Positive Practice in Mental Health Collaborative Event In Partnership with

Positive Practice in Mental Health Collaborative Event In Partnership with Northumberland, Tyne and Wear NHS Foundation Trust Hertfordshire Partnership Foundation Trust Supported by Breakthrough

Introductions and setting the scene Tony Russell - Director of Breakthrough and Founder of Collaborative Gary O Hare - Executive Director of Nursing and Operations

Strategic Direction The environment in which we work: Quality -20% Cost Sustainability We have to improve quality for the patient We have to reduce our overall cost of doing so by 20% We aim to improve clinical effectiveness thus reducing reliance on inpatient beds We have to create sustainable services, delivered by sustainable organisations, operating in a sustainable system

What our partners have told us: We have to get much better at what we do and how we do it We have to get better at listening and acting on what people are telling us We have to be consistently good across all our services We need to get the patient quickly into the right services and then deliver the best outcome possible

What patients and carers have told us: Patient They want high-quality, safe care close to home They want inpatient services to be of a high standard They want services designed and operated around the needs of patients They want the patient to be truly at the centre They want to gain and re-gain independence, as far as possible

The need to realign and balance resources: At any time, 3% of patients are consuming 52% of resources Inpatient Services 92.2M NTW Whole costs Community Services 84.8M NTW Whole costs We spend in inpatient areas to the detriment of community services A few patients consume much of the resource Many in-patients perhaps don t need to be, but we lack the necessary community services to support them out of hospital We need to balance resources to maximise quality over cost

The Access Model Dr Carole Kaplan Transformation Programme Director

The Service Model Request for Help More Intensive Packages of Care Initial Response Initial evaluation regarding nature, risk, complexity and urgency of the problem Information & Advice Hospital Home Treatment Intensity Medium Security Psychiatric Intensive Care Low Security Specialist Ward Environment PICU Crisis Beds Acute Ward Low Security Intermediate In the Community beds Intermediate Facility Acute Ward Crisis Bed Challenging Behaviour Assessment Intensive Home At Home Treatment Intensive Challenging Home Behaviour Etc. Treatment Assessment Formulation & Treatment Planning Mild - severe non - psychotic Signposting to principal service pathway for assessment and formulation Very severe & complex nonpsychotic Psychosis Dementia Neuro - disability Learning Disability Children & Young People Substance Misuse Scaffolding Crisis Assessment Discharge

Principal Community Pathways A programme to design and implement new, evidence-based community pathways for adults and older people. Our ambition is high and is matched by the expectations of service users and carers. The new pathways will: Significantly improve quality for the patient Double current productive time of community services by redesigning current systems Enhance the skills of our workforce Improve ways of working and interfaces with partners Reduce reliance on inpatient beds and enable cost savings This is not achievable in isolation and to be successful we need it to be part of integrated work with partners

Phase 1: The case for change Sunderland was chosen as the location for the development of a new access model following discussions with service users, carers, GPs and commissioners. A key issue was that the Crisis team, commissioned to deliver assessment and support for serious mental health problems, was not responsive as it was saturated with responding to a wide variety of requests. A scoping exercise identified that only 35% of all contacts needed the response of the Crisis Team. 43% of the inappropriate contacts were for advice or help and often these were people clearly in need of support and signposting, but considered to be at low risk of requiring hospital admission.

Initial Response Team South of Tyne and Wear Information Collection & Routing Gateshead Rapid Response 11 Nurses Triage & Action GH UCT Home Based Treatment Assessment Gatekeeping ICTS OPS LD REQUEST FOR HELP South Tyneside Rapid Response 11 Nurses Triage & Action ST UCT Home Based Treatment Assessment Gatekeeping ICTS OPS LD ROUTING Sunderland Rapid Response 11 Nurses Triage & Action SL UCT Home Based Treatment Assessment Gatekeeping ICTS OPS LD

Phase 2 Model Urgent IRT Rapid Response 11 Nurses Triage & Action UCT Home Based Treatment Assessment Gatekeeping ICTS OPS LD Single Point of Referral Triage Team Noncomplex Clinical Diary Routine Complex Huddle Clinical Diary

Phase 1: The Model IRT to offer 24/7 Universal telephone access for requests for urgent help. No restrictions on who could refer Triage and Routing over the phone- (Mental Health and other local Services) Face to Face Triage (Rapid Response) if clear plan cannot be determined over the phone Seven Band 6 Nurses for Telephone and Rapid Response Five Band 3 Nurses for call handling and Rapid Response Use of digital dictation and 3G laptops for clinical documentation Flexible interchangeable roles and rotation between Crisis Team and IRT roles dependant on demand.

Phase 1: Benefits of IRT Quick and efficient responses to requests for help Effective routing to the correct services in and out of NTW Flexible and collaborative working with newly configured UCT which will focus on the work for which it is commissioned Reduction of clinician administration burden, and freeing time to care (mainly through adoption of digital dictation) Improving personal and clinical outcomes for people in crisis with mental ill health by reducing harm and premature mortality, improving patient safety and patient experience

Typical weekly activity Evaluation-IRT in numbers 1500+ Incoming telephone calls 1000 Total Contacts 400 Home-based Treatment contacts 50 Crisis Assessments 100 Rapid Responses and growing 90% calls answered within 15 seconds >98% within 3 minutes (Average=9 Seconds) >80% rapid responses achieved in under one hour

Service User Experience Service Feedback Carer Feedback The Team were excellent Wonderful support! keep this very valuable service going Brilliant team! More manageable Staff Feedback Skills are valued GP Feedback Did the Initial Response Team meet your needs? A lot happier Spend more time Yes Fantastic a huge improvement!! No You should have done it before

Recovery through care coordination research Nicola Armstrong PCP Facilitator Lisa Matthews WRAP educator / volunteer

A 28 month project. The Research Working with NTW NHS Trust, local service user and carer organisations/network and Northumbria University. The views and experiences of service users and carers have driven this project right from the beginning. They have been researchers, collecting and analysing the data and are now sharing the findings. Training programme and accreditation Originally 85 postal questionnaires, leading to 52 service user, 30 carer and 18 professional interviews. Recovery and Care Coordination

