Redesigning adult mental health services A new model for the organisation of adult mental health services provided by Northamptonshire Healthcare NHS Foundation Trust October 2010
Contents Executive summary... 4 Who are we communicating with?... 5 How to use this document... 6 1. Introduction... 7 1.1 National and local policy drivers... 7 1.2 Why do mental health services need to change?... 8 1.3 Supporting economic recovery... 9 1.4 Equality Impact Assessment... 9 2. What s changing?... 10 2.1 Our proposals... 11 Community mental health services... 11 Single point of access... 14 Hospitals and acute care... 15 Buildings and estates... 16 2.2 Matters that have already been decided... 16 The creation of four Operating Units... 16 Changes to use of buildings... 17 Developing mental health services... 17 3. The sector approach... 18 3.1 Integrating specialist community teams into sectors... 19 3.2 What will be different?... 21 3.3 The reconfigured sectors... 22 4. Clear care pathways... 24 4.1 Care pathways... 24 4.2 What will be different?... 25 5. Operating units and service structure... 26 5.1 Structure of operating units... 26 5.2 Operating units and service users/carers... 26 5.3 Operating units and staff... 27 5.4 What will be different for staff and service users/carers?... 27 6. Developments and new services... 29 6.2 Dementia services... 29 6.3 Rehabilitation and recovery services... 29 6.4 Social care and recovery... 31 6.5 Acute and urgent care... 33 6.6 Secure care... 34 2
7. Workforce Development... 36 8. Buildings and bases... 38 8.1 Current main team bases and service delivery points... 38 8.2 Key buildings for review... 38 9. IM&T services... 40 9.1 The EPEX improvement programme... 40 10. Stakeholder expectations... 42 10.1 Feedback to date... 42 10.2 Service users... 42 10.3 Carers... 42 10.4 GPs and primary care... 43 10.5 Northamptonshire County Council... 43 10.6 Northamptonshire Teaching PCT and other Stakeholders... 43 10.7 Staff... 44 11. Communication and engagement... 45 12. Project plan... 46 12.1 Project structure... 47 13. Next steps... 48 14. Conclusion... 49 15. References... 49 16. Telling us your views... 50 Written comments... 50 Feedback form... 50 Have your Say staff sessions... 50 Find out more Service User and other stakeholders drop-in sessions... 51 After the Have your Say period... 51 Appendices GP practices covered by the proposed four sectors... 52 Locality bases & service delivery points... 54 Feedback Form 3
Executive summary Service users, carers and our staff are aware that we have been working to deliver a new model of care for adult mental health services. In doing so, we have to think differently about the way in which we deliver services without compromising on quality and within the constraints of the current financial climate. The current picture has to include considerations of Cost Improvement Projects (CIP) of approximately 3 million, and Quality, Innovation, Productivity, Prevention and Savings (QuIPPS) expectations of 2.2 million. Within Northamptonshire Healthcare NHS Foundation Trust there are many ways that we can deliver improvements and savings including the way we reconfigure our estates, staffing (subject to a further and separate consultation), integrate teams and use technology. This document sets out the framework on how Northamptonshire Healthcare NHS Foundation Trust services will look in the future. There will be opportunity to scrutinise, comment and offer further suggestions for improvement on the model throughout the Have your Say period running until 26 Novemeber 2010. The proposed model will mean moving all adult mental health community services into four sectors. Each sector will be led by a designated clinical director and head of service. It is proposed that, as a minimum, the following services will be available in each sector: Acquired brain injury Traumatic brain injury Complex cases (personality disorder) Community mental health teams Early intervention Forensics Intensive home support Dementia Assertive outreach Dual diagnosis BME input Employment and vocational support and advice All professions where appropriate In addition to the above, some specialist services will be co-located within the sectors, e.g the Rushden and Wellingborough sector could continue to be the team base for dementia services, with the Daventry and South Northamptonshire sector potentially housing the forensic team. 4
We know that service users and carers want the right care at the right time in the right place. Service users and carers also want out-of-hours support. They do not want disjointed services that get in the way of quick access to evidence-based effective care. We want to help people recover and to maintain their identity and roles as part of our society, including supporting service users with employment and vocational goals. To do this we want to support people in their homes, not in hospital unless there is no other option. Equally, when someone is ready to be discharged, we want to be able to make this happen with no delays and with support at home in place, ready and waiting for the person. By co-locating the skills of our workforce within the sectors in the way we have put forward, this is achievable. We believe in taking an inclusive and recovery focused approach and want to make it easy for service users to meet with practitioners in flexible ways that are appropriate to their needs. This will mean that consideration of culture, stigma and discrimination will form part of the way we deliver services. Appointments will be offered in a variety of settings, not just mental health environments, but in GP practices and other community places. For staff, this will mean more time out of the office using technology to cut down on paperwork and duplication of records. As less time would be spent at the base, hot desking will become the norm. By configuring the sectors in the way we have described, using technology will release time to do the things that matter to us. The configuration of staff within the sectors means that a range of expertise will be available to each and every service user. Practitioners will also be able to access supervision, expert advice and peer support when needed. All staff, across professions, will work to a job plan that sets caseload numbers and activity