Executive Director of Nursing and Chief Operating Officer

Document Title Arrangements for Managing Patients Mental and Physical Health Needs across NTW and the Acute Hospital Trusts Reference Number Lead Officer Author(s) (name and designation) Ratified by NTW(C)15 Executive Director of Nursing and Chief Operating Officer Rod Bowles Head of Positive and Safe Catherine Edge Associate Nurse Director Business Delivery Group Date ratified May 2016 Implementation date May 2016 Date of full implementation May 2016 Review date May 2019 Version V01.1 Review and Amendment Log Version Type of Change Date Description of change V01 NEW May 2016 NEW policy document V01.1 Update Nov 2017 Update due to clinical transition This policy supersedes: Reference Number V01 Title Arrangements for Managing Patients Mental and Physical Health Needs across NTW and the Acute Hospital Trusts - Policy

SECTION CONTENTS PAGE NO: 1 Introduction 1 2 Purpose 1 3 Definition of Terms Used 1 4 Duties and Responsibilities 1 5 Principles 2 6 Identification of Stakeholders 3 7 Implementation 4 8 Equality and Diversity 4 9 Monitoring Compliance and effectiveness 4 10 Learning Lessons 4 11 Training 4 12 Associated documentation 4 Standard Appendices attached to policy A Equality Analysis Screening Tool 6 B Communication and Training Checklist and Needs Analysis C Audit and Monitoring Tool 10 D Policy Notification Record Sheet - click here Appendices, listed separate to policy 8 Document No: Description Issue Issue Date Review Date Appendix 1 Appendix 2 Guidelines for Accessing Acute Trust Services for patients currently within Mental Health Services Guidelines for the Management of patients presenting with psychiatric disorder within Acute Hospital Wards 2 Nov 17 May 19 2 Nov 17 May 19

1. INTRODUCTION 1.1 (the Trust/NTW) provides a diverse range of mental health and learning disability services in a wide range of care settings and is committed to collaborative working with its partner organisations to ensure the highest standards of healthcare for its patients. 1.2 During a stay in a mental health or disability in-patient facility occasions may arise when the health status of the patient may require intervention involving acute hospital services. 1.3 This intervention could be in the form of a planned outpatient appointment, a planned admission or an emergency admission. 1.4 On occasions patients being treated in an acute hospital present with psychiatric disorders that require assessment and possible intervention from mental health services 1.5 This policy should be read in conjunction with Trust policies: NTW(C)19 Engagement and Observation NTW(C)07 Promoting Engagement with Service Users, (Policy on Non Compliance with Treatment / Difficult to Engage Service Users) NTW (C)17 Medicines Management policy o UHM-PGN-01 Safe and secure medication handling and supply o UHM-PGN-02 Prescribing of Medicines 2. PURPOSE 2.1 These guidelines are aimed at ensuring the safety and welfare of such patients by clearly outlining the process that will be followed to ensure supportive, timely and necessary assessment and treatment. 2.2 The guidelines are intended to support clear and effective lines of communication between the Trust and the Acute Hospital Trusts. 3 DEFINITIONS OF TERMS USED - Acute Hospital Trust The NHS Trust local to NTW that provide physical health care 1