The Data (Action Research) Collection of Qualitative and Quantitative Analysis Coding - Themes (Generate Questions) Confirmation of Themes Delphi Service User, Carer and Professional Interviews Service User, Carer and Professional Events Other Dissemination Toolkit IMPACT Co production Recovery and Care Coordination

Emancipatory Research Research Ethics Organic Tight structure Challenges hierarchies Free flowing Power sharing Political Culture Cash Regimented Bureaucratic Risk averse Traditionalist Recovery and Care Coordination

My Ethics Experience Recovery and Care Coordination

Delphi Data DELPHI STATEMENTS SERVICE USERS CARERS PROFESSIONALS Recovery is self-defined hope and personal meaning Strong agreement Strong agreement Weak agreement Strong support networks including family and friends increases recovery Moderate agreement Strong agreement Moderate agreement Recovery is a return to functioning at a level experienced before the disorder Disagreement Strong agreement Disagreement Service users should be active participants in care coordination Strong agreement Weak agreement Strong agreement Promoting recovery / mutually agreed goals is central to care coordination Strong agreement Strong agreement Weak agreement Lack of time care coordinators are able to spend in face to face contact inhibits good care coordination Strong agreement Strong agreement Disagreement Recovery and Care Coordination

Recovery Themes Services for life versus getting on with life Reactive versus proactive Involvement versus non involvement Keeping people safe versus positive opportunities Personal responsibility versus being cared for Hope versus hopelessness Recovery and Care Coordination

Recovery Quotes I think I m always going to be in the mental health system (Service User) I don t think there s such a thing (as recovery) in mental health...there is going from what the person was through the mental issues to being something different at the end (Carer) Its not a recovery focused plan and they re not recovering and both parties are stuck. The service user is stuck But actually the professional is stuck (Professional) Recovery and Care Coordination

Recovery Quotes I came into the service with the wrong idea. I came in looking for a fix... and slowly but surely discovered that there is no fix. I m going to have this for the rest of my entire life. I m managing it with medication and a different way of thinking (Service User) Recovery to me is a continuum it s affected so many different things. So wellness, recovery is a line people go up and down you have to take responsibility for yourself you have to trial it on your own and apply it in terms of your own recovery (Carer) so no matter what s wrong with you whether that includes the diagnosis or not the goal is for you to recover. Or, the goal might be for you to leave the service and the rest of your recovery might be done elsewhere (Professional) Recovery and Care Coordination

Care Coordination Themes What it is - confusion? Ticking boxes and/or face to face support The value of good care coordination The impact of poor care coordination The barriers of confidentiality Recovery and Care Coordination

Care Coordination Quote You know it just feels like I am accessing three separate services within one service that is meant to be working as part of a team (Service user) Care coordination isn't about the carer. cos there s been a lot of times where (the service user) has gone into different kinds of services; CBT, CPN, whatever else and they don t seem to communicate a lot with each other, so there s a lot of things get missed out (Carer) care coordination is not for care and treatment of the patient. Care coordination is the administrative process that is used to capture the care and treatment to patients (Professional) Recovery and Care Coordination

Care Coordination Quote I ve always been listened to and I felt they ve worked with me, they ve valued what my opinions are, I ve not been pushed into anything. I've not been treated as someone who hasn t got anything to give in my recovery or anything like that. (Service user) Well I think it was good because it was informative, you know, for me and also felt as though somebody else was keeping an eye on him (workers name) (Carer) Good care coordination is being able to negotiate a relationship where the person can say what they think and you can, as a worker, you can make mistakes, and get it wrong, because there is that trust and respect... (Professional) Recovery and Care Coordination

Recovery through Quality Care Coordination! Change in Culture Moving Forward Learning Together