required related to the complexity of cases. Visible leadership across and within the sectors will enable streamlined decision-making, clear responsibility and accountability, while maintaining the identities of specialist practitioners. We are looking carefully at the buildings we use and thinking about ways that we can work differently. The premises we currently use to work from may change, and staff may be located in a different building that is central to the population the sector serves. We are thinking about how to pool resources so that our services are managed cost effectively and teams aptly supported. We are keen to take comments and suggestions that are helpful to redesigning the service. This is a great opportunity to make change for the better, and to look to the future and its challenges from a carefully thought through position. Who are we communicating with? 5 1. Service users - because we will have fewer bases to provide care from and we want to increase the delivery of services in GP practices and in service users homes. 2. Staff - because we are changing the way and the location services are delivered, and also because we will be reducing a number of posts across management and support services. 3. Carers - because they are a key stakeholder in the delivery of the Service Users care plan and who need to be aware of the impact on Service Users and the way we want to deliver Services in the future. 4. GP practices - because we want primary care to be aware of how the service changes will impact on them and service users.
5. Commissioners - because we want our commissioners to arrange services that are joined up with ours. How to use this document We have themed each section, and highlighted in grey what will be different areas that clearly set out what will be changing. This enables the reader to read a summary of the important parts for each section without having to read the whole section in detail. Details of how you can respond can be found in Section 16 of this document. 6
1. Introduction Northamptonshire Healthcare NHS Foundation Trust provides secondary care mental health services for adults and older people in Northamptonshire. Our services aim to complement those provided by primary care. We offer specialist treatment and care for people who have more severe, enduring or complex mental health problems that cannot be supported in primary care. This document outlines the proposed model for delivering adult and older people s mental health services within Northamptonshire Healthcare NHS Foundation Trust. We want to deliver the right care at the right time by the right people to the population we serve. We want to drive up and maintain the already high quality of our services while making the best use of existing resources to address the cost efficiencies we have to make with as little as possible disruption for staff. All of this involves the Trust embarking on a period of change, and we want to ensure that any changes are appropriately considered, recovery and inclusive focused and deliver the best care we can for service users. Our services have been based on the National Service Framework (NSF) for Mental Health that was rolled out over ten years ago. The NSF focused on numbers of service users treated and numbers of staff, not necessarily service users outcomes. The redesigned model must deliver benefits to service users and, where appropriate their carers, and improve the quality of care that service users receive, whether in terms of clinical outcomes, experiences or safety. This document sets out the proposed changes to the services commissioned from Northamptonshire Healthcare NHS Foundation Trust by NHS Northamptonshire, the primary care trust. It will be updated to reflect the views of key stakeholders following involvement and engagement events and a Have your Say period. The overarching reason for change is to deliver better care and services to service users and carers in line with national and local policy, within the reality of an extremely challenging economic environment. 1.1 National and local policy drivers There are a number of local and national drivers that set out the need for a new service model if the Trust is to meet the challenges presented by current and future directions in national policy. These include: Next Stage Review, High Quality Care for All delivering high quality care through skilled practitioners in an equitable and inclusive way. New Horizons, National Mental Health Strategy - meeting social needs through delivering Flourishing People, Connected Communities by working in primary care settings. 7
New Dementia Strategy and Older People s Mental Health Strategy - new legislation and policy guidance in relation to age discrimination. The new service model must tackle age discrimination which will require a more integrated approach to mental and physical health and social care provision. Humana Review - Joint Commissioning Strategy - introduces a whole spectrum of care across the health economy we need to position ourself to be successful in gaining new business. Equity and Excellence - Liberating the NHS (White Paper) - the need to deliver cost effective, efficient services ensuring better standards of care and value for money. Feedback from engagement events with service users, carers, staff, and stakeholders over the past 18 months. Our Corporate Objectives for the next five years - using technology to implement single service users/clinical and staff records, using technology to minimise staff travel time. Reducing the Trust s carbon footprint by reducing the number of buildings we work from coupled with the need to develop a service model which places our services in primary care. 1.2 Why do mental health services need to change? The Community Mental Health Teams (CMHTs) have offered services based on the National Service Framework for a decade. Services have evolved leading to duplication and layering. There is a need to ensure that gaps and duplications in CMHTs are eliminated, and to deliver evidencebased practice, seamless services and streamlined pathways. Expectations of inpatient environments and the benefits of inpatient care are under scrutiny, supported by informed stakeholders, influenced and driven by service users and carers. There is a national move towards mental