Positive practice Service Background and need it addressed Resources Impact and challenges Sustainability Mental health liaison services in the acute trust – A&E and across wards – dementia and AOWA The core service has been established for at least 8 years in the RUH. It has been expanded over that time to include older adults and is now joint funded with Wiltshire CCG. In addition the Intensive team in provides overnight cover (for last two years) Enabled joint development of risk matrix for mental health clients. Provided training for general staff NHS funding (PCT/CCG) into the specialist mental health Consultant nurse, psychiatrist, psychiatric nurses, admin. working with A&E consultants. Impact: Has enabled the earlier identification and treatment of people with mental health problems and supported diagnosis and care of older clients with dementia (with or without co-morbidity) as well as supporting discharge. Increased staff skills and understanding. Challenges: the consistent implementation of processes with aligned capacity to provide care within the A&E 4 hour target. Managing risk (and hospital capacity/flow) for those clients needing a MH Act assessment – especially out of hours. Provision of a suitable environment for those clients waiting for a MH Act assessment. Continued lack of clarity nationally about how much of this function should be supported through the acute tariff. Therefore growth of service to meet demand reliant upon mental health funding stream only. Needs national clarification. Future work around Parity of Esteem will require workforce initiatives to increase sets of staff. Recruitment of staff will affect sustainability. Reciprocal arrangement for medical liaison into mental health facilities needs to be developed for true sustainability and parity of esteem.
Community Hospital and Care Home liaison service Initially started with psychiatrist input into specialist dementia care home - a “ward round” every 6 weeks with GP (providing weekly “ward rounds” under LES). Supported with close relationship with MH team leader (LA social worker as part of integrated MH team). Further development 4 years ago to increase support into the community sector – especially to improve the care of older people with dementia in order to prevent crisis and hospital admission. Dementia challenge fund monies supported programme of training into Care Home sector on dementia and dementia care. Psychiatrist. Team leader (SW qualified) 2 Bd 6 nurses. Recurring CCG funding. Dementia challenge money used for training element currently annual. Increased capacity in the care home sector to manage complex clients thereby preventing admission into or delay in hospital beds. Prevented older adults being admitted to hospital in crisis. Enabled more people to end their lives in the care home. Increased awareness in the care home sector of dementia and how to care for people. Improved discharge form community hospitals. This is built into the block contract arrangements for specialist mental health services. More support put into this service by targeted resilience monies (see action plan) for people with a secondary diagnosis of dementia with the aim of employing RGNs and social workers into the team. Care Home Local Enhanced Service - GP Provision of GP support into “attached” care in order to support health, manage conditions, prevent admission to hospital in a crisis and enable a good death Funding provided to GP practices by CCG on a fixed term basis currently Recurrent funding agreed for three years from April 2015. Improved quality and continuity of care and interventions. Prevented people being admitted to A&E. Enabled people to die in the ‘home’ where they are residing. Funding agreed for years from April 2015.
Roll out the use of tool in the emergency department Managing capacity within RUH and in community alcohol treatment. The team is respected for expertise by RUH staff. Primary Care Mental Health liaison service To build upon the recognition that the majority of people who experience mental health difficulties will have their needs met within primary care and not within secondary specialist mental health services. PCLS Teams set up with a view to improve mental health for individuals and society as a whole and work collaboratively with others to aim to improving care in the six outcomes identified within DoH’s publication, No Health Without Mental Health” (2011). These are: •More people will have good mental health. Psychiatrist Team leader Band 6 mental health professionals Impact: Improved access for professional advice and support for on a spectrum of mental health issues. Improved communication between mental health, third sector and statutory services Inclusion of mental health professionals within primary care pathways, e.g. community ward rounds to enable timely interventions/ identify that potential mental health issue are considered at the same Review and redesign of wider mental health “access service” to streamline process to ensure that right interventions are delivered in a timely manner
•More people with mental health problems will recover. •More people with mental health problems will have good physical health. •More people will have a positive experience of care and support. •Fewer people will suffer avoidable harm. people will experience stigma and discrimination. Team work closely with other health, social care providers and third sector. time as physical health issues (parity of esteem) Challenges: Prescribing accountabilities Adaptation of the model from a primarily GP referral based system to an open access model. Delivering sustainable service delivery within an open access model Court Assessment and Referral Service (CARS) team Service in situ since 2007 but expanded considerably in 2014 in the context of Lord Bradley’s report. Function is to assess the mental health and learning disability needs of those coming into contact with the criminal justice system across Avon and Wiltshire, regardless of age, with a view to diverting those appropriate for diversion, out of the criminal justice system and liaising with the criminal justice system (assuming capacitated client Across the whole service, that includes B&NES: Team leader. Administration. 2 children and young people nurses band 6. 1 learning disability nurse band 6. 6 mental health nurses band 6 Impact: Improved and timelier outcomes for people with mental health and learning disability needs involved in the criminal justice system regardless of age. Reduction in clients being remanded into custody for want of appropriate diversion. Reduction in need for Commissioned by specialist commissioning (NHS England). Funding also gratefully received from B&NES CCG NHS England contract due for review 2017.