Professional Professional Learning opportunities I think there needs to be investment in not just helping teams to be really robust and creative but a bit same approach for the team in the broader sense including service users and carers. Which is, for example, why this research project is so good, because it s an example of it. So it s not research by the professionals its research by a team. A whole team of service users, professionals, carers. PR17 I think that the times when it s gone really wrong for me is where the MDT haven t been aware of what each other are doing and certainly, the service user in the middle of that hasn t been aware of, you know, all of the different things that are or aren t happening, cos sometimes, its about, things I think people think are happening, but actually, they re not happening. PR16 Information to support We should all know who s involved in the care: what the care is and when it s next planned to be reviewed. Now that s not rocket science: we seem to have wrapped an awful lot of complexity around it, but at the heart of it for me, that s what CPA is and I think that the issue is that organisationally, it s one of the few universal tangible things we ve got in the system. PR15 I think there is a lot of information we can give to people up front, which will I guess, help manage their expectations, the patients and carers about what care coordination is, how long someone is likely to be care coordinated for, what goals will be identified and aimed for. I think there is a lot of information that we can give that we are not giving now. PR04 I think service user involvement is absolutely key, because it communicates that sense that we re all in it together and some are service users some of the time and some aren t, but actually that s a flow and there are times in all our lives when we can be fragile and needy and I think that has to be part of day to day life. PR06 It s not the entire remit of mental health services and that s about signposting and enabling people to use other things that are going on in their lives to build up their wellbeing and I think making connections between people is something we could do better... PR06 Service User I did a WRAP plan. Wellness Recovery Action Plan, which really helped and because the team are aware of it they could, when things were bad, they could actually encourage us to use little bits of my WRAP plan. SU146 I had a WRAP plan. A wellness, recovery action plan. Which highlights my triggers, early warning signs. It tells you what steps I need to take to hopefully prevent things breaking down. It has a crisis plan section. And I would hope that that would be used. And that I would use that in planning for my future care. SU125 So the whole point of you working with someone, you know, it s identifying what recovery journey they re working on and we re agreeing together, collaboratively I suppose, what we re aiming for. PR01 Carer I feel as though I m pushed out, but then when anything goes wrong, I mean, they re saying to me Oh well, she could do this, she could do that I think: Aye, she could do a lot of things, but you haven t got her 24/7. C14 We worked as a team; she valued me as a carer. She has not seen me as interfering she knows I have good experience. C43 Service User Yeah. [CPN] has always been really good with me anyway. Like, he hasn t done anything without my consent. Like, if he s going to make a decision, he always comes to me first and asks about things. I was told when I was diagnosed that it was very, very important that my close friends and family were very boned up about [mental illness] and how they should support me in times of mania and depression I and was also told times when of I was being diagnosed well but that not too it was well very, that very I tip important into mania. that my SU104 close friends and family were very boned up about [mental illness] and how they should support me in times of mania and depression and also times of being well but not too well that I tip into mania. Care coordination is where one person ultimately has responsibility to ensure that everybody s working in the same way and that everybody s aware of what s happening within your care and that information is a two-way process between you and them. SU146 Carer Something that is important to me is to talk about how somebody becoming unwell affects the family C44 There didn t seem to be anything where there was, like, a flow diagram or Or a tree or like a where it said These do this, these do that, and that s where these go into that. C03 A huge thing would have been education and understanding around supporting the crisis, supporting recovery, understanding my partner s diagnosis through crisis, you end up back there again but with no tools to kind of, cope or deal with it I didn't know how to best handle it. C44 Once I reached a point of being physically and mentally well enough to start thinking about what I want I wanted to do next, you know, it was me that went out and looked at what training was on offer, looked at what other organisations were out there that I could become members of, or you know, access their services and it was mostly around like the voluntary and community sector where I got that support. SU126 I think it s just committing and having respect for the triangle of care, because carers should be equal partners. C35 I do feel that I ve moved on from somebody who got distressed and panicked by crisis to someone who has some understanding and education. And I feel empowered and more in control because of that. So I think I m in a better place than I was. C44 LEARNING TOGETHER I want information because I want to know how he s going to recover and if there s a chance that he will be back to the way he was and what the process is, cos they just try every kind of medication under the sun. Maybe if I had information on them, I would know what they re trying now. C07 Challenges around sharing information Professional carers wanting information or wanting to tell you something saying I can t talk to you cos so and so won t talk to you Well, you can always listen as long as you don t give any confidential information away, you can listen. It s very frustrating to be a carer and people say I knew this was going to happen and I told you this was going to happen and nobody listened to me. Some of that will be retrospective I know and maybe not accurate but it s really important. PR02 I mean we are often in a position where we need to consider issues of confidentiality around carers when the patient doesn t want the relative to know, or the next of kin to know about their diagnosis or what kind of treatment they are receiving and yet the family are very concerned about the individual. I think we take the view which is sort of National Guidelines that we need to give carers the information or enough information for them to be able to support that individual like how they can access services in a crisis and who to go to PR04 I ve said about them hiding behind the confidentiality card I guess there is complications in that, but it s certainly been dramatically overplayed. PR08 Carer *Carers+ have a right to know, because sometimes when they discharge people, they just discharge them back home and to say to a family Well, you re not entitled to any information about your loved one. Oh, P.S. We re discharging him on Friday back into your care, that s setting the carer up to fail and the service user up to fail This is what that service user needs. Now, carer, what do you need? Because you have rights in your own right.. C35 I had never dealt with someone with a mental health problem. I was looking online and ringing loads of services and trying to ask them what to do I was ringing and nobody would help us and everything was anonymous and they couldn t disclose anything to us. C07 If you ve got a service user who just goes on his own to his appointments and doesn t ask the carer to come along, the carer just won t come along on their own without that service user asking them. In which case, the professionals should be saying Now, next time you come, you might want to bring along a family member or a friend or something and yes, I ll see you on your own, but we need to have at least ten minutes with them or something, you know? So it should be introduced into the conversation. C35 Service User Yeah. *CPN+ has always been really good with me anyway. Like, he hasn t done anything without my consent. Like, if he s going to make a decision, he always comes to me first and asks about things. Yeah. *CPN+ has always been really good with me anyway. Like, he hasn t done anything without my consent. Like, if he s going to make a decision, he always comes to me first and asks about things. SU133 Care coordination is where one person ultimately has responsibility to ensure that everybody s working in the same way and that everybody s aware of what s happening within your care and that information is a two-way process between you and them. SU146 if I was to become unwell I would want to be receiving home treatment, medication I wouldn t want Haloperidol or Amisulpride or Risperidone. I would want probably Olanzapine I would want me friends and family to be more informed as to what s going on because they have always been victims of patient confidentiality a lot of the time. SU131 Recovery and Care Coordination

