NHS Lothian St John s Hospital, Livingston 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 6 3 Demographics 6 3.1 Numbers of IPCU admissions 6 3.2 Nature of admissions 7 3.3 Management of other population groups 7 4 Links with other secure mental health provision 8 5 Governance arrangements 8 6 Plans for service development 8 7 Other points to note 8 Appendix 1 Glossary of abbreviations 9 = =
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 Lothian on 8 July 2009. 2
1 Overview of local mental health services Lothian is situated in south east Scotland and has a population of around 809,764. The majority of the population live in densely populated urban areas, of which Edinburgh followed by Livingston is the largest in the region. Mental health services are delivered through the Edinburgh Community Health Partnership (CHP), Midlothian CHP and East Lothian CHP and West Lothian Community Health and Care Partnership (CHCP); a joint service between health and social work. There is a range of mental health inpatient provision across NHS Lothian. Services are organised in a range of ways to meet the needs of each locality. General adult community services are mainly delivered by community mental health teams. These teams, comprising a range of health and social care professional staff, provide comprehensive care for people experiencing high levels of mental health needs. Intensive home treatment services currently operate within two CHPs, Midlothian and West Lothian. Mental health services are undergoing a major redesign process with the development of further intensive home treatment services within East Lothian and the City of Edinburgh. Within the community, mental health services aligned to primary care support the care and treatment of people with mild to moderate mental health needs, providing a range of therapeutic interventions. All mental health services are moving towards the use of electronic referral systems with triage at the point of referral. Adult mental health acute, rehabilitation and secure inpatient services are provided as follows. NHS Lothian Herdmanflat Hospital, Haddington Number of beds Acute mental health admissions beds (adult) 12 Mental health older adult care inpatient beds 36 Rosslynlee Hospital, Roslyn Number of beds Mental health older adult care inpatient beds 48 Royal Edinburgh Hospital Number of beds Acute mental health admission beds (adult) 100 Child and adolescent mental health service inpatient beds 12 (south east Scotland) Learning disability inpatient beds 24 Mental health older adult care inpatient beds 168 IPCU 12 (south east Scotland) Medium secure forensic (Orchard Clinic) 45 Mental health rehabilitation inpatient beds 78 3
NHS Lothian (continued) St John s Hospital, Livingston Number of beds Acute mental health admissions 30 IPCU 12 Mental health older adult care inpatient beds 24 Mental health rehabilitation inpatient beds 26 Perinatal 6 (Lothian, Borders, Fife, Highland and Tayside) 2 Intensive psychiatric care unit provision NHS Lothian has two IPCUs. They are located within the Royal Edinburgh Hospital and St John s Hospital. This report will cover IPCU provision at St John s Hospital only. A separate report will be prepared for the Royal Edinburgh Hospital. The IPCU has 12 single rooms with separate toilet facilities for male and female patients. There are no seclusion rooms in the IPCU. There are close links with the perinatel service, also based at St John s Hospital. The IPCU admits patients from NHS Borders as part of a service level agreement between the two NHS boards. The IPCU also admits patients from other areas of Scotland when the need arises, although there is not always bed availability to do so. If the IPCU is full, patients may be required to be admitted to the IPCU at the Royal Edinburgh Hospital. 2.1 Admission to IPCU An NHS Lothian-wide policy for referrals is in place and very much depends on the individual details of each case. Admissions from out-of-area are agreed on a consultant to consultant basis, but admissions from within NHS Lothian may be initially agreed by the nursing staff responsible. In instances where there is any doubt, contact would be made with the on-call consultant. NHS Lothian has exclusion criteria for admission to the IPCU outlined within the operational policy which include: patients with a primary diagnosis of substance misuse, learning disability or dementia patients presenting at high degree risk who would instead be admitted to forensic services, and a patient whose physical condition is frail enough to have concerns over their safe management in the IPCU. 4
2.2 Model of care provision There is one dedicated consultant psychiatrist with input into the IPCU, together with input from a junior doctor and a GP trainee with a special interest who was conducting sessions in the IPCU at the time of the service profile exercise. Responsible medical officer and approved medical practitioner responsibilities are undertaken by the consultant psychiatrist. Social work input comes from patient s mental health officer (MHO) and the community based social work mental health team. At the time of the service profile exercise, there was an outstanding vacancy for an occupational therapist and pharmacy input to the IPCU. It was noted that the average waiting time is around 21 weeks. There is an activity room in the IPCU and access to the kitchen in the rehabilitation ward which is close to the IPCU. In the year prior to the service profile exercise, there had been an art therapy student at the unit undertaking various activities with patients. Administrative support is generally undertaken by an administrative officer who works one day each week, with additional support from medical secretaries as well as the IPCU staff. Weekly multidisciplinary team meetings take place on the ward with input from all medical staff. An additional daily meeting takes place which involves all nursing staff on the ward. Separate meetings are arranged with carers to ensure their views and concerns are taken on board, particularly during the discharge planning process. Staff training needs are identified through regular appraisals and then agreed between staff and charge nurses. Induction training and mandatory training including management of aggression is in place. IPCU staffing profile in St John s Hospital Medical Nursing General adult psychiatrist GPwSI trainee (general psychiatrist with special interests) 31.75 WTE registered and unregistered: Band 7 Band 6 Band 5 Band 2 (unregistered nursing assistant) Whole time equivalent (WTE) 0.4 1 1 13.25 16.5 Social work Mental health officer (delivered by locality) N/A Allied health professionals Administrative staff 0.7 Occupational therapist 0.5 Administrative officer 0.2 The IPCU has a dedicated nursing team. The staffing complement on the ward would be six on an early shift, six during the day and a minimum of four overnight. There is always at least one female staff member on shift. The level 5
