1. Purpose of this paper Mental Health URGENT CARE AND ASSESSMENT Business Case. CCG Summary paper This paper sets out the rationale for investment in new more effective urgent care pathways for people in mental health crisis which will improve the quality of care and outcomes for patients and value for the local health and social care economy. It represents the first stage in transforming the way in which mental health services are delivered locally. 2. Context and background National guidance and best practice Nowhere is this gap between physical and mental health services more obvious than for people experiencing a mental health crisis. People in physical health crisis have a clear path to care and support, while those in a mental health crisis have to navigate multiple entry points and hand offs which delays the start of treatment and support. When people experience, or are close to experiencing, a mental health crisis, there should be services available to provide urgent help and care at short notice. This includes advice from telephone helplines, assessment by a mental health professional, intensive support at home or urgent admission to hospital. The recent Care Quality Commission report Right here right now i found that far too many people in crisis have poor experiences due to service responses that fail to meet their needs and lack basic respect, warmth and compassion. The CQC found that there was a clear need for better 24 hour support and access to ensure that people receive care straight away rather than go to A&E departments or police cells 1. HM Government s Mental Health Crisis Care Concordat. signed by 22 national agencies and government departments who have a stake in the mental health urgent care pathway, sets out the principles and conditions to consistently improve the entire acute mental health pathway, including access to support, advice and assessment services, through prevention and self-help, to the role of primary and secondary care in providing a high quality, timely and effective crisis service across the whole system, including importantly criminal justice agencies. The Concordat describes exactly how local commissioners, working with partners, can make sure that people experiencing a mental health crisis get as good a response from an emergency service as people in need of urgent and emergency care for physical health conditions 2. NWL CCGs and their partners across health, social care, the third sector and the police were amongst the first in the country to develop and submit a signed local crisis declaration and action plan. The new model of urgent care and assessment summarized in this paper is an important step forward in delivering the local crisis concordat action plan. 3. North West London Like Minded Mental Health and Wellbeing Strategy 1 Care Quality Commission. Right here Right now. June 2015 2 HM Government, MIND. Mental Health Crisis Concordat. Feb 2014
NWL Collaboration of CCGs have a significant history of working together to deliver innovation and improvement in mental health. The Like Minded Strategy builds on this success and the lessons learned. People with episodes of severe mental illness, tell us they want to be treated as equal partners in their care, that they prefer to be treated in their own home, with seven day care and support for them and their families. They want holistic care that addresses their social, mental and physical health needs and yet people with serious mental illnesses die up to 20 years earlier as a result of poorer physical health and wellbeing and social outcomes such as employment and housing which are also significantly worse than for the general population. For people who need access to specialist mental health treatments, there is major variation in rates of early identification, timely access to treatment, access to the evidence based treatments that deliver the best outcomes 3. The Like Minded Strategy aims to develop partnerships to prevent mental ill health and promote mental wellbeing for people across North West London. When people have an emerging or existing mental illness we want to ensure earlier intervention and a reduction in the amount of time people spend in hospital through the co-production of integrated care and support in the community which focuses on people s needs and not their diagnosis. It is a major programme of transformation. The urgent care and assessment model, has been co-produced by people with lived experience of mental illness, clinicians, social care and the third sector and brings us a significant step closer to ensuring that everyone s mental and physical health is equally valued. It is the first stage of transformation across the whole system of delivery of current mental health services. People with a lived experience of long term mental health problems want the same things from life as everyone else friends, stable housing and a job and the ability to self-manage their illness. 4. Development of the local Urgent Care Model In order to provide 24/7/365 day a week and achieve the improvements in quality of care and service considerable work was undertaken across NWL to develop an agreed model of care in 2013. A clinically led Urgent Care Expert Reference Group was established jointly chaired by a local GP, Dr Beverley McDonald and DCI Daniel Thorpe, Metropolitan Police. The ERG defined a model whole system pathway and agreed the data set to inform a NWL wide demand mapping exercise. This work would inform urgent care business case development by CNWL Foundation Trust. The business case to include; Implementation of a Single Point of Access to adult mental health services across CCG areas to provide a central point for referrals and assessment; Extension of operational hours in home crisis/urgent assessment and initial crisis resolution service, operating 24 hours per day, 7 days per week, 365 days per year; Achievement of agreed performance trajectories for crisis/emergency, urgent and routine. The 2014/15 contract included a CQUIN which was put in place to support the development of the business case. Following the submission on 19 September 2014, CNWL received feedback via letter on 15 October 2014. 3 Carnall Farrar. Mental Health Outcomes NWL. May 2015