Standard Operating Procedure for Mental Health A&E Liaison response There was a need to ensure that people receive mental health assessments within the urgent care quality standards of four hours in the ED department. As it was also crucial that the Royal College of Psychiatrists Guidance on Best Practice Liaison Services was followed, our local services agreed a SOP. SOP to be embedded. Impact This has a positive impact in of ensuring a shared understanding of protocol and practice. Review in 12 months.
Section 136 protocol facility and funding There was insufficient capacity for assessments under 136. The Avon Commissioners and all associated provider organisations agreed a shared protocol and the CCGs provided increased funding to operate a 4 bedded assessment suite based in Southmead. 135k for 0.67% occupied bed base Challenges The suite is receiving many clients who are assessed as having no mental health problems where there is no further follow up and a proportion of these clients are intoxicated. (Please see action plan). Positively the numbers of assessments in police cells has reduced. Recurrent funding.
136 Diversion Work has recently in developing a similar agreement to that held in Wiltshire between the local police force and CAMHS. This is a formal agreement whereby OHFT CAMHS provide front line officers with direct contact to a Duty Clinician within CAMHS. This is available both in and out of hours whereby officers can contact the duty person for advice when a young person is picked up in a state of distress and presenting with apparent mental health issues. Following discussion on the phone an appropriate course of action between the Mental Health clinician and the officer can be agreed. This may be a recommendation to take the young person to a safe place for a mental health assessment which the Duty person can arrange or may require a Place of Safety whereby a Mental Health Act Assessment will take place (if it is thought the young person needs to be detained for mental health reasons). Senior Mental Health Practitioners, Consultant Child and Adolescent Psychiatrist, Team Manager, Service Managers, Police officers The impact of using the protocol in a neighbouring area has been to provide a supported service to the police force in the management of young people with mental health issues in an effective and appropriate way and has seen a significant reduction in the number of Section 136s in the county. It is anticipated that a similar working protocol being agreed in the Banes area will also support police officers and help to reduce the inappropriate use of S136 with those young people under the age of 18.
A further recent development is a Standard Operating Procedure agreement between AWP, police, CAMHS and other agencies which sets out terms of provision for young people under 18 and under 16 to enable access to the 136 facilities provided at Southmead Hospital in Bristol. This will enable young people access to a place of safety with clear protocols about their care for the duration of their stay to ensure appropriate and effective interventions are available. The impact will be to enable young people appropriate and safe care when they are detained on a S136 in the community with facilities that are fit for purpose. The challenge will be to ensure adequate and appropriate resources are readily available as required and managing risk and flow for those clients needing a MH Act assessment
Action plan Section 1 - Commissioning to allow earlier intervention and responsive crisis services. To include: A: Matching local need and demand with a suitable range of services; B: Improving mental health crisis services; C: Ensuring the right numbers of high quality staff; D: Improved partnership working in Scheme Includes Action Timescales Led by Outcomes Mental health commissioning – widen organisational engagement/involvement structures A,B,C,D a) Ensure that the homeless healthcare team is involved in the mental health and wellbeing forum as well as the offenders mental health meetings. b) In addition to the local SRG meeting ensure that local contacts are made with SWAST for the development of services. This rep will be attached to the crisis concordat task group. From January 2015. Complete AM The homeless healthcare team are more influential in shaping commissioning for this homeless and marginally housed client group who often have unstable and/or untreated mental health needs who can often slip into crisis That the links to the front line ambulance staff in terms of understanding and influencing local mental health service commissioning are strengthened.