health services being delivered in primary care settings. By delivering preventative work and supporting long-term conditions in an inclusive way, the numbers of service users admitted to hospital will be reduced. Service users will find it easier to access physical care services and social support that improves recovery from mental ill health. Service users and carers need support locally. We need to develop community-focused services that treat and support people within, or as close as possible to, their home giving real alternatives to inpatient services and out-of-area placements. We need to make best use of specialist skills. Multi-disciplinary team working with expert practitioners making decisions at the front door. Trustwide specialist teams supporting the sectors and other services, working with service users requiring specialist input. We need to define roles and responsibilities of all staff groups and their individual contribution to multi-disciplinary team working to deliver evidence-based practice, bringing together the mental and physical health needs of our service users. 8
Some parts of the new model have already been decided. These include delivering services from sectors, making cost improvements, more mobile working and using technology. We will continue to drive forward the dementia strategy. We are interested to hear all comments and views that can help us to implement and improve the proposed new model for the way adult mental health services are organised, to deliver effective, efficient, high quality services for the people of Northamptonshire. 1.3 Supporting economic recovery While the main focus of our proposals is our desire to deliver better services for service users and carers, and better opportunities for staff in those services, these proposals also contribute to the efficiency savings that Northamptonshire Healthcare NHS Foundation Trust is expected to achieve. We are expected to make year-on-year reductions in our expenditure, while maintaining the quality and effectiveness of our activities. As a member organisation of the NHS in Northamptonshire, we are also expected to contribute to the overall reductions in spending that the NHS has been tasked to achieve as part of national economic recovery. For 2011/2012, Northamptonshire Healthcare NHS Foundation Trust is expected to make a costimprovement saving of 3 million across mental health services. These proposals could achieve those savings with a 1.2 million reduction in management and back-office costs, 800,000 from changes to facilities and hotel services, and a further 1 million from reductions in accommodation and related costs. We are also looking to invest in local services in Rehabilitation while reducing the spending in the private sector of 2.2 million. 1.4 Equality Impact Assessment Our new model for the organisation of local adult mental health services has been constructed with the expectations and requirements of local and national policies firmly at the forefront. The new model will ensure that services will address equality considerations, particularly: Offering services based on need rather than age. Offering services that can be delivered flexibly, taking account of individual need and personal choice. Offering personalised care plans for individuals that plan and co-ordinate care appropriately. Ensuring that services are focused on individuals recovery. Ensuring that all service users have access to a full range of services, irrespective of race, creed, colour, religion, age, disability, sex or sexuality. An Equality Impact Assessment has been produced to identify areas of concern and ensure that all appropriate action is taken to mitigate these concerns. A copy is available from the Project Office at the address shown at the back of this document. 9
2. What s changing? We are proposing to implement a number of changes as a result of the service redesign and subject to the Have your Say period. These include: The integration of adult and older people s community mental health services The re-organisation of community mental health services into four sector teams Single point of access into the sectors Refining the way we manage Hospital services Reducing the number of bases we use Bringing people out of county back into local services The tables on the following pages explain more about these proposals. 10
2.1 Our proposals Community mental health services We propose to integrate adult and older people s community mental health services. Reasons Older people who receive community mental health services do not currently have access to the same wide range of services and support as adults. Integrating adult and older people s community mental health services will end this inequality. Instead, all adults will receive treatment and support that is more personalised to their individual needs and circumstances, irrespective of their age. We will retain the expertise of our existing practitioners to serve people with dementia and those that have concerns around their physical frailty. Benefits A full range of community mental health services for adults of all ages, with the exception of those better served by the dementia service. Access to Crisis services remain the same and will allow a better continuity of care. We will retain the expertise of our existing practitioners to serve people with dementia and those that have concerns around their physical frailty. There will be a review of medical staff and team skills developments and appropriate training delivered to address any gaps in skills that may be needed. Other options considered Providing separate pathways and teams for older adults within the sectors. 11
