NHS Lothian Royal Edinburgh Hospital 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 _~ÅâÖêçìåÇ N N lîéêîáéïçñäçå~äãéåí~äüé~äíüëéêîáåéë P O fåíéåëáîééëóåüá~íêáåå~êéìåáíéêçîáëáçå Q OKN ^Çãáëëáçåíçfm`r Q OKO jççéäçñå~êééêçîáëáçå R OKP aáëåü~êöéñêçãfm`r S P aéãçöê~éüáåë S PKN kìãäéêëçñfm`r~çãáëëáçåë S PKO k~íìêéçñ~çãáëëáçåë T PKP j~å~öéãéåíçñçíüéêéçéìä~íáçåöêçìéë U Q iáåâëïáíüçíüéêëéåìêéãéåí~äüé~äíüéêçîáëáçå U R dçîéêå~ååé~êê~åöéãéåíë V S mä~åëñçêëéêîáåéçéîéäçéãéåí V T líüéêéçáåíëíçåçíé V ^éééåçáñnódäçëë~êóçñ~ääêéîá~íáçåë NM
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. kepiçíüá~åeoçó~äbçáåäìêöüeçëéáí~äfwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf N
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 23 June 2009. kepiçíüá~åeoçó~äbçáåäìêöüeçëéáí~äfwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf O
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 West Lothian CHP and the East Lothian Community Health and Care Partnership; 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 comprise 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. kepiçíüá~å eéêçã~åñä~íeçëéáí~äie~ççáåöíçå ^ÅìíÉãÉåí~äÜÉ~äíÜ~ÇãáëëáçåëÄÉÇëE~ÇìäíF jéåí~äüé~äíüóçäçéê~çìäíå~êéáåé~íáéåíäéçë oçëëäóåäééeçëéáí~äioçëäóå jéåí~äüé~äíüóçäçéê~çìäíå~êéáåé~íáéåíäéçë oçó~äbçáåäìêöüeçëéáí~ä ^ÅìíÉãÉåí~äÜÉ~äíÜ~ÇãáëëáçåÄÉÇëE~ÇìäíF `ÜáäÇ~åÇ~ÇçäÉëÅÉåíãÉåí~äÜÉ~äíÜëÉêîáÅÉÓáåé~íáÉåíÄÉÇë ié~êåáåöçáë~äáäáíóáåé~íáéåíäéçë jéåí~äüé~äíüóçäçéê~çìäíå~êéáåé~íáéåíäéçë fm`r jéçáìãëéåìêéñçêéåëáåelêåü~êç`äáåáåf jéåí~äüé~äíüêéü~äáäáí~íáçåóáåé~íáéåíäéçë kìãäéêçñäéçë NO PS kìãäéêçñäéçë QU kìãäéêçñäéçë NMM NOEëçìíÜÉ~ëí påçíä~åçf OQ NSU NOEëçìíÜÉ~ëí påçíä~åçf QR TU kepiçíüá~åeoçó~äbçáåäìêöüeçëéáí~äfwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf P
kepiçíüá~åeåçåíáåìéçf pígçüåûëeçëéáí~äiiáîáåöëíçå ^ÅìíÉãÉåí~äÜÉ~äíÜ~Çãáëëáçåë fm`r jéåí~äüé~äíüóçäçéê~çìäíå~êéáåé~íáéåíäéçë jéåí~äüé~äíüêéü~äáäáí~íáçåóáåé~íáéåíäéçë méêáå~í~ä kìãäéêçñäéçë PM NO OQ OS SEiçíÜá~åI_çêÇÉêëI cáñéieáöüä~åç~åç q~óëáçéf 2 Intensive psychiatric care unit provision NHS Lothian has two IPCUs. They are located within Royal Edinburgh Hospital and St John s Hospital. This report will cover IPCU provision at the Royal Edinburgh Hospital only. A separate report will be prepared for St John s Hospital. In addition to the inpatient service provision listed above, the Robert Ferguson Unit, the Scottish national unit for neurobehavioural rehabilitation for patients with behaviour disorder after acquired brain injury, is also based at the Royal Edinburgh Hospital. This unit has 19 beds; NHS Lothian has a purchase agreement in place for three of these. NHS Lothian reported that staff at the IPCU work closely with other acute mental health services on site at the Royal Edinburgh Hospital with weekly bed management meetings held across these services. Information on bed management statistics across all acute wards is held on a live shared drive. The Royal Edinburgh IPCU accepts admissions from out-of-area. There is a service level agreement which covers the transfer of patients from NHS Borders to St John s Hospital and a transfer policy in place between St John s Hospital, NHS Borders and the Royal Edinburgh Hospital should a bed be required for a patient from the Borders when the IPCU at St John s Hospital has no capacity. NHS Lothian noted that the Royal Edinburgh Hospital IPCU has recently undergone a significant refurbishment which staff, patients and visitors have reported has greatly improved the surroundings. 2.1 Admission to IPCU The IPCU accepts both male and female patients aged 18 65. Admission criteria are clearly set out in the IPCU service specification, with the essential criterion that the patient is in an acute stage of mental illness which requires intensive psychiatric care in a secure environment. NHS Lothian has exclusion criteria for admission to IPCU outlined within the operational policy, including: patients with a primary diagnosis of substance misuse, learning disabilities or dementia; patients presenting at high degree of risk who would instead be admitted to forensic services; and patients whose kepiçíüá~åeoçó~äbçáåäìêöüeçëéáí~äfwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf Q