of staffing and mix is, however, flexible depending on the level of clinical need. Newly-qualified nursing staff are employed two at a time assuming they have a basic level of experience. At the time of the service profiling exercise, one of the unregistered nursing staff complement had less than one year s mental health nursing experience. In instances where a patient requires one-to-one observation, additional staff would be sought to cover the resulting shortages. At the time of the service profiling exercise, NHS Lothian reported no current vacancies within the IPCU nursing team. NHS Lothian reported that nursing staff are often on rotation between the IPCU and the mental health acute admission wards. Elements of Star Wards are used within the IPCU and acute mental health admission wards. This is a scheme which works with mental health trusts to enhance inpatients daily experiences and treatment outcomes. NHS Lothian also reported on the recovery-focused model which has been adopted. 2.3 Discharge from IPCU NHS Lothian reported that there are occasionally issues when discharging out-of-area patients back to their host NHS board. A lack of close contact with staff in other NHS boards combined with the geographical distances sometimes involved means there are additional risk factors when discharging such patients. The final draft of a Lothian-wide discharge planning policy was under review at the time of the service profile exercise. This will be developed in conjunction with NHS Borders to ensure joined-up planning and service development. 3 Demographics The adult population, aged 18 64, served by the IPCU is approximately 111,319. In addition, the IPCU also serves NHS Borders where the adult population is approximately 68,209. 3.1 Numbers of IPCU admissions At the time of the service profile exercise, the occupancy rate was around 92%. There were 88 admissions in 2008. It was noted, however, that two patients had been at the IPCU for around two years, which has affected this figure. The length of stay was estimated to be around 36 40 days, with a combination of short and long-stay patients. 6
3.2 Nature of admissions Almost all admissions are subject to detention. It is estimated that around 5% of patients are admitted under the Criminal Procedures (Scotland) Act 1995. Data captured via the West Lothian information system, TRAK, can be broken down as follows: IPCU admissions to St John s Hospital in 2008 Age Under 18 18 30 31 50 51 65 Over 65 Gender Male Female Ethnicity White British Black Not known Detention status Civil law Criminal law Informal (elective) Out-of-area referrals Formal agreement No formal agreement 2 16 69 1 0 55 33 84 2 2 88 0 0 1 0 As previously reported the IPCU will admit female patients. Separate washing and toilet facilities are available for female patients. The IPCU can be split into two sections and additional staffing can be taken on to provide increased observation for female patients. NHS Lothian reported that staff receive a number of gender-specific training courses. 3.3 Management of other population groups The IPCU no longer accepts patients under the age of 18 from outside the NHS Lothian area. Patients under 18 within the Lothian area are only admitted to the IPCU in an emergency situation where the patient cannot be managed elsewhere. Close links would be made with child and adolescent mental health services (CAMHS) in these instances in order to find an alternative bed for the patient as soon as possible. Patients with learning disabilities are also admitted to the IPCU if they are deemed to be unmanageable within learning disability services. The IPCU consultant works jointly with the learning disability consultant. Specialist nursing input would normally be provided by the community learning disability team if the patient has had close contact with this team prior to admission to the IPCU. Admission of patients over the age of 65 to the IPCU is rare, however where this is required, there would be close links made with older people s services throughout the stay and during discharge planning. 7
4 Links with other secure mental health provision Forensic patients from West Lothian would usually be admitted to the Orchard Clinic, a medium secure forensic psychiatry unit at the Royal Edinburgh Hospital. 5 Governance arrangements There is a shared operational policy for both the NHS Lothian IPCU facilities which is revised approximately once each year. The mental health quality improvement team monitors all clinical governance issues and reports any issues to the CHCP and CHP governance structures. The IPCU falls within the remit of the CHCP Quality Improvement Team. Although there is no direct forum for current service users, the mental health forum has input from ex-service users. A patient focus and public involvement group often feeds back to the unit with comments and concerns, including a recent report which suggested that a redecoration of the unit would be beneficial for both service users and staff. A carer group, led by staff and linked to the Carers of West Lothian Group is in place on the acute admission ward. This group has close links to the IPCU. Carers are involved in discussions regarding the transfer of patients from the Borders into the IPCU at St John s Hospital. Advocacy input into clinical governance is delivered via a mental health advocacy group which feeds into the IPCU quality improvement team. 6 Plans for service development Plans for the redevelopment of the Royal Edinburgh Hospital will leave the IPCU at St John s Hospital largely unaffected, as the unit will remain in Livingston regardless. There are plans for a low secure forensic complex care unit at the Royal Edinburgh Hospital, however these are still at the planning stage. NHS Lothian outlined future plans for training on psychological therapies. This will form part of a scoping exercise to clarify which staff have been trained in particular areas to assist in filling any gaps in the skill mix. 7 Other points to note NHS Lothian reported the low rate of absence and sickness within the IPCU, which was only 1.5%. However, recruitment and retention of experienced nursing staff was identified as a current challenge facing the service. In addition, dedicated input from allied health professionals would be of great benefit to patients in the IPCU. Shortages in the areas of psychology and pharmacy were also identified. 8
Appendix 1 Glossary of abbreviations Abbreviation AMP CAMHS CHCP CHP IPCU NHS NHS QIS WTE approved medical practitioner child and adolescent mental health service community health and care partnership community health partnership intensive psychiatric care unit National Health Service NHS Quality Improvement Scotland whole time equivalent 9