We propose to organise community mental health services into four sectors: Kettering & Corby, Wellingborough & Rushden, Northampton, and Daventry & South Northamptonshire. The Early Intervention, Crisis and Assertive Outreach teams will support each sector. Reasons Currently eight community mental health teams for adults and seven community mental health teams for older people exist. Multiple specialist community services exist including: Two assertive outreach teams Two early intervention teams One intensive home support service BME service Two Crisis Resolution and Home Treatment Services, one North, one South and a separate Crisis and Telephone Support Service (CATSS). We want to bring all our services closer together so that we can reduce the duplication of referrals and increase the availability of senior clinicians at the point of assessment so they can diagnose and initiate care plans far earlier. We also want to ensure that we bring all the skills and resources together within the sector, closer to the Service User to meet their and their carers needs. This will ensure a team approach to delivering care that is consistent with the suggestions of the Royal College of Psychiatrists. Benefits There will be single line management structures responsible for the services delivered by the sector. Sectors will be responsible for delivering a full range of community mental health services for adults of all ages, including an integrated rehabilitation and recovery pathway, effective, short-term interventions, and support for longterm mental health conditions. Philosophy of recovery and social care reablement fully embedded within services. Practitioners have told us that specialist care needs to be centralised where necessary, localised where possible, so that practitioners with the right expertise can treat service users safely and closer to home. Sectors made up of staff with a range of expertise and skills who will work more from hot desks with the benefit of lap tops and mobile working, allowing more flexibility in their work-life balance. More care delivered locally from community settings such as GP practices and will make the best use of and reduce physical resources such as buildings and back office costs. Specialist community mental health service staff working alongside community mental health sector teams will provide high quality, integrated care and support. Bringing services closer together, will help to improve joint working across different agencies, making it easier to co-ordinate care for service users to take account of all their health needs. Carers assessments will be offered as the norm. CATSS and Crisis Resolution services will be jointly managed, working closely with inpatient and community mental health services. Crisis and out of hours services will remain as is with a clear expectation that activity increases to reduce hospital admissions and to facilitate early discharge. 12
Sectors need to be aligned to other organisations that influence care delivery The Sectors we propose will be co-terminous with local authority and commissioning boundaries and with GP surgeries. Sectors will be part of a multi-agency sector network, moving away from the traditional individual provider meetings to a multi-agency Mental Health Board which will include all provider services, secondary and third sector services responsible for the delivery of services within the geographical boundaries of the sector. Other options considered Full integration of all community mental health services including the direct management of specialist community mental health workers, such as Early Intervention, Crisis and Assertive Outreach, as part of local sectors. 13
Single point of access We propose to provide a single point of access to services within the sectors. Reason Our arrangements for assessing and accepting people into mental health services are complex. Different teams use different approaches. GPs sometimes have to make multiple referrals and service users have to undergo multiple assessments. This wastes GPs valuable time and confuses and frustrates service users, particularly when they are new to services. It can take longer than necessary before people start their actual treatment. Having a single point of access for each sector will help to speed up referral, particularly in cases where multidisciplinary support from a range of services is required. Benefits A single point of access for all adult mental health and social care services within each sector that operates a single screening and expert assessment process to ensure service users are directed into all the services they require according to their individual needs. Other options considered We considered a single countywide point of access for referrals and assessments. 14
Hospitals and acute care We propose to increase practitioner leadership and manage the two hospitals as one unit. Reasons Adult treatment wards currently operate independently, and are same sex units. Ward managers report to matrons; matrons report to Head of Service. Occupational therapy, and psychology are managed separately. Admission, PICU and Crisis are currently managed separately and operate independently of each other, with support resources for psychology and allied health professionals budgeted and managed separately. Older peoples inpatient services and adult inpatient services managed separately and operate independently of each other with resources for psychology and allied health professionals budgeted and managed separately. Benefits Treatment wards managed by a Matron who is service-user facing, responsible for all aspects of care, and all resources. Accountability for high quality care through the Matron and the Clinical Director. As above. A single management team for all hospital care with matrons based on wards. A reduction in one tier of management with all hospital services and hospital service staff managed in one operating unit. Other options considered To continue managing and working with separate structures for each of our hospitals. 15
Buildings and estates We propose to reduce the number of bases we operate from Reason Some of the buildings we currently use are either under utilised, very expensive to run or not fit for purpose. We also believe that people want to access care from premises that are close to their homes and in their local communities that reduces stigma. We need to rationalise and reduce our estate along with the changing requirements of hotel services. Benefits Increased delivery of care in service user homes, flexible working for staff, sectors maintaining a base that is fit for purpose and fully utilised. A new estates and hotel services model will be developed to reflect need and offer more integrated support. Integration of hotel and estates services into the sectors will deliver an efficient and effective service by pooling resources. Other options considered To continue working in traditional ways that continue to bring service users into community mental health buildings. 2.2 Matters that have already been decided The creation of four Operating Units Reason Provides clear clinical leadership in service delivery, with robust governance arrangements and common standards across the county Benefits Ensures clear accountability for performance and the use and management of resources. Reduces duplication and waste, management and back office costs (subject to a separate staff consultation). Other options considered To continue to work as service directorates with existing leadership provision 16
