Mental Health Crisis Care Programme Update: Clinical Senate Council 24 th May 2016 1
Mental Health Crisis Care Programme: Summary The state of mental health crisis care needs to improve across London. There are unacceptable variations in the help, care and support available to those in a mental health crisis, including those detained under section 136. London s 32 CCGs and NHS England (London region) are committed to improving the quality and consistency of crisis care through Healthy London Partnership s mental health crisis care programme. Currently the programme is specifically focussed on developing a s136 care pathway and Health Based Place of Safety (HBPoS) specification. The crisis care programme is currently engaging with stakeholders across the system on draft versions of both documents, the engagement process has resulted in useful discussions with different stakeholder groups to understand current challenges and what needs to be outlined in the s136 pathway and HBPoS specification to address these issues. The engagement process will continue over the next 6 weeks, discussions will front-line staff will continue as well as pan-london Mental Health and Urgent and Emergency Care (UEC) governance groups. The engagement process has also provided an opportunity to discuss with stakeholders the idea of looking at the s136 pathway from a regional/pan-london level. There is general support across the system with this approach however it is clear that service transformation will need to occur at all levels and schemes such as street triage led locally will contribute to a reduction of s136 and overall transformation of care. The detail of this work will feed into the Sustainability and Transformation Plan (STP) process. Draft versions of the s136 pathway and HBPoS specification have been shared with the recently established Urgent and Emergency Care networks and Crisis Concordat leads as well as initial baseline data collected by the programme. Data will continue to be shared, specifically on s136 to inform the development and delivery of STPs and used to make an assessment on how the pathway and specification are met and the system changes that need to occur. 2
National and Regional Context The case for change to improve London s crisis care services: There is a significant variation in the care and services on offer for London s crisis care patients, this includes those detained under section 136; There are constant tensions between front-line staff from the different agencies involved in the s136 pathway due to lack of clarity and communication across the pathway; Over the past two years London has seen a 9% increase in s136 detentions and this is expected to rise; London service user s continue to describe the poor quality of mental health crisis care largely due to services that fail to meet their needs and lack basic respect, warmth and compassion. Recent national and regional policies outlines the need to improve services: Better Health for London report, 2014: Health and care commissioners should develop a pan-london multi-agency (including the police and ambulance service) case for change and model of care for child and adult mental health patients in crisis. Five Year Forward View 2014: Over the next five years, the NHS will do far better at organising and simplifying the UEC system, this includes the proper funding and integration of mental health crisis services Healthy London Partnership s Mental Health Crisis Care Programme in partnership with stakeholders across the crisis care system is focussed on improving the consistency of care across London s s136 pathway. This includes the development of a London s136 care pathway and HBPoS specification (covering adults and CYP) and exploring wider transformational changes to improve current processes and services, specifically at HBPoS sites. 3
Development of the crisis care work programme Both documents will outline the minimum standard of care to improve the consistency and quality of care across London. Current issues such as governance, staffing requirements, conveyance between sites and the expectations of clinical staff (as well as the Police and LAS) are being addressed through this work. Following an extensive engagement period it is expected that the s136 pathway and HBPoS specification will be completed this summer. An assessment will then need to be made as to how the pathway and specification are implemented across London. Developing the HBPoS Specification and S136 Care Pathway: An early draft of the HBPoS specification includes guidance sourced from a range of publications. The appropriateness and relevance of the guidance has been tested with members from the crisis care multi agency expert group, the Children & Young People programme and subject matter experts across London s crisis care system. Clinical champions were sourced from Mental Health Trusts across London to delve into the detail and ensure the documents are fit-for-purpose and address the right issues in the system. These champions continue to have input into the development of this work. Key areas of the HBPoS specification and the wider vision of transformational change was discussed at London s crisis care summit. Delegates welcomed the specification as well as the idea of a pan- London approach in regards to the s136 pathway and HBPoS sites. Service users have also been significantly involved through the development by I statements and service user workshops across the five London UEC footprints (see slide 5) The programme team is also aligned with national work programmes in particular the NHS England crisis care programme and the Royal College of Psychiatry s revision of their s136 guidance. 4
Service User Engagement Service users that have experienced London s crisis care pathway often state that they felt judged, did not feel safe and were not treated with warmth and respect. In response to this the programme is focussed on ensuring service user needs and expectations are met through the HBPoS specification and s136 pathway. Adult and Children and Young People I statements have been developed, over 200 service users of all ages were involved in the development of these statements through both an online survey and focus groups. The I statements have been shared with UEC network leads and crisis concordat groups to support the development of Sustainability and Transformation Plans (STPs). In addition to the I statements workshops with service users have been set up across the five London s UEC networks to further involve service users in the development of this work and ensure service user needs and expectations are met. Workshops at South London and Maudsley (SLaM) and South West London St George s have taken place, supported by Mind, the further three workshops will take place over the next month. Feedback from the first two workshops identified the need to ensure service users are a key partner in the development of this work, in response to this the programme team are identifying additional ways to ensure there is sufficient service user involvement going forward. Mental Health Crisis Care Service User Workshops 5