4 DUTIES AND RESPONSIBILITIES 4.1 The Chief Executive is responsible for ensuring that an appropriate and adequate infrastructure exists to support the safety and welfare of patients that require access to acute hospitals 4.2 The Executive Director of Nursing and Chief Operating Officer is responsible for the strategic and operational management to support the safety and welfare of patients that require access to acute hospitals 4.3 The relevant Directors and Trust Board will be responsible for monitoring and reviewing the efficacy of these guidelines within the relevant service areas on a six monthly basis. 4.4 The clinicians involved in the care of patients who are receiving care in acute hospitals need to follow the policy as outlined. 4.5 The clinicians need to inform their managers of any immediate issues or difficulties in relation to the application of this policy 4.6 Senior managers need to support clinical staff in the administration of this policy. 4.7 DEFINING RESPONSIBILITY FOR THE PATIENT The means of admission will determine responsibility for the patient 4.7.1 If the patient is admitted directly into an Acute Hospital Ward to reduce the risk of self-harm and to ensure effective monitoring and treatment of medical condition, then the responsibility for the patient will rest with that admitting hospital. This will apply regardless as to whether the patient has been admitted following assessment via The Psychiatric Liaison Teams who are employed by NTW Trust. It should be noted that assessments undertaken by this service do not constitute an admission into mainstream psychiatric services unless this is specifically indicated. 4.7.2 In instances involving patients who are admitted directly into general hospital wards, then the responsibility for finding staff to support that patient will rest with the Acute Hospital Trust. 4.7.3 If a patient requires transfer to the Acute Hospital Trust for medical assessment and treatment whilst in receipt of in-patient care the Mental Health Trust then the responsibility to ensure adequate psychiatric nursing input will rest with the Mental Health Trust. The level of psychiatric nursing input will, where possible, be dependent upon individual patient need, determined by medical and nursing assessment. See Appendix 1 2

5 PRINCIPLES 5.1 The Trust is committed to working in collaboration and providing mutual support in delivering the highest standards of care for patients accessing health services. We will work together to: Improve communication and liaison between the healthcare professionals working with patients with a disability and/or mental health problem and those health care professionals working in acute hospital services Support each other (at an organisational and individual level) in the development of accessible information on the care and treatment that patients with a disability and/or mental health problem are likely to receive in an acute hospital setting Ensure that the patient and with the patients consent, their family or carers (if they are involved) are central to and involved in the planning for their period of care in the acute service The procedures to be followed are identified in Appendices 1-2 6. IDENTIFICATION OF STAKEHOLDERS 6.1 These guidelines have been jointly agreed between The Trust and:- Northumbria Healthcare NHS Trust Newcastle upon Tyne Hospitals NHS Foundation Trust Gateshead Health NHS Foundation Trust South Tyneside NHS Foundation Trust City Hospitals Sunderland NHS Foundation Trust 6.2 This is a new Policy with content that relates to operational and/or clinical practice and has been circulated for a four week consultation to the following in line with NTW(O)01 Development and Management of Procedural Documents Policy :- North Locality Care Group Central Locality Care Group South Locality Care Group Corporate Decision Team Business Delivery Group Safer Care Group Communications, Finance, IM&T Commissioning and Quality Assurance Workforce and Organisational Development NTW Solutions 3

Local Negotiating Committee Medical Directorate Staff Side Internal Audit 7 IMPLEMENTATION 7.1 Taking into consideration all the implications associated with this policy, it is considered that a target date of one year from date of issue is achievable for the contents to be embedded within the organisation. 7.2 The policy will be implemented by cascade through the groups and clinical teams 8 EQUALITY AND DIVERSITY ASSESSMENT 8.1 In conjunction with the Trust s Equality and Diversity Officer this policy has undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. 9 MONITORING COMPLIANCE AND EFFECTIVENESS Monitoring and compliance of this policy will be via its application in clinical teams 10 LEARNING LESSONS 10.1 The Mental Health Trust and The Acute Service Trusts are committed to learning lessons from service users, patients, relatives/carers and staffs experiences with the aim of reviewing and improving services and the way they are provided. The Trusts will work together and share lessons learnt relating to the arrangements outlined in this policy with the aim of improving the quality of care and support provided to people with mental health needs or a learning disability who require acute care. 11 TRAINING 11.1 Staff need to be aware of the policy and its implications to clinical practice. This policy needs to be discussed in team meetings to ensure understanding and safe application. 12 ASSOCIATED DOCUMENTATION 4

NTW(C)01 - Resuscitation Policy NTW(C)07 - Promoting Engagement with Service Users, (Policy on Non- Compliance with Treatment / Difficult to Engage Service Users) NTW(C)17 - Medicines Management policy o UHM-PGN-01 Safe and secure medication handling and supply PGN o UHM-PGN-02 Prescribing of Medicines PGN NTW(C)19 - Observation Policy NTW(O)01 Development and Management of Procedural Documents Transition between inpatient hospital settings and community or care home settings for adults with social care needs [NG27] Published date: December 2015. 5

