NHS Borders Intensive Psychiatric Care Units Service Profile Exercise ~ November 2009
NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity. We have assessed the performance assessment function for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation. For this equality and diversity impact assessment, please see our website (www.nhshealthquality.org). The full report in electronic or paper form is available on request from the NHS QIS Equality and Diversity Officer. NHS Quality Improvement Scotland 2009 First published November 2009 You can copy or reproduce the information in this document for use within NHSScotland and for educational purposes. You must not make a profit using information in this document. Commercial organisations must get our written permission before reproducing this document. Information contained in this report has been supplied by the NHS board concerned, unless otherwise stated, and is believed to be reliable on publication. www.nhshealthquality.org =
Contents Background 1 1 Overview of local mental health services 3 2 Intensive psychiatric care unit provision 4 2.1 Admission to IPCU 4 2.2 Model of care provision 5 2.3 Discharge from IPCU 5 3 Demographics 5 3.1 Numbers of IPCU admissions 6 3.2 Nature of admissions 6 3.3 Management of other population groups 6 4 Links with other secure mental health provision 7 5 Governance arrangements 7 6 Plans for service development 7 7 Other points to note 7 Appendix 1 Glossary of abbreviations 8 = =
Background The Scottish Government s national mental health benchmarking project (January 2008) defined intensive psychiatric care units (IPCUs) as: a multi-disciplinary team with specialised training; the ratio of nursing staff will be higher than a general psychiatric ward. The service is recovery focused; it provides intensive treatment and interventions to patients who present an increased level of clinical risk and require an increased level of observation. (Technical Appendix, January 2008). The National Mental Health Services Assessment: Towards implementation of the Mental Health (Care and Treatment) (Scotland) Act 2003 (March 2004) Report highlighted specific challenges faced by IPCUs in light of changes in mental health legislation. In particular, the report outlines the dual function often ascribed to IPCUs where they function as both a low level secure forensic unit and as an extension of general adult inpatient psychiatric services. This is further complicated by the need for appropriate care environments for females, adolescents, older adults and those with learning disabilities. The report concludes that IPCU provision is a small but important part of services and should remain central to planning decisions when implementing the [Mental Health (Care and Treatment) (Scotland)] Act. Introduction to the IPCU project There is very little published UK data about IPCUs. The NHS Quality Improvement Scotland (NHS QIS) 3-year strategic work programme, Improving the Quality of Mental Health Services, 2005 2008 recognised this and included a commitment to undertake an audit of IPCUs in Scotland. Before undertaking any work to assess how services are delivered within IPCUs, it is important that we have a clear picture of: how many IPCUs there are across Scotland the arrangements in place in NHS board areas that do not have local IPCU provision how the IPCUs are structured and staffed the relationships between IPCUs and other mental health services, and the referral pathways both in and out of IPCUs. In order to gather this background information it was agreed that the IPCU project would be delivered in two distinct stages. Stage 1 is a national service profiling exercise covering all of the territorial NHS boards in Scotland. In a parallel piece of work during Stage 1, the views and experiences of people who have received IPCU care and their informal carers will be sought. This work is being supported by Better Together, Scotland s national patient experience programme and is being delivered in collaboration with the Mental Welfare Commission for Scotland. 1
This report contains the service profiling information. The user and carer experience information will be included in a national overview report alongside the service profile information. The national overview will be published in spring 2010 and will give a full representation of the national picture from both the perspective of those who provide services, and those who use them. The service profiling findings along with the views and ideas of service providers and service users and carers that have been sought and captured during Stage 1 of the project will inform the detail of Stage 2. The service profiling process has two key parts: local information gathering and follow-up meetings. Using a service profiling questionnaire produced by NHS QIS, each NHS board gathered information on the IPCUs in its local area. These data were submitted, together with supporting evidence if applicable, to NHS QIS prior to the follow-up meetings. Follow-up meetings were held with local staff between May July 2009 to discuss the responses provided by the NHS board and seek clarification on any issues. This report presents the information supplied in the service profile form and the discussions at the follow-up meeting with NHS Borders on 18 June 2009. 2