Professional Professional Support I would also like to develop some kind of peer support for those patients so that they are actually meeting other patients that might live in their local community there might be patients that have recovered which will give them more hope. I think there s a lot more interest in the peer support workers that we are starting to use in other services and people are beginning to think how we could use peer support workers in our service. PR12 guess your service users that you ve interviewed will be telling us whether it s changed or not...i think it has changed but I don t think it s quite as clear cut I think more and more people are talking about enabling, about people recovering, about people having more independence, and having more control over their care plan, their journey of recovery. I don t think we re there yet within services. I think the organisation conflicts with that sometimes because to enable someone to have more control over their recovery, we also have to get into some positive risk taking and that means that professionals have to be able to have that conversation. PR01 Stepping outside the comfort zone What I do now, if I meet somebody for the first time I will always say look I won t be with you forever this piece of work that I m going to do with you is going to be time limited. I m not going to come next week and say right. you ve got four weeks and that will be it bye bye, I m not going to change your life, I m not going to change your diagnosis I can t do that but I m going to help you cope with it PR11 If we started to talk about safety planning or planning safety, as opposed to risk management and changing what the concept is through using different words...finding out from people What do you need in order for you to feel safe? to support recovery more as opposed to it just being that process that is just there. If we are putting risk management and support processes in place that s really just preventing people from having the opportunities to try things in life and I think that s the way we currently set things up. I think that happens an awful lot. What we haven t done is assess the risk, but what s the risk of that person not having that opportunity. PR16 Service User when I became well enough I did start getting involved in some local services where they deliver support and education for service users so I have started like doing a bit of peer support. SU126 They do see me they won t go to the care team, they feel they can come and talk to me because I am a service user as they are and I'm on their level. SU101 But if I got to the stage of recovery where I was well enough to go to work or well enough to socialise with other people more than I do now, erm, than I would consider I had been through enough to be supportive enough to somebody else. SU141 I think we have got to recognise the value of people having time, to consider and reflect and think carefully about how we are supporting people with their recovery. I think the less we do that and the more we move towards the treadmill experience, were we just kind of take people through, then the more we are as services at risk of not being able to do kind of what we wanted to do. There is something for me about teams feeling safe to work in that way as well. PR16 You have to allow people to develop, you have to allow people to take risks but it can feel pretty scary if somebody s vulnerable and certainly the clinicians feel they ll get hung, drawn and quartered if something goes wrong. PR08 Carer that would be brilliant if you could get a database of people who are interested in talking to each other about their stresses in their life to do with, and whether they have had success, that s the most important thing. C33 I used to go to meetings and all that and they were very good, oh they were all carers themselves, you know, but erm, I found after a while I got tired of talking about mental health. C12 Service User Yeah. [CPN] has always been really good with me anyway. Like, he hasn t done anything without my consent. Like, if he s going to make a decision, he always comes to me first and asks about things. I just wanted to go and start applying for jobs. But we have now talked about instead of the next stage being going back to work, maybe the next stage is like a short college course or something. I Something was told when with I deadlines was diagnosed and a that wee it bit was of pressure very, very that important I had to that my attend. close But friends again and something family were that s very not boned going up to about totally [mental set illness] back. and SU134 how they should support me in times of mania and depression and also times of being well but not too well that I tip into mania. Erm, it s about for me, it s about the positive risk taking and about allowing us to take some risks in that just because it s a risk doesn t mean that the outcome is a good or a bad thing. SU140 I think that s what my care coordinators do with me. Put me at risk. Because I said, like, I didn't want to travel on public transport. But now I ve got a concessionary travel pass and I do that. It s fine. SU145 Carer I am being that careful but I mean now she says that she needs some of her independence back, which is understandable, I understand, so we are sort of experimenting a little bit where she has got her own little bit of bank account and we pay a little bit of money into that and she has got to use it sensibly because she could just go mad. C10 I think there has been a lot of cossetting in mental health and I think you know, we should be working on people s confidence; we should be working on people s self-belief; we should be helping them to identify their strengths, so we can build on them, because how do you build confidence if you keep on doing the things that s within your comfort zone? C35 a lot more people could be helped if there was more what s the word? Just people who know what they re talking about. You know? CPNs to me, it s just they learn from university; they read from a book I mean, some of them will have experiences of people with mental health problems in their own lives. C06 MOVING FORWARD Responsibility and dependency Professional Your responsible for yourself and were responsible for helping you to make the best of your life and overcome your problems. I think we are far too quick to take responsibility away from service users. I can t see how recovery can happen without them taking it back... PR08 I don t think recovery equals cure in mental health. I think it s about a person... If their symptom free great, if they've got residual symptoms its about that person feeling confident to manage those symptoms when they experience them whilst they are fulfilling the roles they need to fulfil, like parenting, picking the kids up from school, driving, working, whatever. PR04 I think sometimes we sort of engender a sort of dependence which makes us feel wanted. It s not very healthy. PR02 I guess the overall aim is to get people out of services as quickly as possible because I think we have recognised over the years is unintentionally mental health services have often promoted a dependency on services. If you think pre the; last guidance which is 2008 it was severe and enduring mental health issues and it was almost like, enduring means it never goes away and I know it doesn t go away, but it s almost like You ve got an enduring mental health problem, your always going to be with mental health services, which is obviously anti recovery and actually anti being sensible. I think we ve moved towards recognising that it is about supporting people to leave but I don t think the word recovery is used a lot PR14 Carer they are not overprotective and I think they get fed up with me taking things on board they would want her to take more responsibility, which I agree with but I know she's not going to do it C43 to make sure the person that I care for has got all the help that she needs and that she is organised with the proper medical support and erm, that she has everything that she needs and that she s content You want to do the best you can for that person, but it can be very difficult. C01 I think, in the past, I ve taken too much responsibility. You know, tried to do too many things for him and I m really trying to step back and... You know, let him do as much, be as independent as he can be. That is a difficult one at times I think. But, yeah, trying... Definitely trying to do that. C04 I can t get him... It doesn t matter what it is, I can t get him motivated in anything. Everything is such hard work. You ve got to keep pushing, pushing. You know, you feel actually a little bit like a nagger. And I hate that blinking label. C05 Service User Yeah. *CPN+ has always been really good with me anyway. Like, he hasn t done anything without my consent. Like, if he s going to make a decision, he always comes to me first and asks about things. I think that I am lucky in the fact that I have a good team, but also because of how forward thinking I am, I think that also helps, because obviously taking personal responsibility the majority of the time helps to be able to focus the recovery better, but when I lose sight of that, then it s much harder for other people to see it, cos they know that I can take personal responsibility. SU140 But I just need the services to be able to listen to my dad more than anything, because I m a... I mean, I'm just not with it at all. I mean... I can t... I m not in a position to be able to be given the responsibility to help myself. SU119 Well, I have been discharged now so I am kind of responsible, I am making sure I take me *medication+ every night and that s about it, and sort of if I am, I ve kind of, me best friend encouraged us last year when I was going through a particularly difficult patch to like go and get some anxiety management so I had some IAPT intervention two years ago. SU131 Recovery and Care Coordination

