The State Hospitals Board for Scotland Transfer/Discharge Care Programme Approach (CPA) and Multi Agency Public Protection Arrangements (MAPPA) Annual Review (01 July 2015 30 June 2016) Page 1. Introduction 2 2. Governance Arrangements 2 3. Key areas of work 2 3.1 Application of Transfer/Discharge CPA 2 3.2 Patient and carer involvement in meetings 3 3.3 Patient/Stakeholder Feedback 4 3.4 Multi-disciplinary working 5 4. Key performance Indicators 7 4.1 4.2 Circulation of CPA Minutes Transfer/discharge CPA Chair 7 7 5. 5.1 5.2 MAPPA State Hospital MAPPA Notifications MAPPA Change of Circumstances 7 7 7 5.3 MAPPA Referrals 7 5.4 5.5 MAPPA Consultations MAPPA Expansion 8 9 6. Areas of good practice 8 6.1 Patient Involvement 8 6.2 Inter-agency working including Police liaison 9 6.3 Tele- mental health 9 7. Identified issues, potential solutions and future service developments 9 1
1. Introduction The Care Programme Approach (CPA) is a structured process for the management of risk and the care and treatment planning of patients. This is achieved in a manner which is patient focussed and consistent with the principles of Recovery. It relies for its effectiveness on inter-agency communication and partnership working. The CPA values which form the principles of The State Hospitals Board for Scotland Clinical Model, including multi-disciplinary working and patient participation, are critical for the successful implementation of CPA. The State Hospital adopted CPA as the principle mechanism for the planning of transfers or discharges in 2003. As part of the Local Delivery Plan, The State Hospitals Board for Scotland has adopted a target of 100% of all discharges and transfers from The State Hospital to be managed by the CPA process. This includes transfer/discharge, CPA meetings, CPA Reviews and CPA Contingency Planning meetings. Fig 1 reflects the successful implementation of CPA at The State Hospital. There is a need for the transfer pathway and risk management arrangements to be facilitated by the CPA process and/or MAPPA, for a relatively small number of high profile patients. The Social Work Service continues to provide The State Hospital s single point of contact with MAPPA. 2. Governance Arrangements Transfer/Discharge CPA (T/D CPA) and MAPPA arrangements are managed in partnership with South Lanarkshire Council (SLC) Adult and Older Persons Services, as part of the Service Level Agreement between The State Hospitals Board for Scotland and SLC. CPA and MAPPA matters are also considered by the Senior Team and the Clinical Forum. Following a request from the RMO group and consultation between the Medical Director and SLC, the chair of pre-transfer/discharge CPA, pre-transfer/discharge CPA review meetings and contingency planning meetings reverted to the RMO from 1 April 2015. Social work management have maintained an overview of the process, with active intervention when required to support the CPA Administrator and to ensure the consistency and quality of the service. 3. Key areas of work 3.1 Application of Transfer/Discharge CPA 41 patients were transferred or discharged during the review period, which is the same as the previous reporting period. The LDP target was achieved in all cases. The total number of meetings was 75. This figure includes 28 Pre-CPA meetings, 41 CPA meetings, 2 CPA review meetings and 4 contingency planning meetings, which are all recorded and minuted as separate meetings. Page 2 of 11
Pre-CPA meetings are required 1 when there is a need to discuss victim issues; police matters, or other such sensitive information in advance of the CPA meeting. These were held immediately before 26 of the 43 primary meetings. The Early Discharge Protocol has not been invoked during this review period. Fig. 1 - The application of CPA for patient transfers/discharges. 100 80 60 % 40 20 CPA Not CPA 0 3.2 Patient and carer involvement in meetings The Clinical Model requires patients to be actively encouraged to engage in the planning and evaluation of their care. Patient participation at transfer/discharge CPA meetings has continued at a high level. This reflects the importance attached to patients having an investment in their own care planning and is illustrated in Figure 2. Patients participated in 93% of the meetings, which has increased from 85% in the previous reporting period. Figure 2 Patient and Carer participation in CPA Meetings and CPA Reviews Patient participation Advocacy participation Carer participation 100 80 % 60 40 20 0 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 Jul 15 - Jun 16 1 CPA Guidance CEL 13 (2007) Page 3 of 11
