NHS Grampian 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 Overview of local mental health services 3 2 Intensive psychiatric care unit provision 3 2. Admission to IPCU 4 2.2 Model of care provision 5 2.3 Discharge from IPCU 6 3 Demographics 6 3.. Numbers of IPCU admissions 7 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 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 is a national service profiling exercise covering all of the territorial NHS boards in Scotland. In a parallel piece of work during Stage, 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.
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 200 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 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 meeting. 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 gathered at the follow-up meeting with NHS Grampian on 28 May 2009. 2
Overview of local mental health services Grampian is situated in north east Scotland and has a population of around 535,290. About 40% of the local population live in Aberdeen, which is the largest urban area in the region, although a significant proportion live in rural areas. In NHS Grampian, primary care and community services are provided by three community health partnerships (CHPs): Moray Community Health and Social Care Partnership based in Elgin; Aberdeen CHP based in Aberdeen; and Aberdeenshire CHP based in Inverurie. Mental health services for the whole of the NHS Grampian area are hosted by Aberdeenshire CHP. The NHS Grampian mental health service works closely with the mental health services of NHS Orkney and NHS Shetland. The mental health service comprises five directorates: adult mental health; learning disability; Moray integrated health and social care partnership; old age psychiatry; and specialisms. Each directorate includes inpatient services and community services in the form of specialist and community mental health teams. The Royal Cornhill Hospital, Aberdeen, is the main centre in the north east of Scotland for the inpatient care and treatment of people with mental health problems. It is also the main training centre for medical and nursing staff working in mental health. Adult mental health acute, rehabilitation and low secure inpatient services are provided as follows. NHS Grampian Dr Gray s Hospital, Elgin Number of beds Acute mental health admissions beds (adult) 25 (currently at 20) Royal Cornhill Hospital Number of beds Acute mental health admissions beds (adult) 2 IPCU Learning disability inpatient beds 24 Low secure forensic 8 Learning disability (including 2 low-secure forensic) 24 Low secure mental health rehabilitation 6 Mental health elderly care inpatient beds 04 Mental health rehabilitation inpatient beds 40 2 Intensive psychiatric care unit provision There is one IPCU in NHS Grampian, within the Blair Unit, Royal Cornhill Hospital. The Blair Unit also includes a male forensic admissions ward and a male forensic rehabilitation ward. The IPCU covers all of NHS Grampian, NHS Shetland and NHS Orkney and has a total of inpatient beds, two of which are designated for females and are used interchangeably for both female IPCU and forensic patients. NHS Grampian reported that over the past 3 years, average IPCU bed occupancy 3
has dropped from 90% to 50%, however on occasion, occupancy can be as high as 00%. There is no formal policy regarding keeping a vacant bed as contingency for unexpected crisis admissions. NHS Grampian reported that the IPCU staff work closely with general adult mental health inpatient services with regard to bed management and triage of patients. There has never been a situation where a Grampian patient has required to be transferred out-of-area for IPCU care. The IPCU takes referrals from both NHS Shetland and NHS Orkney and there are formal service level agreements in place. NHS Grampian, along with NHS Orkney and NHS Shetland, is also part of a mental health obligate network. The network meets on a quarterly basis and provides a multi-agency, multidisciplinary forum for supporting continuous quality improvement and ensuring the sustainability of remote and rural health systems. Depending on availability of beds, requests for admission from other NHS board areas would be considered. NHS Grampian reported that requests for out-of-area admissions from other mainland NHS board areas are uncommon. When requests are received they are usually from NHS boards that are relatively close geographically, for example NHS Tayside. 