Intensive Team – AWP Review the notion of a “virtual ward” with a capacity of 20 people in. A, B, C Completion of review of role and function of intensive service within context of service provision and delivery 6 months - review to inception. Update 15/05/2015: Waiting to recruit a Band 6 worker. Update 30/09/2015: Band 6 vacancy is changing to a police and homeless liaison post. Update 20/10/2015: At present the capacity of team to provide “virtual ward” is approx. 17-25 people. Currently In the process of recruiting 2 days per week psychology dedicated to intensive. Also recruiting to 2 Wte band 6 equivalents. Providing care to from named individuals is challenging in the context of reduced staffing levels. We recently recruited to a band 5 rotational post. To develop JE Increase capacity of intensive team to deliver home treatment in the context of a virtual ward Improve the quality of home treatment delivered To develop care teams to enable service users to have care from named individuals. To increase access to psychological therapeutic intervention in home treatment To review point of access to home treatment with a view to earlier intervention
Dual Diagnosis Support To provide a dedicated mental health nurse giving OOH advice and support to Police, Ambulance service and to 3rd sector organisations with focus on dual diagnosis and transitions. This is an ageless service which will include the Early Intervention service, Psychiatric Liaison and Intensive Services A, D Recruitment of Band 6 Nurse with substance misuse expertise to provide OOH advice and support to the Police, Ambulance and B&NES Street Homeless project (run by Julian House) also provide assistance with referrals on appropriate pathways to other services. Recruitment – January/February 2015 Training Implementation: February/March 2015 Full implementation and review of service: March 2015 onwards Update 15/05/2015: Unsuccessful in targeted resilience money bid. Continuing to try and get funding. Researching and investigating how to evidence that service will pay for itself. Update 30/09/2015: Band 6 Intensive team vacancy being converted into a police and homeless liaison post within contracted budget as part of a local model. Update 29/04/16: Police and Homeless liaison role has strengthened relationships between organisations and more JE Increase number of contact with services related to substance misuse. Increased confidence in providers with providing advice and assisting with/ managing issues regarding dual diagnosis. Longer term reduction in the presentation of services users to ED/ 136 suites. Reduction in attendance times for ambulance and police services for service users with mental health problems Only people with mental health problems are detained in 136 suites
The pilot post was working well and has been extended for a year. The previous post holder has left and we are currently recruiting for a replacement. The healthcare assistant training is completed. The liaison services are currently rolling out Dementia training for healthcare assistants. Support for the Police through supervision B, D Understand and then replicate a South Gloucestershire initiative to provide mental health case supervision to the police. This would be in line with our current dual diagnosis supervision support provided by AWP to community services. 2015/16 Update 15/05/2015: Considering having mental health champions within the Police service and this would allow for cascade training or offering a point of contact for advice Update 30/09/2015: AWP are looking at providing police training on rotation. There are 5 teams that can be offered training every 10 weeks. Meeting to take CS/AM/Paul Bunt Increased confidence and competence in police to manage people presenting with mental health problems in an appropriate way. (We will enter into discussions about the possibilities of doing this for ambulance staff, although recognise their capacity to attend training is stretched).
Personality disorder community support (AWP – UJ ) A Investment bid to be submitted to CCG by December 1st Once approved training to be completed as per timescales opposite Ensure that, given the high prevalence of Borderline and other Personality Disorders within the homeless population, the Homeless Health Care Team are involved. (Subject to CCG funding approval for scheme) December 2014 on earlier if funds are available STEPPs training will be available January 2015. The First course to start February 2015. Update 15/05/2015: First cohort have started STEPPs programme. All going ahead although not all materials have been delivered by training body. Update 30/09/15: Delivery of the programme continuing. All materials have now been delivered to deliver training. Update 29/04/2016: Programme continues to be delivered on a quarterly basis with all courses being fully attended. Ursula James Increased liaison with and children’s services for young people therefore earlier intervention. Increased awareness of other support the community for service users. Increased confidence in staff across organisations in supporting people with personality disorder. Reduction of repeat presentation within primary care services. Improving of resilience through increasing initiatives in the community A Implement the Wellbeing College in B&NES. January 2015-2017 Update 15/05/2015: All going ahead. 95 different learning opportunities on offer. Update 10/10/15: Continuation of an extra year to 2017 agreed in order to AM/BW Increased ability of the B&NES population to manage their long term conditions as well as their mental health at an earlier stage than is currently possible and
AMPH service B Review arrangements for out of hours AMHP provision and ensure this is effective and meets need As we have combined the OOH services with children’s safeguarding and across 4 counties we need to, in consultation with the police and mental health providers, ensure that AMHPs can be available within locally agreed response times. Explore the potential for better integration of AMHP and EDT services with out of hours crisis provision of health and other partners. 2015/16 Update 30/09/2015: All 4 counties are looking at OOH AMPH provision. At the moment are 3 AMPH members of staff working until 1am. The team are prioritising their response as best as possible. The team find that their options are very limited OOH as there are very few services that are open or professionals that are available. There is a growing culture of working together. The team are also working with the police on individuals and identifying any mental health issues. Update 01/06/2016: Service level agreement for Emergency duty service has been agreed by all four Local Authorities. There are no changes to our of hours AMHP provision from EDT. Lack of resources out of TL/AM/LH A more responsive out of hours emergency duty service so that coverage over 24 hours is equitable and efficient.