Changes to use of buildings Reason Not all of the buildings we use are fit for purpose and not all of these can be made fit for purpose. These include Mill House in Towcester and Redcliffe in Wellingborough. Other buildings are leased and expensive to operate. These include Clarendon House in Kettering. There are also buildings which are not fully used and could accommodate more services and more staff. These include Campbell House in Northampton. We have plans to improve facilities at St Mary s Hospital in Kettering and Rushden Hospital. Other options considered Continuing to operate from multiple bases Benefits Our plans to deliver more services in people s homes and in primary and community settings, with staff spending less time in offices and with more use of mobile computing, can help us to use office accommodation differently, offer more flexible working and increase efficiencies Developing mental health services Reason These are areas where we have identified gaps in the services we provide. Other options considered To continue to manage need by providing out of county and private care Benefits These are important areas that can help us to deliver comprehensive, high quality care that applies best practice, bringing service users back from out of county or private placements to receive their care locally. Taking forward the dementia strategy is an important initiative to enhance the service we provide currently.. 17
3. The sector approach We are proposing to integrate community mental health teams (CMHTs) with other community mental health services to become sectors made up of staff equipped with a variety of skills to meet service user need. Thus, there will be no community mental health teams, only sectors. Reasons for this approach include: Forming a critical mass of expertise available locally, including employment specialists Making the best use of physical resources, reducing back office costs Sectors coterminous with local authority and commissioning boundaries The suggestions by the Royal College of Psychiatrists Minimising reducing posts Sectors will be responsible for delivering a full range of primary and community mental health services for adults of all ages, including an integrated rehabilitation and recovery pathway. Practitioners have told us that specialist care needs to be centralised where necessary, localised where possible, so that practitioners with the right expertise can treat service users safely and close to home. The delivery of the new care pathways is reliant on the successful training and development of staff in NICE guidelines and New Ways of Working in order to deliver mental health services fit for purpose not only today but in the future. Sectors will be the delivery points for all community-based services, with a single line management structure responsible for: Single point of access to each sector Long-term conditions Mental health in primary care Rehabilitation and recovery services Assertive outreach service Occupational therapy services Psychology services Social care services (dependent on Section 75 agreements) Home treatment Sectors will be part of a multi-agency sector network, moving away from the traditional individual provider meetings to a multi-agency Mental Health Board which will include all provider services, secondary and third sector services responsible for the delivery of services within the geographical boundaries of the sector. Specialist teams with distinct remits and functions will be retained and link into sectors in a hub and spoke framework to offer specialist support. The remit of Crisis Teams will focus on delivering 18
the functions they were set up for assessment, gatekeeping, accident and emergency liaison and discharge. Further development opportunities will be offered to staff to equip them with the skills necessary to be part of a fully inclusive sector service delivery. Out-of-hours provision will be addressed, and mobile working will become the norm. 3.1 Integrating specialist community teams into sectors We also considered the option of fully integrating crisis teams within the sectors. However, our proposal is to maintain and refine specialist teams, crisis and out-of-hours services. 3.1.1 Out-of-hours delivery Most community mental health services are available 9am-5pm, Monday to Friday. Service users and carers tell us of the importance of accessing timely support that is available out of hours, including support for older service users. In order to provide out-of-hours services, the role and function of the Crisis Team, Home Treatment Team, CATSS and Initial Screening Assessment Team will be further defined as we go through staff consultation. The Approved Mental Health Practitioner (AMPH) role is integral to the Crisis Teams we await the outcome of the on-going discussions around the Section 75 agreement. 3.1.2 Crisis and Telephone Support Service (CATSS) The CATSS Team will inreach into sectors, screening and recording all out-of-hours calls and referrals into community mental health services and providing a link to the Crisis Team during Out of Hours. 3.1.3 Initial Screening Assessment (ISA) Teams The original teams have already been integrated into Sectors. This role will be further integrated and be managed within the Sectors 3.1.4 Crisis Resolution Home Treatment Teams (CRHTTs) There have been developments in Crisis Resolution Home Treatment teams that have drawn them away from their core functions. Evidence, both anecdotal and factual, shows that the Crisis Resolution Home Treatment teams are not currently used to best effect and are used as a panacea for a broad range of service-user issues. In the future, the teams will focus solely on the key tasks they were established to perform: dealing with emergencies, gatekeeping admissions, bed management, accident and emergency liaison, and early discharge. Any other functions this team currently provides will be removed and delivered by alternative sector workers where there is possible. A working group will be immediately set up to address the urgent issues surrounding the crisis teams during this Have your Say period. 19