Subsequent progress in taking forward the business case or urgent care pathways was slow until March 2015 when it was reviewed again highlighting areas where further clarity was needed in order for commissioners to take a decision and those areas where the information provided was clear and complete. The results of the review were discussed with the Trust at a workshop on 20 th March and it was agreed that further financial, activity and benefits analysis and modelling would be undertaken by both Trusts. In particular the Trust was asked to produce a revised business case appendix containing the additional information and any amendments to proposed model or proposed resources (5-10 pages) including: a) A clear description of current and proposed model (current resources and capacity, current and proposed operating hours and flows) - Resources in the current baseline model (skills mix, numbers and capacity) - Assumptions on current and future flows across the pathway b) Estimate of potential impact - Activity (contacts / assessments / admissions / bed days) - Clear description of the clinical benefits of moving from current hours to future 24/7 service e.g. x number of patients get a response, y not having to go to A&E etc. - Potential financial benefit to the system as a whole This was produced and presented to commissioners on 18 th June 2015 by the Trust. The new model of care is summarised in the diagram below:
The table below outlines the key differences between the current model and the future model described above. Current model Future model 1. Trust defines whether or not the person is in 1. If you say it is a crisis we treat it as a crisis crisis 2. Multiple access points 2. Single point of access which will deal with your call and tell you to contact a different service. A handshake not a hand off. 3. Urgent care advice line from 17.00 to 9.00am 3. 24/7/365 Single point of access unable to arrange face to face contact other than redirection to A&E 4. Limited capacity to provide rapid response to 4. 24/7/365 response to crisis with the crisis out of hours and at weekends following standards: Emergency < 4hours Urgent < 24 hours Routine plus < 7 days Routine < 28 days Provided by a newly formed Home Treatment and Rapid Response Team 5. Home treatment team only available for 5. Home treatment rapid response available to patients already known to the service all referrals who require it. 6. Urgent advice line unable to book or change 6. Single point of access can book and change appointments 7. Onward referral from Assessment and Brief Treatment Teams can be lengthy or delayed appointments 7. Standardised triage and trusted assessments improves continuity of care and access to the right service. 5. Local Context Currently Hillingdon does not have a coherent Urgent Care Pathway or Single Point of Entry, there are multiple referral routes into secondary mental health services. This can result in a confusing experience for those seeking to refer someone, or those seeking support for themselves or relatives. The complexity in navigating such a disparate and confusing pathway inevitably leads to delays in patients being referred and/or seen. This can have a significant bearing on outcomes, particularly in the context of an emergency or urgent referral that requires a rapid response. Furthermore, there is only limited capacity to provide a rapid response out of hors and at weekends, with the Accident and Emergency Department often used as the default in lieu of available services. Consequently people in crisis may not be seen in a timely manner and their condition may deteriorate, hardening the crisis and reducing the chances of supporting them in lower intensity services in the community. Currently referrals can be made to the Assessment and Brief Treatment Team, home treatment Team, Early Intervention Service and Older Adults Home Treatment Service. There are approximately 3000 referrals per annum to these services in Hillingdon, of these 1% were classified as emergency, 38% urgent and 61% routine.
The Hillingdon Mental Health Transformation Board identified the development of a coherent urgent Care pathway as one of its key priorities for 2015/16 and this has been endorsed by the CCG Governing Body in May 2015. In addition the Mental Health Needs Assessment published in January 2015 noted that there appears to be a considerably higher rate of A&E attendances for mental health disorder (640.27 per 100,000) than the rest of the Thriving London Periphery cluster, nearly double that of the next highest CCG, and a key recommendation is that robust mitigation strategies should be put in place to improve crisis response. In addition GPs often report significant difficulties in navigating the current configuration of services and this impacts on other developments locally. For example there is some reluctance to embrace the Shifting Settings of Care initiative partly because GPs feel are likely to be difficulties in referring patients in crisis back to secondary care services in a timely manner. This proposal will clearly address this problem. 6. Benefits realisation The table below summarises the key benefits which will be realised from implementation of the new model of care: Benefit to patients Referrals will be consistently triaged and people will be given consistent advice; and where required be given a timely appointment and assessment People will have timely specialist assessment that meets new standards Continuity of care will be improved There will be a reduction in people presenting to A&E in mental health crisis People will be cared for in the least restrictive setting. Range of improvement In 2014/15 9600 referrals were accepted from the 14,500 referrals received across the five boroughs. Acceptance rates ranged from 50 80% With the future model there will be greater consistency in applying thresholds for care and support from secondary care. All calls to the SPA will be dealt with and patients will not be bounced Urgent and emergency assessments improve from 50% of people seen in < 24 hours to over 95% of people seen < 24 hours. Over 3000 more people have timely urgent assessment. Specialist routine assessments could improve from 50% of people seen in < 4 weeks to over 95% of people seen in < 4 weeks. Over 1500 people have timely routine assessment. All routine assessments will take place in CMHTs for the 2000 people requiring ongoing treatment. There will be no handoff and delay following assessment and initial treatment as there currently is with the ABT teams. Trusted assessments reduce bureaucracy and delays in accessing treatment and face to face contact time of staff will be increased from 25% to 50%. Reduction in A&E attendances for an urgent assessment for around 1000 patients will no longer be necessary with savings to the health system. Timely face to face assessment for people in crisis will reduce the depth and breadth of the problems that ensue and as a result the need for an inpatient stay.