addressing 20-25 people that attend ED once a month on average. Explore the service provided by street marshals/ street pastors/ fast ambulance. Discuss potential for bidding to expand service. Investigate numbers for s136 Alcohol related ED attendance = ±15% of all ED attendances. Investigate number of those intoxicated. (Piece of work being done by Wiltshire to estimate numbers). and training can be provided. is a ‘damp’ house provision with 4 beds to help clients who have relapsed. Review ability to provide S136 suite in area in the longer term A into re-design for in-patient beds. December 2014 AM/BB-J Include in impact assessment process December 2014 Present to Wellbeing PDS as part of impact January 2015
assessment and proposal paper Define next steps if approval gained. Consider whether this can be part of a wider assessment suite that could also work with children and young people. Update 15/05/2015: work on-going looking into having a s136 suite in B&NES and addressing issues with access for under 18s and under 16s. Instigate response service in Specialist mental health services D, B Produce paper analysing opportunities within existing service configuration- paper in draft format at this time Currently we are near to completing the review of access service function is likely to separate assessment and home treatment functions of intensive and more closely align the assessment functions across PCLS, intensive, with some linking to the intensive January 2015 Update 15/05/2015: Paper has been completed and this is now being piloted with PCLS. This will be reviewed in June 2015 with the intention of including the intensive team as well. Update 30/09/2015: Rapid access is underway and is no longer a pilot. Improvements to be made to joint working between PCLS and Recovery teams. Update 29/04/2016: Rapid access is now JE The model is potentially linked to street triage investment bid Patient receives specialist service response at the point of presentation rather than needing further assessment (unless clinically indicated that further specialist assessment needed). Greater partnership will reduce multiple hand-offs and improve patient experience. Holistic approach taken to need therefore improvement in joint care planning and outcomes.
Section 5 - Recovery and staying well / preventing future crisis. To include: A: Joint planning for prevention of crises Scheme Includes Action Timescales Led by Outcomes Liaison for older adults. A Funding approved. Negotiation/ exploration of roles with Sirona. Development of job description for RN RGN. November / December Liaison with partner organisations regarding model implementation. December/January: Recruitment February onwards: Full implementation and review/evaluation Update 15/05/2015: Recurring funds received. Update 29/04/2016: Funding was fixed term and has now come to an end. Some aspects of this role have been developed and incorporated into the pilot project post with the RUH. JE/KG Parity of esteem for people with physical and mental health problems. More people treated by services with which they are familiar. Reduced admission to hospitals. Working in collaboration with SWASFT Plan to develop a facility to feedback into primary care and secondary mental health services with Update 15/05/2015: Looking at how to link in EPCR with other systems. David Partlow Often patients will present and not be conveyed, this may be an early indication of a degree of instability which could be managed earlier. The ability to
appropriate patient contacts made by SWASFT. This will involve presentation on the SWASFT electronic clinical record due to be rolled out in B&NES in the summer of 2015. Implementation date: Autumn 2015 feedback into services will allow for continuity and a higher level of care. Further develop shared patient notes to join up GP, Acute, ambulance and MH services A Special patient project in moving forward and mental health is part of that project. Again, this could link in the future to SWASFT work with the enhanced summary care record and their ability to access this via the SWASFT electronic record. Already used in some instances. 2015-16 Update 10/10/15: Next phase of work on special notes for people with mental health problems has begun with Katia Montella leading it in B&NES AM/CP/DP Ensure that all services have access to appropriate care for people who use services in an emergency or crisis situation Implement social prescribing project to prevent escalation of non-medical conditions The aim of this service is to redirect suitable patients away from the NHS and towards opportunities in the local community The new commissioned service will start on 1 Jan 2015 and will aim to begin effective delivery by April 1st 2015. The commission initially is for 27 months AM/BW Be responsive in addressing health, practical and social issues that may negatively impact on the health and wellbeing of people who