physical condition is frail enough to have concerns over their safe management in the IPCU. All referrals are, however, assessed on a case-by-case basis. Although a patient may meet the exclusion criteria, it may be deemed appropriate for them to be admitted to IPCU for a short stay depending on risk or out-of-hours factors. On these occasions there would be close contact with specialist services in the planning of care, treatment and discharge. 2.2 Model of care provision Medical input to the IPCU consists of a dedicated consultant psychiatrist who spends the remaining half of their time in rehabilitation services. There are also two junior doctors spending approximately half their time on the IPCU. The IPCU consultant undertakes responsible medical officer responsibilities for the day-to-day care of patients. Mental Health Act duties would normally be carried out by the referring consultant. Social work is accessed through the community mental health teams through the mental health officer system. There is a large gym hall, kitchen and art room within the occupational therapy (OT) corridor at the IPCU. OT is an integral part of treatment. Occupational therapists run a weekly programme that includes gym group, snack group, creative group and baking group, as well as individual sessions on topics such as anxiety management. Example of a local initiative Many classes and activity groups, such as snack group, creative group, women s group and a relaxation class are available to patients in the IPCU within the large gym and kitchen area. Nursing staff and keyworkers, as well as occupational therapists, assist in promoting and hosting these classes. The physiotherapist will see patients individually on the ward and the hospital-based physiotherapist has run a joint body awareness therapy session on the ward with OT staff when appropriate. It was recognised by staff on the ward that there were particular unmet needs for psychology and dietetic input for patients in the IPCU. A multidisciplinary ward round takes place on a weekly basis with an additional daily ward run carried out by medical and nursing staff. Multidisciplinary team meetings are held four times each week. There is a weekly advocacy drop-in service which patients can use, and the advocacy service also feeds into the acute inpatient forum. Advocacy is also available on an individual referral basis. kepiçíüá~åeoçó~äbçáåäìêöüeçëéáí~äfwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf R
fm`rëí~ññáåöéêçñáäéáåoçó~äbçáåäìêöüeçëéáí~ä jéçáå~ä kìêëáåö ^ääáéçüé~äíü éêçñéëëáçå~äë ^Çãáåáëíê~íáîÉ ëí~ññ déåéê~ä~çìäíéëóåüá~íêáëí gìåáçêççåíçêecvof POKSRtqbêÉÖáëíÉêÉÇ~åÇìåêÉÖáëíÉêÉÇW _~åçt _~åçs _~åçr _~åçpeìåêéöáëíéêéçåìêëáåö~ëëáëí~åíf _~åçoeìåêéöáëíéêéçåìêëáåö~ëëáëí~åíf lååìé~íáçå~äíüéê~éáëí lååìé~íáçå~äíüéê~éó~ëëáëí~åí t~êçåäéêâéëëeé~êíçñpoksråìêëáåö Éëí~ÄäáëÜãÉåíF tüçäéíáãé Éèìáî~äÉåí EtqbF MKR MKR N N NVKS M NMKRR NKM MKR MKR Approximately 70% of the nursing staff in the IPCU at any one time would ideally be registered and there is always at least one female member of staff on duty. At the time of the service profiling exercise, one of the registered nursing staff complement had less than one year s mental health nursing experience. Student nurses are employed at the IPCU on placements through a rotation system. NHS Lothian discussed a new pilot called Changing Experience which allows staff to rotate between wards in order to gain more of an insight into related services at the hospital. At the time of the service profiling exercise, it was reported that there were difficulties recruiting staff to the IPCU and there were five outstanding vacancies. Outstanding staff shortages are currently addressed by the use of certain core individuals who are on the nurse bank system. 2.3 Discharge from IPCU NHS Lothian s operational policy, the latest draft of which was being drafted at the time of the service profiling exercise, will outline the revised discharge planning procedures for discharge of patients from the IPCU. NHS Lothian reported that, where possible, nursing staff are empowered with making key decisions in discharge planning matters. Discussions would take place between the IPCU, the referring team and the patient as to when the patient is ready to return to an open ward. 3 Demographics The total adult population aged 18 64 served by the IPCU is approximately 323,360. 3.1 Numbers of IPCU admissions The electronic Patient Information Management System (PiMS) records information on all inpatient mental health admissions including admissions to kepiçíüá~åeoçó~äbçáåäìêöüeçëéáí~äfwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf S