2. Admission to IPCU The IPCU accepts both male and female patients between the ages of 6 65 and there is a formal operational policy, including admission criteria, in place. The policy was developed to ensure that there are no more restrictions placed on a person than are warranted by their clinical condition. The policy also states that there should be positive therapeutic benefits to the patient from being admitted to IPCU, and acknowledges the importance of considering the emotions that the patient and their carers and/or relatives are experiencing at a potentially distressing time. The operational policy outlines a number of exclusion criteria for admission to the IPCU which include: young people under the age of 6 patients with learning disabilities patients with dementia patients with problems due to substance misuse in the absence of additional serious mental disorder, and patients whose physical condition is too frail to allow their safe management in the IPCU. The operational policy also outlines that patients admitted to the IPCU should, almost without exception, be detained under an appropriate section of the Mental Health (Care and Treatment) (Scotland) Act 2003. In practice, there are some informal admissions to the IPCU each year; usually these are at the request of the patient. NHS Grampian has developed local guidance which includes advance statements and a system for giving informed consent. The informed consent includes stipulations regarding the levels of restriction that will be enforced in the IPCU setting if a person chooses to go there. In 4
practice, informal patients are managed on a case-by-case basis. Bespoke restrictions may be put in place relative to their needs and wishes. While there is consultant general adult psychiatry input to both NHS Orkney and NHS Shetland, there are no inpatient mental health beds in either NHS board. Patients from the islands have full access to acute admissions beds within the Royal Cornhill Hospital as required. In practice, if it is considered that a patient from the islands requires inpatient mental health care they would be first admitted to the general adult ward at the Royal Cornhill Hospital for assessment. NHS Grampian reported that the transport links between the islands and the mainland are good and the air ambulance service operates well. NHS Grampian routinely supplies nursing staff from the Royal Cornhill Hospital to escort patients from Orkney and Shetland who require admission either to the IPCU or the admission wards. 2.2 Model of care provision The IPCU has a dedicated nursing team. The remainder of the multidisciplinary staff complement works between the IPCU and the forensic wards, and includes consultant psychiatry input from both forensic and general adult psychiatry, psychology, social work, occupational therapy and administrative support. There is also a life skills team which is again shared between the IPCU and forensic wards. A local GP holds three clinics each week at the Royal Cornhill Hospital which are available to all inpatients. IPCU staffing profile in NHS Grampian Medical Nursing Consultant psychiatrist General adult psychiatrist Specialist registrar Junior doctors 8 WTE registered and unregistered: Band 7 Band 6 Band 5 Band 3 (unregistered nursing assistant) Consultant clinical psychologist Whole time equivalent (WTE) 3 0.3 variable 0 6 Clinical psychology Psychologist (trainee) Social work Mental health officer 3 Pharmacy Pharmacist 4 hours per week Allied health professionals Administrative staff Occupational therapist Occupational therapy technical instructor Physiotherapist Technical Instructor Adult learning Co-ordinator 0.6 per week 0.08 2 hours per week hour per week Administrative officer 3.08 5
Example of a local initiative Patients in the IPCU can attend the weekly GP clinics to address any issues with their general healthcare needs, and to get advice and support on health screening and health promotion. The usual nursing complement on the ward for any shift is three plus the ward manager; this would include a minimum of two registered staff. At the time of the service profiling exercise, two of the registered nursing staff complement had less than one year s mental health nursing experience. Staffing levels and mix are modified in relation to clinical activity; sometimes using nursing bank staff to supplement the team. At the time of the service profiling exercise, NHS Grampian reported that there were two registered, and two non-registered, nursing vacancies within the IPCU nursing team. The co-location and collaborative working between the IPCU and the forensic service means that staff can be shared across the wards. This allows a degree of flexibility in the skills and gender mix of nursing staff and provides additional capacity to quickly respond to incidents using an alarm system which is common to both services. Three consultant psychiatrists have beds within the unit which again allows for flexibility and sharing of expertise across the IPCU and forensic service. Joint multidisciplinary patient-focused meetings are held twice weekly and are attended by the full multidisciplinary team. While patients do not routinely attend these meetings, they are involved in their care planning as much as they are able. A recovery plan document is completed for all patients; this includes sections specifically for patients to complete and sign off. Dedicated service user meetings are also held to allow people to input to discussions about the IPCU and the care that they receive. 2.3 Discharge from IPCU The operational policy includes a section on discharge from the IPCU. This stresses the need for forward planning of any discharges and for keeping the patient and the host ward well informed of the discharge plan and associated timescales. This forward planning also allows time for the host ward to source a bed for the patient to return to. NHS Grampian did not report any difficulties with discharge of patients from the IPCU. 3 Demographics The total adult population aged 6 64 served by the IPCU is approximately 48,26. This includes the population resident in Grampian (390,259), Orkney (3,233) and Shetland (4,724). 6