Whilst patient participation and advocacy involvement has increased, carer participation has remained the same. It should be noted that the proportion of patients transferred with Named Persons or other family members who are closely involved in their care can vary from year to year which may help to explain why despite best efforts to promote carer participation there has been no increase in this area. Following the meeting the care and treatment plan and notes of the meeting are shared with the patient. This ensures that the patient s views have been properly represented and that the patient understands his own responsibilities as part of his recovery. 3.3 Patients/Stakeholder feedback CPA meetings are planned to be as patient friendly as possible. It is important to ensure that patients are relaxed and that the meetings are conducted in plain English. Feedback from patients (Tables 2,3 and 4) has been positive. For those patients who do not understand the English language, a full interpretation and translation service is provided. Feedback is usually sought from the patient at the time when the minutes and care plan are shared with the patient. If the carer has attended the meeting, the relevant feedback questionnaire is posted to the carer at the same time as their copy of the minute. Table 1 CPA User feedback, responses to standard questions did you attend the meeting? was everybody at the meeting that you wanted? did you request advocacy support? were you asked to comment on the care plan? did the Care plan indicate who was involved in your care and what their tasks were? did the care plan make it clear as to what individual people were required to be doing as part of your plan 09/10 10/11 11/12 12/13 13/14 14/15 15 /16 100% 95% 95% 82% 95% 95% 95% 81% 77% 83% 82% 90% 90% 95% 48% 55% 91% 82% 66% 76% 80% 100% 86% 83% 94% 100% 86% 90% 95% 91% 91% 94% 90% 95% 100% 95% 91% 91% 88% 95% 95% 100% Page 4 of 11
Table 2 CPA User feedback Meetings considered by A positive Neither patient to be: experience good not Bad bad or of little value 2008/09 26 (76%) 6 (18%) 2(6%) 2009/10 18(85%) 3 (15%) 0 (0%) 2010/11 21(100%) 0 (0%) 0 (0%) 2011/12 22 (96%) 1 (4%) 0 (0%) 2012/13 14 (88%) 2 (12%) 0 (0%) 2013/14 20 (100%) 0 (0%) 0 (0%) 2014/15 18 (86%) 3 (14%) 0 (0% 2015/16 17 (85%) 3 (15%) 0 (0%) Table 3 Patient feedback Patient Comment 1. Everyone was very helpful. 2. Mr X would like to be transported to court in the back of a car instead of G4S van and cage with handcuffs as he is unsure of safety risks involved with this in case of an accident. 3. I think everything was fine. 4. I don t think that they could have improved the meeting. Everything conducted was wide coverage. 5. Looking forward to moving on. 6. Happy with doctor saying that I m moving on. Happy with people in Rohallion. Covered a lot of the issues that has happened to me. 7. Everything was fine. 8. Less people attending the meeting. 9. The meeting went very well. Table 4 Carer Feedback Carer Comment 1. It was very good from The State Hospital Team. Not so good from his CPN or Mental Health Officer as not enough information or help given. Page 5 of 11
3.4 Multi-disciplinary working Table 5 reflects attendance at CPA, CPA Reviews and Pre-CPA meetings from within the multidisciplinary clinical team, and allows comparison with previous years. A new field has been added to provide data in relation to the receiving RMO s attendance. Table 5 Multidisciplinary team participation in CPA meetings Discipline 09/10 10/11 11/12 12/13 13/14 14/15 15/16 TSH RMO 86% 90% 92% 94% 89% 97% 100% Social Work 78% 76% 90% 79% 81% 74% 86% OT 35% 74% 79% 65% 50% 58% 38% Psychology 47% 43% 64% 59% 74% 74% 72% Nursing Keyworker (KW) 39% 45% 38% 29% 38% 32% 42% Nursing 61% 67% (Other) 62% 71% 58% Nursing 59% 81% 74% 67% (External) 38% 42% 65% RMO (Receiving) 89% State Hospital RMO attendance has increased to full attendance in comparison with previous years. It is important to note that if it is not possible for the RMO to attend, alternative medical and chair cover can be provided. Social Work attendance has increased in comparison with the previous two years. Occupational Therapy attendance has reduced significantly. Psychology attendance has slightly reduced in comparison with the previous two years. Nursing Keyworker attendance is at the highest level since 2010/11. Nursing other attendance has shown a 13% decrease in comparison with the previous year. Nursing external attendance has increased in comparison with the previous two years. Transfer/discharge CPA meetings are not planned to a regular timetable. The short lead-in time for some meetings can present particular challenges for MDT members who work shifts; have annual leave; group work and training commitments or who work part time. Furthermore there can be unavoidable clashes with the hub-based therapeutic group work timetables. On the other hand Transfer/discharge CPA meetings are usually held within the patient s own hub, which may be convenient for members of the multidisciplinary clinical team. Page 6 of 11
Other professionals attend as required. This includes representatives of the Pharmacy team; Dietetics and the Skye Centre. Participation of members of the Outing Service has been particularly valuable, as patient transfers usually require pre-transfer visits etc and it is important for the staff who have responsibility for facilitating these visits to be fully involved in the care planning process. 4. Key performance Indicators 4.1 Circulation of CPA Minutes In November 2009 the Clinical Governance Committee advised that a draft should be available to RMOs within 10 days and that the completed documentation should be circulated within a further 3 weeks. This standard has been met for 98% of the draft minutes provided to RMOs and the standard for final circulation has been achieved with 89% of the documentation. 4.2 Transfer/discharge CPA Chair From 1 April 2015 the chair of transfer/discharge CPA meetings, transfer/discharge CPA review meetings reverted from social work to the patient s RMO. Whilst no formal KPI s or specific engagement with the patient group have been developed to monitor the impact of this development, there does not appear to be any information to suggest that there has been any detriment to patient care arising from the change. 