Process and system versus relationship Professional Oh, they go to ASDA and have a cup of coffee with their service users. That s the culture that goes before us and that s the culture that we re still up against. PR05 If you feel personally responsible for every single decision you make around risk and then it goes wrong, it s going to be your fault, then you start acting in a different way. Whereas if you ve established that on an equal footing with the service user, and that if something goes wrong, then it s going to be a joint responsibility, that would be different. Now I m not sure the services are really set up for that. PR02 And there is no evidence basis for many of the interventions that people like to have. It doesn t mean they don t work. There s part of me thinks if something works, does it really matter if there is an evidence base? Some of my colleagues would be horrified if they heard me saying that you know. Some of the homeopathic things and counselling, not a lot of evidence, but people like it. So it s tricky isn t it. It s an NHS where we are strapped for cash, so what do we provide I think...tends towards the more probably medical focused interventions. PR02 Getting on with life Professional Everybody is capable of improving and it ll depend on what they call recovery, I think. There will be some people who will remain very unwell, I imagine, and end up for example, in rehabilitation services but even within that, I think there has to be hope of, you know, some improvement in quality of life. PR02 But, there s also a significant number of people who feel very anxious about I guess recovery. You know, what happens again, in case they want to remain involved with services, just in case they become unwell and I think for a lot of people that s understandable. PR04 People are often suffering a great deal, but I wonder if we underestimate people s strengths, and what they can build on and work with and so obviously that then affects how hopeful or positive you are and the direction you take, but it s really really important that you do maintain that energy and focus. I think the notion of resilience is really helpful, cos I think that s something we can build up and something that s generalised to all of us and all of us at times may experience depletions in that for good reason. PR06 Service User And the whole health team were sitting there and my wife and I were outside but by this time the health team had already had time to sit down, must have spent 20 minutes, I don t know, 20 minutes, half an hour, all discussing and when I went into the room with my wife, you felt as though you were being put on the spot and then they started discussing things and you'd have the psychiatrist sitting there and he s looking at maybe *name of member of staff+ or he s got somebody sitting there and he s looking at a social worker or you've got somebody there and he s looking at an occupational therapist and they're all jumping in but the carers and the service user or me as an identity in myself didn t get the chance to say what I wanted to say and just felt as though I was answering questions to tick their boxes and I actually did leave the room and I refused to go back in. SU101 Carer if she *CPN+ could see a problem with my wife she would there and then phone the doctors; I want an appointment or am I going to do this or that. That was great but now people just seem to be - if you don t mind me saying - ticking boxes. C09 the risk assessment was just a piece of paper that I got a copy of, and I put in the drawer. Because I knew in reality, as I said earlier, when it went wrong there wasn t anybody there. To risk plan meant nothing. C03 Service User Yeah. [CPN] has always been really good with me anyway. Like, he hasn t done anything without my consent. Like, if he s going to make a decision, he always comes to me first and asks about things. I think I'm always going to be in the mental health system. SU110 I was told when I was diagnosed that it was very, very important that my I just close feel friends as if, like, and everybody family were is very just wanting boned up the about best [mental for me, illness] you and know. how And they that... should they re support all working me times for me of mania and... and And depression trying to... and Trying also to times make of me being to the well best but I not can too be, well you know. that I tip So into it s... mania. It s working well, like. It s champion. SU148 Recovery doesn t mean cure, it s just getting to a stage where you can still live a decent quality of life that you want to live. It might be different to what you originally thought it was going to be, but then again it can be really better. SU124 Carer the last two years, he s actually turned around. He s now on a treatment order, community treatment order, has been for the last two years and he s actually turning his life around he s well on the way to recovery He s actually got a part time job now as well, so so he s doing really well. C16 I think he has just sort of settled in a nice comfortable rut and he is quite happy to stay there whether he thinks he s recovering or not I don t know. C22 Because they actually listen. They don t listen to the degree of you either.. they actually look at you and listen and make you feel like they're listening and care. That s what it is. They know how important it is to get it right. SU106 No, I find that they would be more able to help if they weren t under so much stress themselves. You know the time would be the same with them but it would be of a better quality. SU120 CULTURE CHANGE Times of crisis Professional I think maybe there is the potential to try and look past the kind of crisis, to look at objectives and goals, but it s difficult, because if crises are kind of persistent and frequently you do get into responding to those. PR06 God, this sounds awful I think if staff tick too many of the boxes on the first risk assessment, then they ve got to do a crisis contingency plan and I think they avoid it. PR12 Yes we do a care plan, a risk management plan? How often do we say and if in crisis, ring the crisis team. PR03 Carer it was actually getting professionals to listen. Erm, realise that we weren t crying wolf; that he needed help. You know, he never ever rang up unless there was a problem. You know, we supported him, did whatever chivvied him along and it was only when an acute episode occurred that the help wasn t around. C16 *The policewoman+ said: Why did you ring the police? and I went Because I was told. The crisis team couldn t help us and I was led to believe that I would ring the police and the crisis team would follow on and they didn t. There was nobody. Nobody came after that. C39 Service User Yeah. *CPN+ has always been really good with me anyway. Like, he hasn t done anything without my consent. Like, if he s going to make a decision, he always comes to me first and asks about things. I ve always been listened to and I felt they ve worked with me, they ve valued what, you know, what my opinions are, I've not been pushed into anything. I've not been treated as someone who hasn t got anything to give in my recovery or anything like that. No, I just sort of feel I've been involved in every step of the way with them all. SU113 Crisis services, cos they don t treat you they say that they look at you as an individual there and then, but actually, they don t; they ll say we know this person and this is how this person behaves in this situation, rather than looking at the here and now and why am I presenting at that time. SU140 Recovery and Care Coordination

What Next? We are designing a Toolkit to support recovery focused care coordination. We need a commitment to change research steering group Trust training and PCP... Potential Future Experience/Impact film PCP Evaluation PCP? and Clinical Research Group Recovery and Care Coordination

The project received the Best Service User Involvement Plan Award at the National Institute for Health Research, Mental Health Research Network, Scientific Research Conference on the 21st April 2010. Contact emails: toby.brandon@northumbria.ac.uk helen.atkin@northumbria.ac.uk nicola.armstrong@ntw.nhs.uk Steering/Research Group: Nicola Armstrong, Helen Atkin, Deb Helme, Alison Flaherty, Caroline Kemp, Lisa Matthews, Stephanie Morley, Louise Thomson, Mick Hill, Oliver Wood, Liz Bowman, Alasdair Cameron, Paula Edwards, Shula Ramon, Jan Wallcraft and Simon Douglas Recovery and Care Coordination

This work presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit Programme (Grant Reference Number RfPB PB-PG-0808-17269). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The research team are grateful for the on-going support of the NIHR Recovery and Care Coordination