the IPCU. Data from PiMS indicate that there were 94 admissions to the IPCU in 2008. The average patient age was 35. The average length of stay was calculated as 27 days, however it was noted that a few patients requiring longer-term care can distort these figures. The occupancy rate for the IPCU for the year ending May 2009 was approximately 93%. 3.2 Nature of admissions The most common admissions to IPCU are those patients who require additional input and treatment and are subject to a short-term detention or compulsory treatment order. Although the IPCU does admit patients from outside the NHS board area, this occurs infrequently. Of the recent out-of-area admissions, a small number were patients from NHS Fife who required alternative accommodation due to refurbishment works at the IPCU at Stratheden Hospital, Cupar. fm`r~çãáëëáçåëíçoçó~äbçáåäìêöüeçëéáí~äáåommu ^ÖÉ déåçéê bíüåáåáíó aéíéåíáçåëí~íìë lìíjçñj~êé~ êéñéêê~äë råçéênu NUÓPM PNÓRM RNÓSR lîéêsr j~äé céã~äé tüáíépåçííáëü tüáíé_êáíáëü ^ëá~å _ä~åâ líüéê `áîáää~ï `êáãáå~ää~ï fåñçêã~äeéäéåíáîéf cçêã~ä~öêééãéåí kçñçêã~ä~öêééãéåí N PS QT NM M TU NS TM V R R R VM Q M Q NQ As previously reported, the IPCU will admit female patients and, following the recent refurbishment, there is now a separate area for female patients. This includes separate toilet facilities and a female only sitting room area. While the dining room is mixed, female patients can eat in the female only sitting room or within their bedroom area if they wish. Staff are aware of the need for an appropriate staffing gender mix to properly support and respect the dignity of female patients. There had been a recent trend in the period preceding the service profiling exercise whereby the number of female patients in the IPCU has risen and on occasion can be greater than the number of male patients. Nearly one third of the bed occupancy at the IPCU in the past year has been for female patients, which is higher than the average across Scotland. kepiçíüá~åeoçó~äbçáåäìêöüeçëéáí~äfwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf T
3.3 Management of other population groups Despite the exclusion criteria stated within the IPCU service specification, there are occasions where patients meeting some of the exclusions would be admitted to the IPCU. For example, where there was deemed to be an extreme risk around the safety and wellbeing of the patient or that of others, the patient may be admitted to IPCU. Similarly, out-of-hours patients may be admitted for a short stay whilst appropriate provision of alternative care was sought. There is an agreed nursing care pathway for young people admitted to general adult psychiatry wards. Patients under the age of 18 are sometimes admitted to the IPCU. When this happens, staff would liaise closely with child and adolescent mental health services (CAMHS) and one-to-one observations may be used depending on the individualised risk assessment. Patients over the age of 65 are rarely admitted. On the occasions when this does happen, their care plan is developed based on individual risk assessment and relative to their physical and mental capabilities. Close liaison would be maintained with the care of the elderly team. The IPCU will admit patients with learning disabilities. The IPCU consultants work jointly with the sector learning disability consultant in care planning treatment and discharge for this group of patients. When patients with learning disabilities are admitted, specialist nursing input is usually provided by the community learning disability team if the person has been in contact with them at the time of admission. If they are not already in contact with community learning disability services, referral can be made to the pilot learning disability outreach service for specialist nursing and medical input throughout the period of the admission. Community or outreach learning disability nurses will: maintain contact with the patient; monitor and support the IPCU staff team; assist with assessment, treatment and discharge planning; make referrals to other specialist services as appropriate; and make recommendations regarding the safe management of the patient within the IPCU environment. 