people with mental health problems for commissioners, providers, service users and carers to meet together and discuss issues and future developments. Eg, the Wellbeing College specification was developed by Forum members. The Social Prescribing Service (above) and Sirona Community Links Service (social prescribing element) both link and support people into a wide range of local funded and unfunded groups, activities & services in order to address their holistic needs. (Eg unfunded groups like Bath City Farm and Greenlinks). New Hope (service user group) produce a 'Hope Guide' commissioners' intention at that point to put out to tender an overarching specification to provide a flexible and responsive approach to mental health and wellbeing support in the community. Social isolation will be an important element of this. A Wellbeing College, if demonstrated to be successful, could be a central part of this overarching specification. It is currently being considered as to whether a Wellbeing College would take on a role as a commissioning body in terms of purchasing and developing early intervention, prevention, and self management courses and activities from 3rd party organisations. improve health and wellbeing. To support people to their conditions To reduce social isolation within an appropriate supported environment. To and make use of shared experience in helping people to support themselves and manage their long term conditions. To increase the range of people’s skills and interests and to support them to develop peer-led groups which meet those interests To train and support people to become peer mentors to provide a positive experience for themselves and in helping others. To provide a wide range of information and support to enable people to take up opportunities which
detailing opportunities that people can take up. To further develop a multi-organisational approach in supporting people with mental health needs, service specifications were revised in 2014. A Building Bridges Forum was established, supporting services to work together, and meet to share views and experiences, discuss issues and developments. Current members include - Sirona Community Links -supporting networks in the community, to build resilience and help people live independently, with a strong social prescribing element. This aspect will be consulted on during 2015. Wide ranging discussions will take place during 2015 with all interested parties to develop an agreed and effective specification for the proposed overarching commission. The Wellbeing College and such developments as the Building Bridges Forum can be viewed as forerunners of the overarching commission, providing an opportunity in to gather evidence, experience and best practice in order to effectively support people and offer social interaction opportunities in the community. Update October 2015: increase their wellbeing and reduce social isolation
Assess elements of preventative that can be delivered through Wellbeing College – 2 year pilot. A Independent evaluation taking into account both health and social outcomes – incorporating 5 ways to wellbeing, e.g. into more health based outcomes. College will also assess courses themselves for style, content and effectiveness, getting feedback from participants. Evaluation will inform a business plan for the format of any future Wellbeing College to be commissioned in 2016. Link with social prescribing and social options into the community support. The college is a 2 year (2014-2016) with an independent evaluation spanning approximately 12 months. The college monitoring will take place over full 2 year period. Update October 2015: The Wellbeing College contract is being extended for 1 year to allow developments to take place and more effectively evaluate the model. All WC providers/LA/PH/CCG. People to self-manage their long term conditions and through peer support, enable them to share experiences and solutions and support. To assess whether the educative, short term intervention approach to self-management enables people to avoid accessing higher level services - GPs, acute, MH services in crisis To assess whether early intervention, through mainstreaming and appealing to the whole community, reduces the need for people to take up services subsequently.
Wellbeing House A To provide short term respite beds within a safe environment and provide therapeutic interventions throughout their stay to prevent crisis and help people to better manage environments and situations that may cause stress and lead to crisis. To be in operation by Summer 2015. 1 year pilot. Update 30/09/2015: Wellbeing House is now open for referrals. Feedback on the house has been positive so far. Those in the house have received meaningful interventions. A holistic practitioner is working at the house and using a wellbeing options tool that uses the 5 Ways to Wellbeing. Also linking in with outside agencies, looking at what client’s would like to do and supporting their journey. Looking at how to maintain the service in the longer term. PW/Sirona To provide short term respite to individuals, enabling them to be removed from stressful environments as a way of preventing people from reaching crisis.