1 Overview of local mental health services The Borders is situated in south east Scotland and has a population of around 116,000. The majority of the population live in rural areas, and the largest towns in the region are Galashiels and Hawick. With approximately 350 staff and an annual operational budget of 13 million, NHS Borders mental health service provides treatment in a variety of settings including: consultant-led community mental health teams (CMHTs); a range of community, day and residential facilities; and inpatient services. Adult mental health services have undergone a period of development following the review of services previously provided at Dingleton Hospital, Melrose. The adult mental health services consist of the west, east and south CMHTs, based in Melrose, Duns and Hawick respectively. There are also day services attached to these teams. The CMHTs accept referrals of adults (16 69 years) who present with a range of acute psychiatric disorders, including major mental illness, severe adjustment disorders, and emotional and behavioural disturbances requiring psychiatric assessment. Referrals of more specialist patient groups such as dual diagnosis and eating disorders are also accepted. NHS Borders CMHTs provide an assessment and treatment service, mostly in people s own homes or a community setting of their choice. In addition, there is a crisis team which provides safe and effective community-based assessment, treatment and social interventions as an alternative to inpatient care. A range of inpatient mental health care is provided at a number of sites across the NHS board area including: Borders General Hospital, Melrose East and West Brig, Galashiels Galavale House, Galashiels, and Huntlyburn House, Melrose. Huntlyburn House provides specialist care for adults (16 years and over), who are experiencing an acute phase of their mental illness. Practice in this unit is based upon collaborative participation across all disciplines. East and West Brig provides inpatient care for adults with enduring mental health needs who require rehabilitation on a short or medium-term basis. This would include patients in the acute phase of their illness and those presenting with high risk behaviours. Galavale House also provides rehabilitation beds. 3
Acute mental health and rehabilitation services are provided as follows. NHS Borders East and West Brig Number of beds Mental health rehabilitation 17 Galavale House Number of beds Mental health rehabilitation 9 Huntlyburn House Number of beds Acute mental health care 30 2 Intensive psychiatric care unit provision NHS Borders does not have an IPCU. There is a service level agreement in place between NHS Borders and NHS Lothian for the provision of secure services including IPCU care. NHS Borders does not have any assigned IPCU beds within NHS Lothian. Each proposed transfer is negotiated as it arises and admission is dependent on there being an available bed at the time. Patients in need of this level of care would normally be transferred to St John s Hospital, Livingston. If St John s Hospital is unable to admit the patient due to lack of available beds, NHS Borders would next contact the IPCU at the Royal Edinburgh Hospital. Referrals from NHS Borders would be considered for admission in the same way as a referral from within the NHS Lothian board area. 2.1 Admission to IPCU Admissions to the IPCU at St John s Hospital are routed approximately 50:50 through Huntlyburn House and East and West Brig. In crisis situations, patients may also be admitted directly from other units in NHS Borders. NHS Borders follows the set protocols within the psychiatric emergency plan (PEP) and transport plan when transferring patients to St John s Hospital. Discussion would take place between the referring consultant from NHS Borders and either a member of the medical team or a suitably experienced trained nurse from NHS Lothian s IPCU. On the rare occasion that both of the NHS Lothian IPCUs are at capacity, a patient may be transferred to the nearest IPCU facility with an available bed. Within the past year, a small proportion of patients have required to be transferred to an IPCU outwith the NHS Lothian area. NHS Borders acknowledged the risks and difficulties associated with the transfer of acutely unwell patients out-of-area. The risks include disturbance and distress for the patient often sustained over significant time due to the distance between units, transfer of patients who may be heavily sedated and the additional complications of transfers at night. NHS Borders reported that it can be difficult to identify escorts to accompany patients. The requirement to provide staff to escort transfers can also cause significant staff pressures for the acute services, particularly during out-of-hours periods. 4
Any patients requiring admission to IPCU out-of-hours would be managed by Huntlyburn House in liaison with the crisis team. Staff in NHS Borders acknowledged that the risk management policy could be improved through greater flexibility with the organisations involved in transporting patients such as the Scottish Ambulance Service (SAS) and the local constabulary. Example of a local initiative NHS Borders staff, and staff from Lothian and Borders Police, receive joint training to ensure that anyone involved in a patient transfer is aware of the risks involved and the procedures to follow in the event of an emergency. 2.2 Model of care provision For patients who are transferred to the IPCU at St John s Hospital or to another unit out-of-area, the model of care delivery would be such as is employed by that unit. NHS Borders staff maintain regular telephone contact with staff at the receiving IPCU while the patient is a resident there. 