3.. Numbers of IPCU admissions Information supplied by NHS Grampian indicates that there were 33 admissions to the IPCU during 2008. 3.2. Nature of admissions The 33 admissions during 2008 can be further broken down as follows. IPCU admissions to NHS Grampian in 2008 Age Under 8 8 30 3 50 5 65 Over 65 Gender Male Female Ethnicity White Scottish Indian Not known/specified Detention status Civil law Criminal law Informal (elective) Out-of-area referrals Formal agreement No formal agreement 0 7 8 8 0 26 7 29 3 4 8 0 0 In terms of presenting conditions, NHS Grampian reported most patients have some form of severe and enduring mental illness, often schizophrenia or bipolar personality disorder in the acute manic phase; most also have co-morbid conditions. As reported previously, there are two dedicated female bedrooms within the IPCU, however there are no female only sitting areas available. All patients undergo ongoing risk assessment to minimise risk to themselves and others. 3.3 Management of other population groups The IPCU rarely admits under 8s. The number of such admissions over the last 5 years total five. If under 8s are admitted they would always be put on one-to-one observation and the IPCU team would liaise closely with child and adolescent psychiatry for the duration of their stay. Older adults are similarly rarely admitted. Again, one-to-one observation would be undertaken to ensure their safety. People with a primary diagnosis of learning disability would very rarely be admitted to the IPCU. Any who are admitted would have an individual risk assessment undertaken and the priority would be to transfer them to a specialist learning disability service as quickly as possible. The IPCU will admit female patients stepping down from higher levels of secure care. Male step-down patients would be admitted to the forensic ward. 7
4 Links with other secure mental health provision There is no medium secure dedicated inpatient forensic provision in NHS Grampian. NHS Grampian is linked into the planning process for the North of Scotland Regional Medium Secure Facility which is under development in Perth. 5 Governance arrangements NHS Grampian has a local forensic/ipcu clinical governance group which reports into the overarching mental health clinical governance group. This is chaired by a consultant psychiatrist/associate medical director. The chair of this group also sits on the NHS board clinical governance committee. There is no direct service user or carer input into either of these groups, however, at the time of the service profiling exercise, this was being considered. The clinical director for mental health services chairs the clinical management board which receives reports every 2 months from mental health clinical governance. The clinical management board meets monthly and has user and carer representation. This is the forum where mental health service planning and/or redesign would be discussed. Staff training needs are monitored through the NHS Knowledge and Skills Framework and the NHS Grampian appraisal system in conjunction with overarching plans for service development and training. The New to Forensic training covers most of the core aspects required by staff working in the IPCU and is offered to new staff. To increase capacity to offer psychological interventions, a few of the nursing staff have undertaken specific training in delivery of psychosocial therapies. NHS Grampian reported that funding to support staff training is readily available, however releasing staff to attend the training, and availability of clinical supervision can be an issue. 6 Plans for service development NHS Grampian had no plans for the development or expansion of IPCU provision at the time of the service profiling exercise. 7 Other points to note NHS Grampian highlighted that in some areas of Scotland, in the absence of dedicated forensic services, IPCUs are used as low secure forensic units. Inappropriate admission of forensic patients to an IPCU can have a detrimental effect on the care, treatment and recovery of the other IPCU patients and vice versa. 8
Appendix Glossary of abbreviations Abbreviation CHP IPCU NHS NHS QIS WTE community health partnership intensive psychiatric care unit National Health Service NHS Quality Improvement Scotland whole time equivalent 9