3.1.5 Assertive Outreach Teams (AOT) Assertive outreach workers will continue to assertively engage with service users as part of the sector staff and as a specialist team. Two teams will converge into one and continue to maintain the team identity. This means that the assertive outreach workers will maintain their skills but be based within the sectors, coming together regularly to maintain their core purpose as a specialist service. It is expected that these teams will simplify their referral processes by working closely with the sectors, and be closely aligned to where service users access the services. The consultant for this service will remain as a specialist consultant with the responsibility for the team. Assertive Outreach teams will work to reduce admission rates in to hospital beds and will increase the number of contacts with service users they are supporting in line with national guidance. 3.1.6 Early Intervention Services (EIS) Early Intervention services will continue to work as a specialist team. Two teams will converge into one and continue to maintain the team identity. This means that the EIS workers will maintain their skills but be based within the sectors, coming together regularly to maintain their core purpose as a specialist service. It is expected that these teams will simplify their referral processes by working closely with the sectors, and be closely aligned to where service users access the services. The consultant for this service will remain as a specialist consultant with the responsibility for the team. EIS teams will work to reduce admission rates in to hospital beds and will increase the number of contacts with service users they are supporting in line with national guidance. Early Intervention services will continue to work with service users at the earliest of stages of mental ill-health as possible, working with high risk groups and engaging with them in a variety of settings. 3.1.7 Personality Disorder Services (complex cases) The interventions provided by Team 63 will be further developed to provide a distinct personality disorder or complex cases service, focused on engaging at the earliest opportunity with this group of service users and on maintaining them in the community. Its main function will be to prevent avoidable admissions to hospital, in addition to supporting the sectors when required. A project team will be established to develop this service. 3.1.8 Transitions and Liaison Team (TLT) There are a range of opportunities on the horizon for service users with a diagnosis of Asperger syndrome. Business cases are currently being drawn up about how we move forward in the future. 3.1.9 Developmental Disorder Services No changes are being planned for this service. 3.1.10 Traumatic and acquired brain injury No changes are being planned for this service. 20
3.1.11 Eating Disorder Services The model that this team works to is one the Trust is keen to emulate across the many services we offer. Further work will take place to this effect. 3.2 What will be different? One contact number per sector Calls/referrals received and fielded by skilled staff during and out of office hours Improved GP response More efficient links into appropriate services Single point of access to sector Access to services, locally Quicker access to skilled staff deployed flexibly to meet the needs of the service, including assessments Crisis and home treatment workers Crisis workers focused on assessment, bed management, A&E liaison and discharges Home treatment workers in the sectors visiting at least twice daily Treatment pathways Delivered in four sectors to maintain relationships locally in primary care settings Strengthened working partnerships Pooling of resources Data quality Out-of-hours service Joint working where appropriate with GPs, A&E, primary care, Changing Minds, social care, housing, employment, education and third sector parties Existing resources shared for efficiency and viability in delivering the service Improved outcome measures through one central administration unit Timely and appropriate interventions to crisis need. 21
3.3 The reconfigured sectors Reconfigured sectors will serve the following areas within Northamptonshire as follows: Kettering / Corby Wellingborough / Rushden Kettering Corby Oundle / Thrapston Wellingborough Rushden / Raunds Northampton Northampton Towcester South Northants & Daventry South Northants Daventry Brackley Adult population 113,600 Adult population 122,500 Adult population 156,700 Adult population 128,300 The reconfigured sectors allow for a redesigned service model that will deliver: Inclusiveness - the right care in the right way for service users including workers skilled in dual diagnosis and BME issues. Care delivered using evidence-based practice by a skilled and confident workforce. Services delivered within sectors from referral through to treatment, linking with inpatient and rehabilitation services including third sector organisations. Local services delivered to local people in a more efficient and targeted way, meeting the needs of the local population and reducing need for referrals to other areas. Opportunities to integrate assertive outreach, intensive home support service and early intervention workers within sectors. Community services operating as a business unit, pooling resources and making best use of specialist skills within the sectors. Integrated support functions within sectors to deliver efficient and effective services. Fit-for-purpose buildings, with fewer bases and better environments. 22
Illustration of proposed sector model and clinical pathway Single Point of Access one (Telephone Number) telephone number per sector: 1. Referral 2. Assessment 3. Care co-ordinator Acute care Dementia Forensics Treatment Pathways Sector Corby / Kettering Sector Wellingborough / Rushden Sector Northampton Sector South Northants / Daventry Each sector will provide the following range of local community mental health services: Long-term conditions, Short-term prevention and early intervention, Mental health rehabilitation, Social care, Therapies, Assertive Outreach services, Early Intervention services, and access to Crisis services. 23
