New Care Models for forensic services: Will they improve service user outcomes? Dr Quazi Haque, Executive Medical Director, Elysium Healthcare
Growth in Beds in High, Medium and Low Secure
Timeline Now 2017 New Models of Care (5YfV) National Commissioning had benefits (specification, compliance and oversight) but was hampered by organisation transition, financial cliff edge and moratoriums on developments. Breakdown in effective care pathways and money not working in the system New Models designed to unite provider and purchaser role Phase One and Phase Two of the new models 4 secure new model phase one pilots start April 2017 Return to regional planning, money following the patients and a needs led development Phase two May 2017
New Model Ambition Where The Mental Health Taskforce report set out the rationale for developing new models of care for mental health: Promoting innovation in service commissioning, design and provision that joins up care across inpatient and community pathways (reaching across and beyond the NHS); Making measureable improvements to the outcomes for people of all ages and delivering efficiencies on the basis of good quality data Eliminating costly and avoidable out of area placements and providing high quality treatment and care, in the least restrictive setting, close to home Pilots (Phase One) London we can expand on this pilot West Midlands Wessex Southwest we can expand on this pilot
New Model of Care The Southwest Secure Network Phase One Pilot
SW Why New Models? Five Year Forward View Huge challenge for the NHS needing to fix the 20/30bn funding gap by 2020 Need to provide innovations to develop real solutions to unmet need and local pathways Mental health pathway improvements Commissioning gap the split in funding creating huge travel distances and inequitable access to care 52% of southwest secure patients were not in the southwest Moratorium on new service developments creating real difficulty in creating solutions We couldn t continue as we were we were already planning to develop a network 9 months prior to the New Model Invitation
New Care Models Southwest Southwest was a successful Phase One Bidder Went live April 2017 Bid includes all providers of mental health secure care in the southwest as partners in a clinical network Led by Devon Partnership NHS Trust as the Accountable Care Organisation Key aim is to repatriate patients to the southwest, to offer a southwest provided whole system solution, to define need, offer consistent high quality care and to provide improved community services
Headlines Circa 450 people in secure care Circa 52% out of region already reduced to 45% Circa 25% females only 10% treated in region Indicative budget circa 70 million 2 CFT across 7 CCG area s Specialist teams Pathfinder and FIND
Where our patients were placed
South West Regional Secure Services: Programme Governance Structure Note the partnership board, communication and stakeholder group, and clinical design groups all dedicated patient involvement
New Care Models Clinical Case Clinical outcomes Care closer to home Least restrictive Outcome based Removing variation
New Care Models Clinical Case Achieved by Remove variation & increased flow in bed management. No unnecessary out of region placements Regional bed management and increase in region bed stock to c320 Reduce people in secure inpatient care investment CFT. Investment in specialist teams to in reach into mainstream secure service Regional Clinical Network
New Care Models Clinical Network benefits and challenges Standardised Access criteria developed by Clinicians Standardised outcomes and performance developed by Clinicians Sharing good practice and quality standards driving improvements Clinician validation and peer review of outliers e.g. LOS variance, seclusion Clinical Network has designed the commissioned care pathway
New Care Models Provider Partner, Patient benefits and challenges Care Pathway Part of the pathway providing care to meet need Consistency of approach improving what is provided locally Developing this as partners Prevention of delay with local engagement through partnership early indicators that this is rapidly developing bumpy start Travel distance as close to home improving access to family and friends about time!! Patients and Families have asked for this repeatedly, every new development and every consultation.
Low Secure Length of Stay
Low Secure Bed Occupancy
Medium Secure Length of Stay
Medium Secure Bed Occupancy
New Care Models Provider Partner, Patient benefits and challenges Improved access to local teams see this increasing Change and developing trust independent sector working as part of the NHS in an integrated way Making this work, commitment to the approach bumps and all
New Care Models How do we know its works This is a two year project with ambitions stretching over the next 5 years. Its been operational for 2 months Success Everyone (almost everyone) has come home providing comprehensive services in area Those that have pan regional needs may be in a setting meeting their needs even if out of area Everyone is being cared for by a dedicated Forensic Community Team Patients and family satisfaction has improved, travel distance reduced and needs are met Outcome orientated, evidence based whole care pathway embedded as the normal practice. It s a sustainable and affordable system.
