DEVELOPING A STRATEGIC DIRECTION FOR OLDER PERSONS MENTAL HEALTH SERVICES INTRODUCTION SUMMARY DOCUMENT Cwm Taf has been working to improve mental health services for all adults living in Merthyr Tydfil and Rhondda Cynon Taf. A first phase of work, which looked at services for people of working age, has been completed and the second phase of work concentrating on services for older people is now underway. PRINCIPLES We aim to develop a needs-led service, which is supported by the new all- Wales Strategy Together for Mental Health. The plan is underpinned by the following principles: Equity - Mental health services should be available to all according to need, regardless of where someone lives, their age, their ethnic origin, gender, culture, religion or sexuality or any physical disability. Geographical variations in standards of care are unacceptable. Empowerment - Service users and their carers need to be involved in the planning, development and delivery of mental health services. This will require sustained support, care and information from mental health services. Empowerment should be at all levels, from encouraging selfmanagement and active participation in their own care through to formal involvement in planning. Effectiveness - Mental health services should improve quality of life by treating symptoms and their causes, preventing deterioration, reducing potential harm and assisting rehabilitation. Efficiency - Mental health services must use resources efficiently and be accountable for the way public money is spent. Health, social services and other local government agencies should work together and with voluntary agencies and the private sector to achieve best value. 1
KEY MESSAGES Older people s mental health services have traditionally been available for people over 65. We believe eligibility for the new services in Cwm Taf should be based on what best meets the needs of patients and not age. In other word, needs-led. The following areas have been identified as part of this work: - Develop and enhance the role of the crisis team Extend home treatment to include all ages this will help reduce admission rates and length of hospital stay A needs-led primary care mental health support service this will offer general and age-appropriate services across the age spectrum Improve discharge efficiency Improve services to residential and nursing home residents Develop additional day care services Improve services to primary care Address inequitable workloads at consultant and locality levels. WHY WE NEED YOUR VIEWS On 15 January 2014, Cwm Taf University Health Board agreed to start a period of engagement with service users, carers, staff, Cwm Taf Community Health Council and the public about our ideas to improve older people s mental health services. This will run between 17 January and 28 March 2014 and will involve extensive discussions with a wide range of stakeholders to raise awareness, seek views and ideas to inform and develop a range of options for the future of older people s mental health services. The outcome of the engagement exercise will be included in a robust project plan for implementation of the proposed service changes, which may then be subject to formal consultation. During this initial stage we will need to carry out a range of engagement activities and communications to set the context / case for change and explore the options for services. Your views will help to inform this work and this is your opportunity to have your say on the future shape of older people s mental health services within Cwm Taf. WHERE ARE WE NOW? Historically, services have been organised around an age-defined threshold - 65 - for transition from services for adults of working age to services to older adults. 2
Inpatient services for older person s mental health are currently provided at the following sites and compared to other Health Boards/Trusts are quite high in number for this patient group: - Hospital Ward Number Ysbyty George Thomas Fernhill 19 Ysbyty George Thomas Dinas 19 Ysbyty George Thomas Cambrian 19 Royal Glamorgan Seren 14 Royal Glamorgan St David s 10 Royal Glamorgan Enhanced Care Unit 5 Dewi Sant 1 18 Ysbyty Cwm Cynon 7 15 Prince Charles Hospital 35 15 However, our community services in Cwm Taf for older people with mental health problems in comparison to other Health Boards / Trusts are relatively small and include: - Four memory assessment services Four Community Mental Health Teams Three day services (none in the Cynon Valley) 3.2 Psychologists, of which only 1.6 wte are in the community One Discharge Liaison Nurse Limited crisis management out of hours WHY DO WE NEED TO CHANGE? There are a number of risks associated with the current service model, which we must address to ensure we can provide an effective and efficient service to meet the needs of older people living in Cwm Taf: - Ward 35 is too isolated at Prince Charles Hospital to treat patients who have challenging behaviour and the environment is too constrictive for 15 patients. This has resulted in excessive and unsustainable use of one-to-one nursing and a temporary reduction of beds to 12 Ward one in Dewi Sant Hospital, in Pontypridd, is isolated, on a second floor level, not purpose built and has limited out of hours cover and multi-disciplinary support Delayed transfers of care and continuing healthcare delays are problematic Community mental health teams are very low in staff numbers when annual leave and sickness absence occur, the impact on staffing levels is significant. Staffing levels are unsustainable when compared to the projected population growth The current nursing establishment at the Royal Glamorgan Hospital Older Persons Mental Health Unit is not sufficient to meet the range of 3
care needs of patients admitted there. This can result in protracted lengths of stay and the need to occasionally close beds temporarily to maintain safety when the case mix of patients is complex There is an increasing reliance on nurse bank because of fluctuations in staffing levels, which is impacting on already tight financial budgets. WHERE DO WE WANT TO BE? We are proposing that within the new service structure eligibility for services will be based on what best meets the needs of the patient rather than purely on the basis of age. Patients with mixed needs would be jointly managed between services for adults of working age and older adult services where required. This model would be supported by the development of locality teams, which would contain all the expertise needed to deal effectively with the broad range of mental health issues which present to the service. The following areas of change and development have been identified to provide an effective and efficient service to meet the needs of the older adult population of Cwm Taf. 1. Develop and Enhance the Role of the Crisis Team The mental health crisis team provides point of access for assessment of people presenting in an emotional and often social crisis. The team should be developed and the skills enhanced to enable efficient assessment of those presenting with age-related mental disorder. This will provide safe and effective signposting to appropriate community services where these exist and ensure that admission to hospital is an intervention of last resort. 2. Extend Home Treatment to Include Patients of all Ages This has reduced admission rates and length of inpatient stay for adults of working age and should be extended to include older adults with the aim of achieving the same goal. This element may be particularly important if concentrating inpatient beds in fewer hospitals is the preferred model. 3. A Needs Led Primary Care Mental Health Support Service The Primary Care Mental Health Support Service organises assessment of need in respect of access to non-urgent services. The service is defined in legislation as ageless and will offer general and age-appropriate services across the age spectrum. This will include screening of those presenting with memory issues and access to the memory assessment pathway via a clinical nurse specialist for dementia. 4