5. MAPPA 5.1 State Hospital MAPPA Notifications Notifications are required to be made immediately on admission. A total of 35 patients were admitted to The State Hospital during the reporting period. 15 of those patients admitted were restricted upon admission with a further 5 becoming restricted following admission. Community Justice Authorities (CJAs) have been notified of the 15 patients who became restricted patients during the reporting year. They were either admitted as restricted patients or placed on a restriction order by Scottish Courts during the course of their admission. As at 30 June 2016, each of the 81 restricted patients have been notified to their relevant CJA. 5.2 MAPPA Change of Circumstances CJAs have been advised of the 30 restricted patients whose legal status has changed during the course of the year, or changes associated with death, discharge or transfer to another hospital. 5.3 MAPPA Referrals and Meetings For State Hospital patients, the purpose of a MAPPA referral is to ensure that there is an opportunity for full multi-agency consideration of public and victim safety issues. This normally occurs when a patient is either being considered for a move to a non- Page 7 of 11
secure environment or is discharged to the community however, MAPPA is routinely consulted when Suspension of Detention proposals are received for restricted patients. The potential exists for a MAPPA meeting to be convened to consider the public safety and victim issues which may arise from a patient outing for clinical, rehabilitation or compassionate reasons. During the course of the reporting period there have been no MAPPA referrals completed. This compares with the previous year where 1 referral led to a MAPPA meeting for a State Hospital patient. There has been no MAPPA involvement in the review period with regards to potential admissions. This is consistent with the previous 3 reporting years. 5.4 MAPPA Consultations The role of MAPPA Single Point of Contact (SPOC) is undertaken by the Social Work Service. In effect, the Social Work Team Leader, the CPA Administrator and individual Social Workers have consulted with MAPPA as required. 5.5 MAPPA Expansion Section 10 of the Management of Offenders etc. (Scotland) Act 2005 (the 2005 Act), requires the Police, Local Authorities, Health Boards and the Scottish Prison Service as the Responsible Authorities to establish multi-agency arrangements to assess and manage the risk posed by certain categories of offender. Section 10(1)(e) has now been commenced by Scottish Ministers which, from the 31 March 2016, extends these arrangements beyond registered sex offenders and mentally disordered restricted patients to also include those offenders who, by reason of their conviction, are assessed as posing a risk of serious harm to the public. This has introduced a new risk of serious harm offender category. Responsible authorities are required to consider the application of the new category to individual offenders, where they themselves assess that it is necessary and proportionate to protect the public from risk of serious harm. A small number of State Hospital patients who would not have been subject to MAPPA under the previous arrangements, have been considered as potentially meeting the risk of serious harm category. In all instances to date liaison with the relevant MAPPA Co-ordinators has indicated that the new category does not apply to the particular patient, however the MAPPA Co-ordinators have welcomed the contact and provided clear information which is helpful in terms of forward planning. 6. Areas of good practice 6.1 Patient Involvement The majority of patients state that they had a positive experience. However, more comprehensive stakeholder feedback mechanisms might be beneficial. Consistent with the Clinical Model, efforts are made at every meeting to ensure that the meetings are as patient-centred as possible, in order to maximise patient involvement. The feedback evidences the success of this. Page 8 of 11
The principles of Recovery form an important part of the Clinical Model and the CPA process. The care plan may address hope, belief and personal responsibility which are evidenced in some of the patient comments. Plans may also include matters associated with social inclusion. Opportunities are taken to involve the patient in his care and treatment and to enable the patient to take more personal responsibility with regards to his own needs and managing risks. However, due to matters associated with public protection and victim issues, it is often necessary to have a Pre-CPA meeting which the patient cannot be party to. It can be challenging to ensure the participation of the key stakeholders in the patient s care planning. Efforts are always made to facilitate the attendance of named persons and representatives of the key agencies. 