NEW CARE MODELS South London Forensic Partnership Dr. Mari Harty Clinical Director
Key features Partnership is jointly lead by NHS England Commissioning (NHSE), Oxleas NHS FT, South London and Maudsley NHS FT and South West London & St Georges NHS Trust. Current population 3.2million 91 different nationalities and communities 200 or more languages 530,000 South Londoners experience clinical levels of mental ill health in any one year Forensic Activity About 450 patients (NHSE list) Estimated expenditure Circa 75m (inc: circa 30m OOA) Circa 190 Patients OOA 160 across 7 private providers 30 in 8 other NHS provider 12 Clinical Commissioning Groups 2 STPs South East and South West London
Population 3.2million
New Care Models Components SINGLE POINT OF ACCESS: Developing a new single South London point of referral, assessment and triage with a new clinical case management offer across the whole pathway with linked budgetary responsibility SPECIALISATION: Developing specialism not every trust providing the same services. Take a fresh look at our estate development and if appropriate prepare and share recommendations for redevelopment and rationalisation across partnership SHIFTING CARE: Investing in re ablement shifting care to a strong step down, rehab and community offer, integrated with housing and welfare providers to ensure safe recovery on transition from inpatient provision Accountable Care COMMISSIONING Directorate (The Hub) End to end clinical case management knowing where all our patients are at anyone time and what advanced plans are in place for their care and recovery Using our benchmarking and patient informatics Applying buying skills to source and deliver new products and services for patients Maintaining a live database s using this as a quality management tool to ensure that at any time patients are on the agreed standardised pathways, minimising unwarranted variation but protecting personalised care planning Setting up and agreeing contracts across the whole supply chain to ensure patient flow is maintained PATHWAY STANDARDISATION advancing quality, by building on our existing approaches to Quality Improvement across an agreed series of patient pathways. Our objective is to improve throughput (flow) and patient outcomes, actively monitoring protocol compliance.
Provider Flows (Men) Prison Gatekeeping (new referrals only) Slow Stream Core Gatekeeping SPoA (Known referrals or referrals from other sources) Fast Stream Specialisms Community/Step down Out of Area
NHS England Contract Variation Budget OXLEAS South London MH Partnership Management Agreement A d m i n I S A t I Performance o n CSM Managing Director Clinical Director Finance Director Contracts Manager Bed Management CSM OAT Clinical Lead Out of Area Assessment Team QI Associate Director of Standards Interface CM Accounts Manager/s CSM Data Analyst/s The Hub CSM Clinical Director Whole Women s Pathway AP RP SP CP Clinical Director Men s Acute Pathway (AP) Clinical Director Men s Assertive Rehab Pathway (RP) PROVISION Clinical Director Men s Specialism Pathways (SP) Clinical Director Men s Community Pathways (CP)
Governance & Clinical Leadership SLaM Oxleas SWLstG South London Mental Health Partnership FORENSIC Back Office OTHER Operational Board IMPLEMENTATION Approvals, Planning and Delivery Joint Clinical Director and Service Director Leadership Group E N A B L E R S Clinical Strategy (Inc.: Centres of Excellence QI Access and Standardisation The Hub Care Budget Services (Inc. OATs Women's Pathway Specialisms Single Point of Access Fast Stream (acute) Slow Stream (assertive rehab) Community/Step down Men s Pathway Prison Triage LD Pathway?
PROGRESS 1 Shadow period 0ctober 16 March 17 2 year pilot live from 1 st April 17 Operational Board chaired by Oxleas CEO Hub Management Team established Out of Area (OOA) MDT established Patient database Transfer of budget for IS patients to Partnership July 2017 Patients allocated to pathways Pathways clinical leads identified
PROGRESS 2 Progress census date 1 st March 209 patients in independent sector (SWLSTG 72; Oxleas 44; SLAM 93) includes 50 LD patients 267 beds in partnership (SWLSTG 52; Oxleas 109; SLAM 106) 67 cases in Independent sector assessed by OOA team 11 patients repatriated to date Partnership working for new admissions ( prison, PICU referrals) 3 patients placed in independent sector Pathway models being developed
Women s pathway Single point of referrals (Oxleas) Fortnightly multidisciplinary referrals and bed management meeting Single operational policy agreed Partnership working peer case discussion Review of Independent Sector patients repatriations conducted Full use of partnership beds Reduced use of out of area Independent Sector
Emerging themes Large cohort of patients in assertive rehabilitation pathway Demand for locked rehabilitation step down provision Interface with PICU, prisons Implications for Clinical Commissioning Groups (CCGs)
We will see improved outcomes through proactive community provision to reduce dependence on inpatient care