The Design Phase Stewart Gee PCP Programme Manager

A? B SMR

GP / Other CPN B6 physio 1.24 hrs Medic OP Service 0.64 hrs B6 Discharge Understanding our current state Explored 720 patient journeys, by cluster and locality, looking at patient clinical contact and bed usage Created current Value Stream Maps (VSMs) and do analysis of what happens now? NTW 0 1 2 3 4 5 6 7 8 10 11 12 13 14 15 16 17 18 19 20 21 NC Total Total Number of Clients 300 173 488 1,490 1,530 552 534 732 745 601 2,334 1,348 496 134 43 226 194 1,764 1,804 776 187 4,293 20,745 Female 138 107 288 906 890 317 308 408 478 242 1,139 544 202 62 29 55 59 1,101 1,197 518 117 2,361 11,466 Male 162 66 200 584 640 235 226 324 267 359 1,195 804 294 72 14 171 135 663 607 258 70 1,932 9,279 Percentage Split 1.8% 1.1% 3.0% 9.1% 9.3% 3.4% 3.3% 4.5% 4.5% 3.7% 14.2% 8.2% 3.0% 0.8% 0.3% 1.4% 1.2% 10.7% 11.0% 4.7% 1.1% 100.3% Percentage Split 0-17 only 2.5% 1.5% 4.1% 12.5% 12.8% 4.6% 4.5% 6.1% 6.3% 5.0% 19.6% 11.3% 4.2% 1.1% 0.4% 1.9% 1.6% Total Number of InPatients 5 2 4 21 27 17 11 20 30 26 35 93 76 42 6 43 30 6 36 52 46 9 637 ADULT CONTINUING CARE 1 1 1 4 14 1 1 2 25 ADULT MH ACUTE ASSESSMENT & TREATMENT 2 1 1 11 11 11 5 14 24 15 21 40 19 28 5 15 11 3 1 2 6 246 ADULT MH PSYCHIATRIC INTENSIVE CARE 1 2 1 2 2 5 2 6 1 2 4 1 29 ADULT MH REHABILITATION 1 1 3 3 4 9 34 34 2 26 14 1 132 OPS ACUTE ASSESSMENT FUNCTIONAL 3 1 3 8 14 5 3 1 8 2 10 7 5 2 4 1 1 78 OPS ACUTE ASSESSMENT ORGANIC 1 4 22 23 6 2 58 OPS CHALLENGING BEHAVIOUR 1 3 13 23 40 OPS LONG TERM CARE 2 12 15 29 Total Number of Community Clients 327 180 526 1,623 1,687 619 606 802 842 648 2,674 1,551 539 118 41 221 214 1,879 1,892 798 149 4,293 22,231 ADULT ASSERTIVE OUTREACH 1 1 1 4 30 45 21 5 53 118 1 2 282 ADULT CMHT 193 100 281 1015 1133 434 400 600 661 218 2015 1081 348 76 31 131 56 32 21 13 5 1629 10474 ADULT COMMUNITY MENTAL HEALTH 170 95 266 896 907 359 323 474 566 192 1,657 878 274 64 30 111 35 26 18 10 5 1,387 8,743 ADULT COMMUNITY NURSING 23 5 15 119 226 75 77 126 95 26 358 203 74 12 1 20 21 6 3 3 242 1,731 Care Pathway - CURRENT ADULT COMMUNITY PERI-NATAL 1 2 2 24 54 4 3 3 1 7 1 47 149 ADULT COMMUNITY REHABILITATION 1 1 2 2 1 18 40 31 1 6 6 1 1 111 Locality Population: Newcastle ADULT CRISIS RESPONSE & HOME TREATMENT 1 5 34 22 6 10 16 6 13 11 5 8 1 1 1 2 1 20 163 Cluster: 18 ADULT DAY SERVICES 1 12 3 5 2 4 2 5 14 3 2 1 54 ADULT DRUG & ALCOHOL 2 2 1 1 4 10 ADULT PSYCHOTHERAPY % Patients by 5 4 12 32 39 11 87 39 63 3 8 1 1 % Patients by 116 421 Population Data 14% Primary Care Entry Point Entry Point COGNITIVE ANALYTICAL THERAPY 4 1 5 13 22 3 4 2 4 1 2 5 66 1% Hospitalised COGNITIVE BEHAVIOURAL THERAPY 76% GP/Other 3 9 28 43 53 31 30 26 3 11 7 1 1 2 Discharged1 69% 56 305 21% Treatment completed / discharge EARLY INTERVENTION PSYCHOSIS 4 3 5 1 1 1 1 4 Treatment 319 28 12 4 3 1 1 23 411 10% Deceased OPS CHALLENGING BEHAVIOUR1% Cluster 1 1 1 1 8 27 50 Cluster 19 9 23% 32 129 5% DNA / Withdrew OP CMHT OP Medic 1% Inappropriate referral Expected prevalence OPS of COMMUNITY MENTAL HEALTH 1% Cluster 2 51 54 146 285 137 31 14 0.33hrs 32 8 50 175 73 28 7 4 3 4 1,131 1,038 466 Cluster 20100 4% 1,047 4,884 16% Internal transfer Cluster 18 patients in OPS DAY SERVICES 3 10 13 35 25 3 3 1 4 12 7 6 2 27 38 15 11 215 Newcastle Actual FLOW IN Assessment / Review Assessment / Review Actual FLOW OUT OPS MEMORY One ASSESSMENT patient every SERVICE 5% Cluster 3 14 Patient assigned 3 Cluster 10 3 1 1 1 4 2 1 Patient 1 discharged from 561 680 201 Cluster 21 24 1% 473 One 1,980 patient every Number 2.33 1.14 days 18 1 566 400 1 Cluster 18 OPS PSYCHOLOGY 2 1 10 43 18 4 3 4 2 5 3 1 26 10 1 9 1.44 1.5 days 3% Cluster 4 Medic Medic Cluster 4 1% 142 OPS YOUNGER PEOPLE WITH DEMENTIA 7 Physio1 Dementia 24 13 12 3 6 66 0.61 hrs SELF HARM LIAISON SERVICES 9% Cluster 19 3.8 hrs 10 2 3 18 16 2 2 3 3 2 7 3 1 22 17 6 Cluster 3 3 1% B6 170 290 Mean Days in Cluster 5% Other 