4. Clear care pathways We are proposing to establish clear separate pathways for people with long-term mental health conditions and for people who require shorter interventions. We also considered the option of continuing to work as now, without fully configured pathways. Our clear care pathways have already been agreed in principle with NHS Northamptonshire. This work, led by the PCT and Northamptonshire County Council, has been underway for the past 18 months and has included engagement with stakeholders. Within Northamptonshire Healthcare NHS Foundation Trust, the main focus of the presentations held for staff and stakeholders since March 2010 has been the outline service model that includes the new care pathways. 4.1 Care pathways The care pathways proposed within the adult mental health community sectors will provide opportunities to improve care, develop services in primary care and make efficiency savings. Further adjustments will be made following the mental health service redesign programme Have your Say period. We believe that implementing the clear care pathway will result in minimal disruption. Most staff will continue to work within their existing sectors based on their skills, knowledge and experience. A staff development programme will be put in place to maximise the skills, consider career development and succession planning of all staff working in the sectors, supporting the delivery of the care pathways. This will be reliant on the successful training and development of staff in NICE guidelines and New Ways of Working in order to deliver mental health services fit for purpose not only today but in the future. Service users requiring treatment from our services will be allocated to the appropriate care pathways dependant on need and location. Need will be determined by conducting a comprehensive assessment of physical, mental health and social care needs, supported by a unique personalised care plan. This will create the pathway for the service user, utilising the range of resources within the sector. The clear care pathway will reduce the number of times a service user tells their story. One set of documentation will follow the service user through their journey. Wherever possible, interventions will be offered at the service user s preferred location. This major change in service delivery is reliant upon the successful implementation of electronic systems and communication devices. Care pathways will provide greater understanding and clarity of roles for staff. Training linked to the care pathways will be offered, including dual diagnosis as a core requirement. Service users of the sectors will be clustered into long-term conditions and mental health in primary care. This will support the care pathways by providing information to manage capacity and demand and will deliver increased quality, productivity and efficiency. Clustering in this way will also enable greater clarity around Payment by Results. 24
4.2 What will be different? Care pathways Care pathways will be split into long-term conditions and mental health in primary care with more emphasis on short-term interventions, link working in GP practices and outreach to other primary care settings and community resources Standardised care pathways across the four sectors, with a unique care plan Employment, housing and social care needs NICE guidelines Delivering services Team work and decisionmaking Training and development Staff groups Increased emphasis on employment, housing and social care needs Work to NICE guidelines and best practice within all sectors The most skilled and confident practitioners delivering services at the front end Multi-disciplinary team working and decisionmaking Training and development linked to care pathways Maximising the skills of multi-professional staff groups 25
5. Operating units and service structure Operating units are a relatively new concept within Northamptonshire Healthcare services and will be created as part of the new service model. Operating unit is the overarching term used to describe the staff structure and service purpose that come together as a unit. Operating units have clear lines of accountability for service delivery, performance, financial management and service users experience and quality outcomes. Initially it was proposed that five operating units be created - acute care, community services, rehabilitation and recovery, dementia services and forensic services. However, the engagement feedback suggests four operating units would be preferred with rehabilitation and recovery localised and delivered as part of the community mental health services within the sectors. This would further improve opportunities for self-directed support, by linking with primary care to promote social inclusion. Berrywood and St Mary s Hospitals will join to form one acute care operating unit. 5.1 Structure of operating units Each operating unit will be led by a head of service and clinical director accountable to the Executive. The head of service and clinical director will be responsible for strengthening managerial and professional accountability within the operating unit under their remit to improve front-line decision making and accountability for the delivery of clinical services and effective resource utilisation. This includes lead posts for each of the five core professions, nursing, allied health, medic, social care and psychology in each of the sectors. 5.2 Operating units and service users/carers For service users, carers and other referrers, the creation of operating units will mean: Streamlined pathways from community care into and out of acute care One assessment process and documentation from referral through to treatment Services delivered locally within sectors whenever possible. Service users will tell their story once Service users will be seen by the most skilled and confident practitioners able to make sound judgements based on NICE guidelines and best practice Prescribed care plans will be developed which will be unique and personalised to meet individuals needs. Service users will receive the appropriate treatment and care speedily Opportunities to improve and establish Choose and Book appointments. 26