6.2 Inter-agency working including Police liaison Receiving services have usually been represented by the receiving Consultant Psychiatrist and a senior nurse. It is less likely that there will be psychiatric representation from the receiving facility for patients returning to prison, as in most instances the transferring patients will not be formally under psychiatric care. Public protection and effective liaison with the police is critical with regards to restricted patients. The Police and the Scottish Government Restricted Patients Team are invited to all meetings for restricted patients. It is necessary to confirm to Police Scotland any compelling reasons for police participation as they require to focus their resources on patients returning to the community. In many instances police liaison can be appropriately limited to enquires made by the Social Work service prior to the pre-transfer/discharge CPA, with a view to any relevant information being shared with the outgoing and receiving services usually at the pre- CPA meeting. Video Conference equipment is also frequently used to minimise travelling time for parties who require to be a part of the transfer/discharge process. 6.3 Tele-mental health The use of Video Conferencing equipment has increased from 64% in the previous reporting period to 74% in the reporting year. Telephone conferencing equipment continues to be used as a back-up if required. As reported above patient and other stakeholder feedback is mainly positive. 7. Identified issues, potential solutions and future service developments. CPA Identified issues Potential Solutions Attendance levels from the various disciplines continues to be variable Multi-disciplinary attendance Carer involvement Carer Attendance remains at a relatively low level. A discharge ICP and associated VAT documentation is at an advanced stage of development by the Clinical Effectiveness Team Liaison has taken place with Involvement and Comment Very high levels of RMO attendance particularly welcome. Social work have participated in the ICP and VAT developmental work. It should be noted that the proportion of patients transferred with Named Page 9 of 11
Equality Lead and Head of Psychology to seek ways to address this matter. Persons can vary from year to year which may partly explain variation in carer participation. Patient involvement 1. To seek ways to improve feedback mechanisms from patients and to continue to uphold high standards of patient satisfaction. Patient feedback mechanisms to be reviewed Patients attended 93% of meetings (excl pre-cpa s) within the review period, which is a 8% increase from the previous period Police involvement Staffing Management of transfer/discharge CPA 2. Improve patient understanding with regards to CPA & MAPPA processes Risk assessments to fully take into account Police intelligence The Social Work Team Manager post has been vacant throughout the review period. Chair of pre/trans discharge CPA meetings etc reverted to the RMO from 01/04/15. Team Leader and social workers have contributed to the Patients Leavers Group VISOR terminal in TSH to be fully utilised. The Team Leader has ensured that patient care and other operational elements of the service have been prioritised. CPA Administrator continues to support process, with overview maintained by social work management. Advocacy, social work, and the clinical team have a key role supporting patient involvement. Police attendance at CPA meetings remains problematic, however VC and social work liaison prior to the meeting is utilised as required. A new Social Work Team Manager has been appointed and is waiting a start date. No indication that the change has had an adverse impact upon the quality of service delivery. Consideration to be given to management arrangements once new manager is in post. MAPPA Identified issues Potential Solution Comment MAPPA expansion to include new risk of serious harm offender Some patients who are not currently subject to MAPPA, may meet the criteria Ongoing scrutiny and Liaison with MAPPA Co-ordinators Any policy review will require to be progressed on a multi-disciplinary and Page 10 of 11
category commenced 31 March 2016. for the new category. multi-agency basis as required. Local policies and guidance will require scrutiny to determine whether or not they require revision. Policy review as required MAPPA Single Point of Contact MAPPA Single Point of Contact formerly undertaken by CPA Manager The role of MAPPA Single Point of Contact is undertaken by the Social Work Service. In effect, the Social Work Team Leader, the CPA Administrator and individual Social Workers have consulted with MAPPA as required. Local policies and guidance will require scrutiny to determine whether or not they require revision. Revised Early Discharge Protocol Local policies and guidance will require scrutiny to determine whether or not they require revision. To be progressed on a multi-disciplinary and multi-agency basis. Current arrangements continuing at present. Staffing Strategic engagement and representation The Social Work Team Manager post has been vacant throughout the review period Representation of TSH at national and other external MAPPA forums The Team Leader has ensured that patient care and other operational elements of the service have been prioritised. Team Leader has represented TSH at the MAPPA Operational Group A new Social Work Team Manager has been appointed and is waiting a start date. Potential to further develop strategic engagement once new manager is in post. MAPPA Management Need to consider detailed management arrangements following the removal of the CPA Manager Post. Current arrangements continuing at present with emphasis on operational issues and patient care. Consideration to be given to MAPPA management arrangements once new manager is in post. Page 11 of 11