302 214 178 181 172 182 176 202 184 144 247 207 209 142 201 172 144 160 176 161Other 160 1% Mean Days Open to NTW 1,996 1,240 1,260 1,208 1,026 1,135 1,357 1,815 1,530 708 2,692 2,845 2,897 1,813 1,493 2,154 3,271 624 803 1,085 1,378 Inpatient Service Users with IP stays in last 12 Months 13 13 37 97 143 70 48 81 167 Intensity: 137 241 50 mins days 302 155 85 11 83 79 36 106 93 57 2,054 0 per month % SU with IP stays in last 12 months 4.3% 7.5% 7.6% 6.5% 9.3% 12.7% 9.0% 11.1% 22.4% 22.8% 10.3% 22.4% 31.3% 63.4% 25.6% 36.7% 40.7% 2.0% 5.9% 12.0% 30.5% Mean OBD for Service Users with InPatient Stays 359 121 90 90 112 64 217 125 103 74 194 420 923 172 76 329 515 75 131 300 957 Mean Frequency of Contacts within Cluster (days) 37.0 38.5 37.0 31.3 25.0 21.7 25.0 25.0 20.4 13.7 27.0 18.2 15.4 16.1 40.0 13.5 6.3 47.6 43.5 43.5 58.8 30 mins 261 days 30 mins Locality: Newcastle 0 0 Pathway: Cognitive Cluster 18 Resources Defect List Clinical Resource required = Sum of cycles / Flow in = 6.62 / (5.34*1.14) % Appointments DNA / Cancelled 11.5% = 1.09 wte 0.2 Medic Inappropriate referrals during LOS 0.25 0.1 Physio 0.78 Band 6 Required Beds 0 beds Work In Progress (WIP) Cluster 19 Actual WIP 400 Patient FLOW Standard WIP 223 Flow In one patient every 1.14 days = LOS / Flow In Flow Out one patient every 1.44 days Net change in number of patients per year 67 patients / year Cluster 20 Explored flow and interfaces High-level Summation (Direct contact for Clusters: 3,4,6,8,10-14, 18-20) Output of data analysis and VSMs: North South This is the sum of the community clinical WTE Newcastle Sunderland Gateshead TOTAL Tyneside Tyneside data in the resource box of the current state value stream maps. It suggests thewte required Community WTE 25.9 7.6 23.3 11 12 79.8 to deliver the clinical contact derived from Number of beds 134 9 137 71 46 395 Cluster 21 Non-Psychosis Possible Assumptions for worst case scenario: Impact on above figures Calculated resources required to deliver the current state (25% contact, 75% bed usage) Northumberland has bed need and WTE need equal to mean Factor in Northumberland average of all other clusters data The 8 clusters not examined have bed need equal to 1/7th of the clusters that were examined (1/7th reflects snapshot bed usage of Increase Beds by 14.3% those clusters) The 8 clusters not examined have WTE need equal to 25% of the average of the clusters that were examined (25% represents Increase WTE by 25% snapshot patient population by cluster) Possible worst case scenario North South Newcastle Sunderland Gateshead North'l'd TOTAL Tyneside Tyneside Community WTE 32.4 9.5 29.1 13.8 15.0 20.0 119.7 Number of beds 153 10 156 81 52 90 542 Actual position of WTE and beds North South Newcastle Sunderland Gateshead North'l'd TOTAL Tyneside Tyneside in Newc/Nty Community WTE 266 221 487 figure Number of beds 753 Acute OP Stepped PICU OP Organic TOTAL Bed Type Assessment Functional care Number of beds 32 263 86 172 200 753 This increases the community clinical WTE and bed numbers derived from the sampling of patient journeys, to take into account that not all clusters and localities were considered. This is the result of applying the assumptions above to the data table at the top of the page This is the actual community clinical WTE and Bed numbers by locality, taken from dashboard and staff numbers (from finance) Psychosis Community WTE Efficiency (contact resource/total clinical resource) Assuming contact activity is fully recorded Bed Efficiency (Bed need / Beds available) Efficiency 25% 72% From the sampling of patient journeys, aggregated with assumptions above, this is the overall % WTE in direct contact with patients and bed utlisation / efficiency. Actual bed utilisation from the dashboard is 78%. The 25% direct contact correlates with figures produced in the Transforming Community Services project having observed teams at work