5.3 Operating units and staff For staff, operating units will bring opportunities to be part of a larger multi-skilled professional workforce, delivering evidence-based practice. Sectors will be part of the operating unit, able to make decisions with more autonomy. The head of service, clinical director and professional leads will be responsible and accountable for all sector-based and other related services as part of the individual operating unit. Practitioners and other staff will have a clear governance structure. Pooling of resources within each sector will provide greater flexibility, reduce costs and enable the deployment of staff to deliver efficient and effective services to our service users, carers and stakeholders. 5.4 What will be different for staff and service users/carers? Geographical boundaries Line management structure Changes to improve access to services and reduce travel time for staff and more time with service users. Single line structure with each sector led by head of service with clinical director Assertive outreach workers based within the sector under single line management with a dedicated consultant and AOT caseload workers Early intervention maintaining specialism for contracting purposes and team identity, in reaching into sectors with a dedicated consultant and caseload workers Psychologists, occupational therapists under single line management structure reporting to the professional leads in each sector. Social care subject to Section 75 agreements Less management posts in the future through reduction in lines of management between the director and frontline staff. More leadership at front line through skilled and confident workforce including appropriate delegated decision-making Professional leadership Five, core professional, leads. 27
Single point of access to sector Delivery points Communication Care packages Timely comprehensive assessments, working with GPs, A&E, Changing Minds and primary care. Care integrated into sectors to deliver home treatment as an alternative to hospital admission and continuity of care through collaborative working with care co-ordinators. Fewer buildings and upgraded buildings for identified delivery points. Improved information sharing between service users, carers, customers and staff Assertive outreach team and intensive home support working collaboratively to support the return of Individual Packages of Care (IPCs) and provide more intensive input within sectors, minimising the need for IPCs, whilst maintaining specialisms for contracting purposes. 28
6. Developments and new services This section describes the developments and new services planned as part of the new service model for adult (over 18) mental health services. 6.2 Dementia services The implementation of the dementia strategy and the introduction of a standardised and enhanced memory assessment service across the county, delivered from a variety of community settings including from service users own homes, is regarded as a key and priority area for development. Community services will be delivered via two specialist dementia teams, based at the Berrywood Hospital and St Mary s Hospital sites. Teams will use satellite locations and mobile technology to facilitate close community working and reduce the need for excessive travel time. Evidence-based treatment and support programmes will be delivered from locally based community settings. Crisis Liaison services will be strengthened to reduce the necessity for inpatient admission and to support early discharge from hospital. 6.2.1 What will be different? Dementia service Staff training and development A new specialist dementia service will be set up Staff training and development in specialist services Crisis and AOT engaging with adults of all ages Countywide services Countywide specialist services supporting staff in sector teams 6.3 Rehabilitation and recovery services There is now a compelling case for proper access to rehabilitation services across the whole of England and a number of national and local drivers for change. Locally, there is a need to initiate a process of service redesign and development of rehabilitation and recovery pathways which will continue to improve the quality of services and reduce expenditure on individual packages of care (IPCs) in future years. There is a Joint Managed Network Board with the PCT and Northamptonshire County Council to steer the service redesign programme. The Board will also work to eliminate the current 27 million expenditure on IPCs through the development of local services and robust mechanisms to 29
strengthen case management and contracting processes, to deliver improved gate keeping, price challenge and value for money. The new model for rehabilitation services will be a tiered approach delivering a recovery based rehabilitation service across the pathway from tier one to four. Recovery-based rehabilitation service Tier 4 Secure care Tier 3 Inpatient rehabilitation Tier 2 Community mental health teams Tier 1 Primary care / third sector The new model of delivery will achieve the following: Reduce IPC overspend through repatriation into Northamptonshire Healthcare and other appropriate local services. A coherent service model, which will define clear access criteria at each level of intervention within a managed network across inpatient, community and other agencies. Strengthen partnerships to deliver the managed network and to achieve a fully integrated care pathway to ensure seamless packages of care and to direct those in need of dementia services. Redefine the role and functions of current Northamptonshire Healthcare rehabilitation services with recommendations for further service redesign/development opportunities. The following premises currently used for rehabilitation and recovery services will be reviewed for future use and suitability; for example: Meadhurst, Kettering (Northamptonshire County Council) Moray Lodge, Duston (Northamptonshire County Council) Hazelwood bungalow, Corby (Northamptonshire County Council) 78 Headlands, Kettering (Northamptonshire Healthcare NHS Foundation Trust) Robin Lane, Wellingborough (Northamptonshire County Council) 30