2.3 Discharge from IPCU There is no formal policy in place for the discharge of patients from IPCU. In practice, this is managed on a case-by-case basis. Prior to discharge, a minimum of two members of staff from NHS Borders (usually the responsible medical officer and a nurse) would meet with IPCU staff and personally review the patient at St John s Hospital. The purpose of this meeting is to ensure that the final assessment is consistent with the type of care that NHS Borders is able to provide for the patient at whichever inpatient unit they will be returning to. This meeting is particularly important for patients returning to Huntlyburn House given its isolated location and the client group normally resident there, which includes potentially vulnerable patients. At the time of the service profiling exercise, NHS Lothian was developing a single operational policy to inform the admission and discharge process for patients from NHS Borders. NHS Borders will be involved in the consultation on the draft policy and the final version will be shared when complete. NHS Borders reported that more involvement and consultation around the development of IPCU policies would be welcomed, and that joint working in this area, for example around development of a shared care pathway for transfer, would be of benefit. 3 Demographics The total adult population aged 18 64 in Borders is approximately 88,000. 5
3.1 Numbers of IPCU admissions NHS Borders reported that in 2008 there had been 11 out-of-area IPCU admissions; two patients who were admitted more then once are included in this total. The majority of these admissions were to the IPCUs within NHS Lothian; other patients had been admitted to IPCUs at Stratheden Hospital in Fife, and Leverndale and Gartnavel Hospitals in Glasgow. 3.2 Nature of admissions The 11 admissions to IPCU out-of-area can be broken down as follows. IPCU admissions to NHS Borders in 2008 Age Under 18 18 30 31 50 51 65 Over 65 Gender Male Female Ethnicity White Scottish Not known/specified Detention status Civil law Criminal law Informal (elective) Out-of-area admissions Formal agreement No formal agreement 0 5 4 2 0 7 4 4 7 11 0 0 8 3 3.3 Management of other population groups NHS Borders highlighted the particular difficulties sometimes posed by older adolescents who are too complex and/or too high risk to be managed within child and adolescent mental health services. There have been occasions where young people under the age of 18 have been admitted, via Huntlyburn House, to the IPCU at St John s Hospital. NHS Borders does not have a discrete learning disability inpatient facility. As a result, people presenting with mild learning disabilities and mental health problems may occasionally be considered for admission to Huntlyburn House if no alternative bed is available through the South East Scotland Learning Disability Managed Clinical Network. Regular communication with the learning disability nursing staff and consultants would be paramount during these periods of stay at Huntlyburn House. NHS Borders highlighted the difficulties of managing this client group. Admission to Huntlyburn House is not ideal, however there is no other inpatient facility in NHS Borders specifically for people with learning disabilities. Forensic patients stepping down from high security facilities would generally be admitted to the Orchard Clinic, Edinburgh, in the first instance. Patients stepping down from medium secure care would return directly to NHS Borders. 6
4 Links with other secure mental health provision Forensic patients from NHS Borders would be transferred to the Orchard Clinic. 5 Governance arrangements Clinical governance issues relating to mental health services are usually raised and discussed at clinical management level. There is a mechanism for raising governance issues at NHS board level and at the time of the service profiling exercise, wider operational transport issues relating to the SAS were being discussed. NHS Borders reported that there had been no occasions where governance issues relating directly to IPCUs had required to be discussed at the NHS board clinical governance committee. There is ongoing engagement with all stakeholders including SAS, patients and carers on the current version of the PEP, which was implemented 3 years ago and is due for review in summer 2009. Borders Voluntary Care Forum has close links to the acute in patient mental health services at Huntlyburn House. 6 Plans for service development There are plans to improve communication with transport services to ease the process of transferring patients to NHS Lothian; however, the logistical issues of transfer remains an outstanding issue for NHS Borders patients in need of IPCU care. NHS Borders is to be involved in the consultation on the NHS Lothian operational policy for IPCU. 7 Other points to note It was acknowledged that there are difficulties around the risk assessment process for both admissions to and discharges from IPCU. In particular, issues with the robustness of the risk assessment prior to transfer back to NHS Borders was identified as an area where further developments could be made. Staff identified additional support, perhaps in the form of an outreach support worker or from a regional network, to assist in developing this part of the service. 7
Appendix 1 Glossary of abbreviations Abbreviation CMHT IPCU NHS NHS QIS PEP SAS SLA community mental health team intensive psychiatric care unit National Health Service NHS Quality Improvement Scotland psychiatric emergency plan Scottish Ambulance Service Service level agreement 8