What we learned about our current community pathways Not always obvious that the patient was on a pathway Patients were often with us for a long time, during which they seemed to have relatively little direct clinical contact Where patients came from (cluster-wise) and where they went to (cluster-wise) did not always make sense some pathways looked almost random Concern that we may be making some patients worse Flow was variable, yet resources were not, causing peaks and troughs right across the pathway and the inevitable blockages and waits that ensue

How CPN s spend their time

Need to capture patient experience at every point of the pathway Not all assessments in clinic - travel time may be required to patient home Standard work required to reduce variability in which assessments are sought Non-med prescriber or pharmacy role possible? Should we keep in contact with these people, say with a support worker every 3/6 months in a phonecall or visit? The approach we took We held a series of clinically-led workshops Pathway: Cognitive Future State Value Stream Map Date: Cluster: 18 Version: 0.1 Drafter: P Ian Railton Patient/Family/carer present Process box 25 September 2012 Which explored the current state VSMs Effect Care Coordination Undertake Care Coordination throughout Face to face Telephone call resource Ideas for further development task time 9.5% Number of patients in queue Overall % patients that flow this way 1 30% 1 Efficacy Review Review treatment; instigate psychological step 1 and offer step 2/3 as appropriate, Occ/Soc & Fam/carer interventions instigated 1% 1 1% 1 Specialist Occ/Soc From OT Spec Assesssment P? 600 mins Step 3 Psychological Structured Psychotherapy 10-12 sessions 1 1 12 month Review Undertake review; agree discharge / further treatment / involvement of others Repeat 1 Discharge Complete discharge tasks P Clinical Psychologist (6-8) Initial Assessment & Access Phase Assessment & Formulation 720 mins Formulation 3 days max 28 days max within 1 month of results - FP10 FP10 Further Consider Assess current Diagnosis & Involvement of Risk Contact with MHCT scored & Care Coord Consider further Review assessments Initial diagnosis & Step 2 Step 2 Receive referral information Initial triage detailed care working Check meds others Assessment family / friends clustered identified assessments / investigations formulation sought assessment arrangements formulation 50% 62% Psychological Psychological Log on Rio from other captured and Assessment Holistic re: capacity, assess level of including inform initial following MDT and investigations in MDT Discuss with pt / fam Confirm medication Education Coping with 1 referrers re: 1 logged 1 appointment 1 assessment of 1 MH status, 1 carer need; 1 safeguarding 1 management 1 1 discussion 1 1 1 and confirm 1 tolerance. Issue 1 8 8 risk, needs, offered risks and how services plan clustering. Meds FP10 higher dose Group - 8 per forgetting 6-8 wk 1 physical programme urgency 90% needs health, Cog work for patient 80% prescribed group complete function, etc P P P P P P P P P P 1 1 10% 21 70 180 14 total wait?? days days 2 clinicians (L8 & 6) days days admin CPN 6 CPN 6 CPN 6 CPN Band 6 MDT: Level 8; CPN Band 6; AHP/Psy (3 professionals) MDT + spec ass Level 8 CPN 6 CPN 6 CPN 6 CPN 6 mins 10 mins 15 mins 5 mins 90 minutes 15 minutes 15 mins 45 mins 15 mins 60 mins 60 mins 480 mins 60 mins 10% 10% 2% 1 FP10 Consider Assess current Diagnosis & Risk Contact with MHCT scored & Care Coord Consider further Further Further Further 2.5% detailed care working Review medication Review medication Assessment family / friends clustered identified assessments Assessments Assessments Assessments assessment arrangements formulation 2.5% Holistic re: capacity, assess level of including inform initial following MDT and investigations and investigations and investigations and investigations Patient not tolerant Patient not tolerant 1 assessment of MH status, carer need; safeguarding management discussion 1 1 1 1 1 1 1 1 1 1 1 risks and physical how services plan EG Neuropsychiatry Assessment EG OT EG? 1 10% needs health, Cog work for patient complex needs complete function, etc P P P P P P P P P Patient Contact Resource Time per patient per task Access 30 mins 30 mins Initial Assess Level 8 90 mins 9 mins 90 minutes 180 mins 120 mins mins 30 mins 30 mins Initial Assess CPN 90 mins 81 mins Average clinical time per patient journey 480.3 minutes Average clinical contact time per patient journey 369 minutes Resources per locality (WTE) Resources per locality (WTE) MDT 45 mins 40.5 mins to compare with baseline data 38% Further Assessments 300 mins 54 mins Northumberland 1.09 Northumberland 0.84 Assessment & Formulation (MDT) 45 mins 40.5 mins Newcast 1.33 Newcastle 1.02 Assessment & Formulation 45 mins 45 mins Sunderland 3.19 Sunderland 2.45 Sucessful meds 15 mins 7.5 mins South Tyneside 1.48 South Tyneside 1.14 Med resistant 60 mins 1.5 mins Total 7.09 Total 5.45 Step 2 psychological 135 mins 83.7 mins Flow rate in Q1&Q2 2012) Step 3 psychological 720 mins 7.2 mins Northumberland 1.38 Specialist occ/social 600 mins 6 mins Newcastle 1.13 Efficacy and periodic review 120 mins 74.4 mins Sunderland 0.47 Discharge 0 mins 0 mins South Tyneside 1.01 Assumed LOS in cluster Assumed review period 12 months 12 months Average patient journey and designed a future state VSM based on the CPP specifications 40-50% contact 50-60% bed usage? mins

The design workshop process Invite people Gather data Design and Standard Work #1 Refine Reasonable adjustment for pathway Design and Standard Work #2 Scope Boundaries Principles Benefits People Constraints Workshop Product Specification Design Workshop Check Does this meet the Product Specification? Check Does this reflect previous discussion and principles? Sign off Ready to test Week 0 Week 6 Week 7 Week 8

Our Clinical Workshops Access Assessment & Formulation Treatment Discharge Transitions Advice and Information Urgent Referral Non-urgent referrals Marketing Information and Preparation Assessment and Formulation Cluster and Book Meet and agree Treatment Treatment Optimising resources Develop discharge plan Implement discharge plan Augmenting Transitions

Other Workshops Non Clinical Activity CPA Scaffolding Estates Admin I.T

Treatment Patient pathway Planned Access Assessment Formulation Treatment Review Discharge = time per patient X number of patients = Total Time By skill level, cluster, pathway and sub-pathway CPP Specifications SMR Patient Need Evidence Base Treatment options per Cluster For each Treatment Type(200+): Length of one treatment session Number of sessions (range) Preparation time per session Number of staff required to deliver treatment session Skill level of staff delivering treatment Expected % patients by cluster having treatment Group size (1:1 or group treatment) Treatment venue (home, clinic, community) X the number of patients = Total Time required for Treatment ----> WTE (by skill level, cluster and pathway) Clinical Judgement

Non-clinical activity workshop

Principles for the Estate Workshop Service User + Carer first Right location and facilities for staff Community IN the community - make it accessible 24/7 IT support Seniority doesn t have priority for space inside + out No auto entitlement to own space No exclusivity for service re a building/space (hot desking areas) Remain open minded re use of open spaces High quality patient areas All trust areas equal importance/status Standardisation across areas Maintain social elements/ team aspects of work

Where are the patients?

Psychosis & Non-psychosis 3 Sunderland 1 South Tyneside

Cognitive and Learning Disabilities Cognitive LD

Principal Community Pathways Detailed Design So far 362 people have attended the 27 clinical and supporting systems workshops, these have included: GPs, Local Authority staff, Acute Trust staff, Community and voluntary sector staff, CCG staff, NTW staff and most importantly our service users and carers. Our Trust-wide Service User and Carer Reference Group has been involved throughout We have presented our plans to various groups including HealthNet and South Tyneside GP Education Forum We ve been walking the wall with all of our stakeholders and have so far run sessions for over 1200 people