There may be a reduction in bed days in an acute psychiatric setting of between 6000 and up to 12000 i.e. 5 10 % of the current bed base. 7. Finance Investment Hillingdon CCG currently invests 19,574,175 to CNWL Mental Health Trust. The Priority setting Paper approved by the Governing Body in May 2015 highlighted the need to develop the Urgent Care Pathway and noted that its development would require a Business Case outlining the service and financial implications. The Paper also highlighted the Parity of Esteem initiative which charges CCGs to be just as focussed on improving mental health as well as physical health, and that patients with mental health problems don t suffer inequalities either because of the mental health problem itself or because they don t get the best care for their physical health problems. There is a clear national commitment to ensuring that CCGs do not underinvest in mental health services in relation to their investments in physical healthcare. In Hillingdon, to achieve parity of investment in line with physical healthcare would require a 7% increase in investment in Mental Health Services ( 2.8m). The Trust has identified additional investment of 1.98m to support the implementation and full operation of the Home Treatment & Rapid Response Teams. This investment will enhance and develop the Home Treatment Teams into Home Treatment & Rapid Response Teams to provide a 24/7 response to people in crisis within 4/24 hours. Two extra staff per borough from 08.00-22.00hrs and two extra staff per inner and outer hub from 22.00-08.00hrs. For Hillingdon this would mean 357k full year effect and 232k part year effect In 2015/16 the Single Point of Access and Home Treatment & Rapid Response Teams will be fully operational from 1 October 2015. Start-up, ie recruitment, training and soft launch will take place from July September.
The table below outlines the new investment based on share of registered population across BHH and CL/WL CCGs, showing Part Year Effect for 2015/16 and Full Year Effect from 2016/17: Current Service Cost (HTT) Cost of proposed model (HTRRT) Urgent Care Model New Investment 1) registered population % shares BHH 2) registered population % shares CL/WL 2) Share of investment based on registered population shares CCG: 000 000 000 000 Brent 1,790 2,155 365 40% 434 Harrow 1,295 1,660 365 28% 304 Hillingdon 1,500 1,865 365 33% 357 Central London 2,473 2,917 444 46% 412 West London 1,890 2,334 444 54% 476 Total 8,948 10,931 1,983-1,983 16-17 recurrent / FYE 3) PYE (Oct 15 onwards) Nonrecurrent set up costs Total 15-16 FY/PY effect Brent 434 217 66 283 Harrow 304 152 46 198 Hillingdon 357 178 54 232 Central London 412 206 62 268 West London 476 238 72 310 Total 1,983 992 300 1,292 Notes: 1) Business Case references SPA set up from reconfigured community services realising 1.2m net efficiencies 2) CCG Registered Population is from PDS data from 17/05/2015 3) 16-17 onwards, deflator/growth to be applied Potential Savings The Trust propose the hypothesis based on current demand is that effective crisis response will in future years free up bed base, for example a 5-10% (approx. 30 beds) reduction in the Trust s bed base may release savings around 1.5 to 3m.
Further efficiencies would be realised through the implementation of the new pathway in itself, such as reduction in duplication of LPS assessments and reduced internal assessments. The development and implementation of the Single Point of Access and Home Treatment & Rapid Response Teams constitutes the Front End of the wider transformation opportunities that will be achieved through community redesign and rationalising the acute capacity. A programme of productivity improvements and transformation will be agreed during 2015/16 as part of the 3.1m non-recurring Transformation Incentive monies included in the 2015/16 Contract Agreement. Process redesign to include re-planning community redesign making feasible productivity gains without over-cutting frontline services would be a part of this; together with a plan for the rationalising of acute capacity, including what community teams and primary care will look like by end September 2015. 8. Risks Key risks and mitigating actions are listed below Risk All parts of the system need to be able to collaborate effectively to ensure that patients can flow through the system; poor relationships are likely to result in reduced performance. Improving performance requires a whole system approach to patient flow, matching capacity and demand and removing some of the visible and hidden backlogs along the patient system Provider fails to deliver the new model of care effectively Mitigation Implementation of the new model of care will be monitored at local partnership groups and learning will be shared across all CCG areas at the Like Minded Strategic Implementation and Evaluation Board The model of commissioning should be less transactional and focus more on outcomes and challenging providers to develop solutions Implementation of the urgent care model is the first step in a wider service redesign of the whole system of care including community services currently managing routine care and specialist services The project will be funded outside of the baseline and will be managed as a joint project collaboratively between the CCG and the Trust with issues and delays flagged early i Care Quality Commission. Right here Right now. June 2015