4. Improve Discharge Efficiency When admission to an inpatient hospital bed is needed discharge planning should start as soon as a person is admitted or even sooner if that admission is planned. This allows all potential barriers to discharge to be identified as early as possible and reduces the length of stay to the minimum period necessary. 5. Improve Services to Residential and Nursing Home Residents Significant numbers of admissions to older people s beds from residential and nursing homes arise because of mental health and behavioural issues could be avoided if those issues were identified earlier and if appropriate interventions were offered. Some of these could be achieved by developing a care home liaison and in-reach services, including: - Enhancement of the Community Integrated Assessment Service (CIAS) into a holistic frailty service including mental health as well as physical assessment and intervention Redevelopment of existing ward-based nursing and psychology roles to provide in reach to nursing homes on a regularly scheduled and urgent (as required) basis to provide advice and guidance, to develop nursing home staff skills, to support management of residents who might otherwise require admission and to support early discharge to nursing homes. 6. Develop Additional Day Care Services Day care services are currently unevenly distributed across Cwm Taf. There is evidence these services can be effective in preventing unnecessary admission to hospital by providing support to patients and families, including day respite. Development of equitable services in each locality could result in fewer patients needing to be admitted to hospital for inpatient care. 7. Improve Services to Primary Care Joint home visits with GPs and engagement with GP nursing home rounds will be promoted and encouraged to support decision-making and improve knowledge and expertise to improve the quality of care and delay or avoid unnecessary hospital admissions. 8. Address Inequitable Workloads at Consultant and Locality Levels to Improve Equity of Services Community mental health services for older adults are currently organised into four geographic localities - Merthyr Tydfil, Cynon Valley, Rhondda and Taff Ely. The populations of each sector vary considerably resulting in 5
inequitable case loads for consultants and teams. This is reflected in assessment clinic waiting list size and waiting times and has an adverse effect on the quality of care. Consideration will be given to reorganising locality boundaries to bring them into line with those of the adult service to accommodate any remaining inequalities in service demand. HOW WILL WE GET THERE? Over the next three years we will redesign older person s people s mental health services shifting the focus of treatment and care from in-patient settings to the community to improve the quality of patient care. Our aim is for patients to have high-quality treatment and care in the right place at the right time without delays and to be treated by people with a high level of expertise. We expect inpatient assessments to be progressive; continual assessment to be consistent and liaison services to be enhanced. Developing acute assessment services on one site will enable smaller professional groups such as psychology and therapies to provide more intense support for patients, carers and staff In year one, we will focus on inpatient care and building a sustainable model; in year two we will ensure we have robust community and liaison services and in year three better outcomes overall compared to our current baseline across a range of key performance indicators. In summary, we need to do different things not just do things differently. Achieving this will ensure that Cwm Taf deals with the projected growth in health demand and ensure high quality treatment and care for older people. The combination of reconfigured inpatient mental health services for older people, enhanced liaison services and reinvestment from increased productivity will provide better outcomes for patients and the community. Doing nothing is not an option as the demographic profile demonstrates a growth in demand which will engulf the current model of services, not only in mental health but the wider healthcare system. On the basis of the changes we propose in this new model of service, we plan to have: - Shorter inpatient stays for assessment through locating all assessment on one site at the Royal Glamorgan Hospital 6
Reduced lengths of stay in specialist dementia beds through enhanced community services, better discharge, faster access to diagnosis & therapies and avoiding unnecessary admissions Safe and high quality patient environments and investment in staffing and community based services through bed reductions at either Ward 1 Dewi Sant Hospital or Ward 35 at Prince Charles Hospital Fits with WAG Strategy Hospital Care & Long term Care Age Neutral & Needs led CMHT & CRHT Primary Care Self Help (only 1 in 4 mental health problems in the older person is a dementia) HOW YOU CAN GET INVOLVED We are committed to making sure people in Cwm Taf know about our intentions and make their views known about what they can expect from our services. Copies of the full document can be found on our website at www.cwmtafuhb.wales.nhs.uk. We welcome views from service users, carers, staff, partner organisations and anyone with an interest in mental health services in the Cwm Taf University Health Board area. On the basis of the changes we propose in this new model of service we would like to hear your views on the following questions: - 7
Question 1: Do you agree that there should be greater access to communitybased mental health services? - This will be achieved through moving resources from hospital beds to community services, reducing beds in either Ward 1 or Ward 35. - This will result in reduced lengths of stay in specialist dementia beds through improved assessment, treatment and discharge arrangements. Question 2: To ensure we have a shorter-length of stay for assessment, do you agree that all assessment beds should be located on one site at the Royal Glamorgan Hospital? - This will be supported through a concentration of expertise and diagnostics in one site (currently two) - Robust transport plans will be implemented to support patients and carers Question 3: Do you agree with the way we propose to change the services to ensure that patient care and treatment is safe, equitable and accessible? - This will be achieved by improving inpatient care pathways and by improving access to local care and treatment. The closing date for comments is 5pm on Friday 28 March 2014 and comments should be sent to: - Comments can also be emailed to: - Mental Health Your Views Cwm Taf University Health Board Ynysmeurig House Navigation Park Abercynon CF45 4SN cthb_mentalhealthyourviews@wales.nhs.uk 8