one Consultant Psychiatrist on-call covering RCH in-patient facility, NHS Elgin in-patient facility and the community of Aberdeen). This is unlikely to improve in the near future. Out of hours advice from RCH therefore cannot be relied upon and has indeed been found unsatisfactory by GBH physicians as the system of accessing advice is convoluted, and does not serve the needs of acute patients in a timely way. Discussions with NHS Orkney and NHS Western Isles lead us to believe that there is potential for the islands to create a workable out of hours model that is both effective and supports general physicians. However, issues that will need to be addressed include agreements on who can refer to the on call psychiatrist (e.g. only Consultant to Consultant referrals) and what would be the procedure for psychiatric admission (a dedicated admission coordinator might be required). Liaison Psychiatry involves input from the mental health department to the GBH for patients primarily admitted for physical health reasons, but whose condition includes psychiatric symptoms for which advice on diagnosis and management is sought, or the patient has a co-morbid psychiatric condition requiring management during their hospital stay. Examples are patients with encephalitis, strokes, delirium, psychiatric and behavioural complications of dementia, and drug detoxes. These are quite regular referrals, some 2-3 per month. These generally are routine referrals, managed within working hours, frequently enough to requiring inclusion in job plans. For general psychiatry, these assessments fall to the psychiatrists. The assessment of dementia patients is done by the dementia specialist nurses and input for the substance misuse cases is offered by the SMRS team. With regards to the recent real time demand on the out of hours on call Consultant Psychiatrists, it is not onerous in intensity, but unpredictable. July 2018 the locum
psychiatrist had five calls; three early evening calls needing assessments in A&E, one emergency call out between 2am 4am and one Sunday phone call. This is often medication advice or admission advice and both of which generally can be done over the telephone; meaning the patient can be admitted/stay on the ward and be seen by the Psychiatrist at the earliest opportunity within the working day. However an on-call Consultant Psychiatrist is essential as the Consultant Physicians at GBH are working outside of their practice with psychiatric patients and therefore need the additional advice. Unscheduled care is also unpredictable and is often led by the out of hours presentations that have occurred. If the Consultant Physicians are agreeable with advice to admit patients to the ward then the Consultant Psychiatrist will visit the ward at the earliest convenience i.e. the following day or the Monday if admitted at a weekend. These patients tend to be not acutely unwell, i.e. not in need of an off island transfer, but in need of assessment and at times a safe environment that can be provided within GBH. Options 1. Status Quo: Continue using agency locums. This is too costly and provides no continuity when locums leave their position. 2. Recruitment of fixed term: There is currently a raft of vacancies across Scotland and it would be extremely unlikely that recruitment would be successful. 3. Recruit permanently: This would create resilience and sustainability across the service. There would also be an opportunity income generate through shared arrangements with other Health Boards. Recommendation It is recommended that the Board approve option 3, being the recruitment of a Consultant Psychiatrist in order to develop a sustainable model of psychiatric care.