4 Links with other secure mental health provision The Orchard Clinic, based on site at the Royal Edinburgh Hospital, provides 45 medium secure forensic beds for all NHS boards in south east Scotland. Plans are also under development for the provision of low secure forensic beds. The Royal Edinburgh Hospital IPCU does not generally admit patients who are subject to court detention orders, as these patients would be admitted to the Orchard Clinic. However, there have been a small number of these admissions in exceptional circumstances. Patients who are stepping down from The State Hospital are not admitted directly to the IPCU. kepiçíüá~åeoçó~äbçáåäìêöüeçëéáí~äfwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf U
5 Governance arrangements NHS Lothian is currently developing a shared operational policy for both the NHS Lothian IPCU facilities. The mental health quality improvement team co-ordinates all clinical governance issues within acute mental health services and feeds into the wider healthcare governance group. An audit of incidents within the IPCU has been ongoing for over 7 years, with the aim of providing a clear picture of trends in types of incidents and disturbances which will assist future planning and service provision. The patient and carer s councils feed directly into the acute inpatient forum which covers all acute mental health services. There is active engagement between the patient and carer s council and mental health inpatient services. In addition, there are also user and carer representatives who feed into the mental health and wellbeing group. The views of patients are also canvassed during the ward rounds through the weekly view of the week which is shared in the unit. The patient and carer s councils perform a collective advocacy function. 6 Plans for service development There are plans for re-developing the services currently on the Royal Edinburgh Hospital site, although these are still at the very early planning stages. NHS Lothian staff raised the issue of difficulties which occur due to the acute wards being at the opposite end of the site to the IPCU. This can lead to difficulties transferring patients from one ward to another. All East Lothian acute mental health beds are to be moved to Royal Edinburgh Hospital site. Following this, the Royal Edinburgh Hospital IPCU will admit patients from Edinburgh, Midlothian and East Lothian with the IPCU at St John s Hospital admitting patients from West Lothian and NHS Borders. 7 Other points to note It was noted that there was a wide-range of gender-specific provision of care for female patients, particularly in the environment which includes separate areas for female patients. In addition, some staff have attended training courses which give insight into the journey and experience of a woman in mental health services. NHS Lothian is keen to promote a team approach to recreational activities within the IPCU. The activities on offer to patients in the OT area of the unit, were seen as extremely beneficial to both the patients and the staff. It is hoped the incident audit census will assist future planning of the service and provide a clear picture of trends in this area. kepiçíüá~åeoçó~äbçáåäìêöüeçëéáí~äfwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf V
Appendix 1 Glossary of abbreviations Abbreviation CAMHS CHP IPCU NHS NHS QIS OT PiMS WTE child and adolescent mental health services community health partnership intensive psychiatric care unit National Health Service NHS Quality Improvement Scotland occupational therapy Patient Information Management System whole time equivalent kepiçíüá~åeoçó~äbçáåäìêöüeçëéáí~äfwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf NM