Appendix A Names of Individuals involved in Review Catherine Edge Rod Bowles Equality Analysis Screening Toolkit Date of Initial Review Date Screening March 2016 March 2019 Service Area / Locality Policy to be analysed Is this policy new or existing? NTW(C)15 Arrangements for Northumberland, Tyne and Wear NHS Foundation Trust patients who require access to acute hospital services NEW What are the intended outcomes of this work? Include outline of objectives and function aims These guidelines are aimed at ensuring the safety and welfare of such patients by clearly outlining the process that will be followed to ensure supportive, timely and necessary assessment and treatment. The guidelines are intended to support clear and effective lines of communication between the Trust and Acute Hospital Trusts providing inpatient medical and surgical services to the people of Sunderland, South Tyneside, Gateshead, North Tyneside, Newcastle and Northumberland Who will be affected? e.g. staff, service users, carers, wider public etc Staff, patients and carers Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them Disability Sex Race Age Gender reassignment (including transgender) Sexual orientation. Religion or belief Marriage and Civil Partnership Communication needs will need to be addressed, for people with visual and hearing impairments and for people with learning difficulties. For people with physical impairments we will need to ensure that their access needs can be catered for. Need to ensure that person s language and cultural needs are addressed during stay in acute care. This needs to be a smooth transition. To ensure that communication needs are addressed and that physical access meets the person s needs. Healthcare should be in line with the recommendations in the Department of Health publication See BME issues. Faith will need to be catered for as will cultural and religious dietary requirements. 6

Pregnancy and maternity Carers Other identified groups ; Children and Young People People involved in Criminal Justice System NTW (C) 15 To ensure that they are cared for in an age appropriate setting and that their education needs are addressed during their stay in an acute setting. Security, dignity and respect issues How have you engaged stakeholders in gathering evidence or testing the evidence available? Through standard policy process procedures How have you engaged stakeholders in testing the policy or programme proposals? Through standard policy process procedures For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs: Through standard policy process procedures Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life. Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic Eliminate discrimination, harassment and victimisation Advance equality of opportunity Promote good relations between groups What is the overall impact? Positive Addressing the impact on equalities From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010? If yes, has a Full Impact Assessment been recommended? If not, why not? Manager s signature: Date: March 2016 7

Appendix B Communication and Training Check list for policies Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy Is this a new policy with new training requirements or a change to an existing policy? If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below. Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice? Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Resolutions etc. Please identify the risks if training does not occur. Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training. Is there a staff group that should be prioritised for this training / awareness? Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session, E Learning Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc. NEW POLICY Formalisation and update of current working practice No All Clinical staff Senior managers Awareness Understanding Staff update via team meetings Trust Policy Bulletin n/a 8

Appendix B continued Training Needs Analysis Staff/Professional Group Type of training Duration of Training Frequency of Training All MDT s and Senior Managers in clinical areas Awareness Policy renewal All Directors and Trust Board Awareness Policy renewal Copy of completed form to be sent to: Training and Development Department, St. Nicholas Hospital Should any advice be required, please contact:- 0191 245 6777 (internal 56777- Option 1) 9

Statement Monitoring Tool Appendix C The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework. NTW(C)15 - Arrangements for NTW Trust patients who require access to acute hospital services - Monitoring Framework Auditable Standard/Key Performance Indicators Frequency/Method/Person Responsible Where results and any associated action plan will be reported to, implemented and monitored; (this will usually be via the relevant governance group). 1. Was a joint care plan agreed between mental health services and the Acute Hospital Trust. 1) Policy Authors 2) By thematic review of Electronic Incident Reporting and complaints data ( by exception) Inpatient Responsive Quality and Performance Sub - Group 3) Annually 2. Did regular clincial reviews take place between services 1) As above 2) As above 3) As above Inpatient Responsive Quality and Performance Sub - Group 3. Did a pre discharge meeting take place btween mental health services and the Acute Hospital Trust. 1) As above 2) As above 3) As above Inpatient Responsive Quality and Performance Sub - Group The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out. 10