Overall Engagement Over the past six weeks the programme team have engaged widely with key stakeholders across the crisis care system. The diagram displayed below represents the different agencies engaged in this work. The engagement process has focussed on ensuring front-line staff from EDs and Mental Health Trusts are involved and bought in to the work programme. This has involved 1:1 discussions with liaison psychiatry teams, ED nurses and consultants and operational staff across different Trusts. Discussions have also occurred with Approved Mental Health Practitioners across London, LAS and the three London Police Forces. In addition to these discussions the programme team have ensured pan-london UEC and Mental Health governance groups are sighted and engaged in this work. Feedback from these groups shows overall support for this work and a clear drive to work together as a system to ensure its success going forward. Over the next month the programme team and clinical leads are engaging with the following pan-london groups: Mental Health Strategic Clinical Leadership Group Mental Health Trust Chief Operating Officers Forum UCLP Acute Trust Medical Directors London Mental Health Medical Directors London Mental Health Commissioners Network The programme is also working closely with the NHSE Crisis Care programme and the National Crisis Care Concordat team. 6
Key areas within the documents The specification and pathway documents cover a range of areas to provide clarity and improve the consistency of the service across London. The following areas in particular have been the focus of discussions with stakeholders, largely because they are the areas which lack guidance often resulting in poor practice and tensions between the different stakeholder groups. Intoxication pathway: There is a need to clarify the different levels of intoxication and at what point individuals are transferred to an Emergency Department vs a Health Based Place of Safety. The term incapable is being used as the trigger to send the individual to ED, case studies are being developed to assist with this decision making. Responsibilities of Emergency Department staff with a s136 detainee: Clarifying the legal and clinical responsibilities when a s136 is in an ED, including who can legally remove the s136 and when MHA assessments should take place in ED rather than transferring an individual to a HBPoS. Conveyance between HBPoS sites and EDs and well as transfers from the initial pick up: Clarifying who has overall responsibility during conveyance and who has the responsibility of the coordination and organising role when transfers take place. Also outlining appropriate timeframes in which transfers should occur. Physical health competencies of HBPoS staff: Outlining the physical health competencies that HBPoS staff should have, this includes the ability to manage simple open wounds to avoid unnecessary transfers to the Emergency Department. The Mental Health Act assessment process: Outlining the key roles within the MHA assessment process, the timeframes and legalities in terms of abiding with the Mental Health Act. The location of a HBPoS: Understanding whether a HBPoS should be co-located or in close proximity to an ED to streamline the initial part of the pathway. 7
Piloting the HBPoS specification South London and Maudsley (SLaM) Mental Health Trust: Integrated HBPoS site London s Health Based Place of Safety Specification is being piloted by SLaM s bespoke new Health Based Place of Safety site. SLaM are consolidating four HBPoS sites into one which will be based at the Maudsley hospital. The site is due to open in the summer and the London HBPoS specification will be included in their new operational processes. The programme team are working closely with colleagues at SLaM to develop the specification and ensure it is fit-for-purpose. Healthy London Partnership are also working with SLaM to develop a thorough evaluation process which will understand the specification s impact as well as the impact of consolidating four HBPoS sites into one. The evaluation process will cover pre and post state and will include a real time survey which will be completed after each patient comes into the suite, a mix of service user and staff interviews (including interviews with nurses, SpRs, AMHPs, paramedics and local Police officers) and an analysis of data that is currently collected by the Trust. The evaluation process will inform the wider implementation plan, particularly showing the impact of fewer but a well resourced HBPoS site. The evaluation report will be shared to London Mental Health Boards once completed. 8
Supporting Transformational Change The UEC network leads developing the UEC element of the Sustainability and Transformation Plans acknowledge the need for a pan-london approach in terms of crisis care (particularly the s136 pathway). The recent UEC Board which includes the UEC network leads agreed to have a general position statement developed for crisis care which outlines the challenge, ambition and commissioning intentions. Baseline data from the Health Needs Assessment (see slide 10) and service user experiences will be shared with UEC networks and crisis concordat leads to inform planning and decisions regarding wider system change that will support more effective care models and therefore improve patient outcomes. The diagram below outlines the high level process the programme will take over the next six months in line with STP timeframes. STP timeframes 9
Baseline Data Exercise Alongside the development of the s136 care pathway and HBPoS specification a baseline exercise is being carried out which will identify what London s current state is regarding the s136 and broader mental health crisis pathway Health Needs Assessment Data Exercise: In partnership with the Health in Justice Strategic Clinical Network a procurement exercise has been undertaken to commission a Health Needs Assessment focussed on s136 and mental health crisis across London; The contract was recently awarded to Therapeutic Solutions who have significant experience in health needs assessments, bespoke evaluations and service reviews as well as working with the Metropolitan Police in other research studies; The data collected will provide a detailed, accurate picture of s136 prevalence and demand as well as current service provision. It will also look at current processes and the interface between London s mental health services, the Police and Acute hospitals (particularly EDs). The final report is due to be completed in September however interim data reports are expected over the coming months. Data specifically focussed on s136 across London s UEC network regions will be prioritised to inform the development of STPs and wider transformational changes across London. 10
Next Steps Further engagement across the system to ensure the HBPoS specification and s136 pathway continues to be developed by stakeholders and there is sufficient buy-in going forward. Over the coming months the work programme will also attend pan-london governance groups including the Acute Trust Medical Directors, Mental Health Chief Operating Officers and the London Cavendish Square Group. Continuing to support the Health Needs Assessment exercise to further understand London s s136 pathway. Data collected from the Trusts, Police forces and LAS will start to be shared with stakeholders over the coming month as the data is analysed. Capacity and demand analysis will be completed using data from the Health Needs Assessment, this will support the system to begin to model options outlining how the HBPoS specification and s136 pathway are met. Ongoing support to the planning and delivery of Sustainability and Transformation Plans and working with each Urgent and Emergency Care network to understand what needs to be done across the system to meet the HBPoS specification and s136 pathway. Key Questions: Does the senate council have any feedback or comments on the crisis care work programme to date? Are there any significant issues and/or concerns that need to be taken into account as this work moves forward? Does the senate council have any recommendations in regards to the overall approach? How would the senate council like to be kept informed of this work? Would the council be able to provide an independent view on the work programme going forward? 11