forums that support delivery of services/review crisis concordat plan Forum name Membership Frequency Discussed Seen plan Commented Adult Mental Health and Learning Disability Offenders Forum AWP – Intensive team; CARS; Commissioners (CCG/LA/NHS England): MH, LD, substance misuse, health and justice (MH); Probation; Sirona – complex health needs/LD/adult autism services; Police; Bath MIND DHI (criminal justice/substance misuse); and Julian House (Criminal Justice and Housing) Quarterly Mental Health and Wellbeing Provider Forum Commissioners (CCG/LA) – MH; AWP – various; Sirona – various; St Mungos Broadway; Bath MIND; Rethink; Soundwell; New Hope (SU group); Keep Safe Keep sane (carers group); Creativity Works; Knightstone Housing; CAB; The Care Forum; Second Step; Julian House. Commentary provided by Homeless health care team even though they are not represented at this meeting. (see action plan) Bi-monthly Mental Health Care Pathways Group GP – St St James, Catherine Cottage AWP – Clinical Director, Managing Director, Head of Professions Commissioners (CCG/LA) – GP Lead and MH CSM Sirona; MH &W Forum - rep; Practice Manager - rep Bi-monthly Mental Health Collaborative meeting RUH – Director/Assistant Director of Nursing/LD Lead/ A&E consultant; CCG – Director of Nursing/MH SCM; AWP – Clinical Director/managing Director/Access and liaison services lead/Liaison team manager. Bi-monthly Crisis Concordat Task group AWP – Clinical Director/managing Director/Access and liaison services lead; RUH – A&E Consultant; Police; Commissioner (CCG/LA); AMPH Lead, SWAST clinical lead. Monthly
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 trust. Consultant nurse, psychiatrist, psychiatric nurses, admin. Joint 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 skill 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 Enhanced Service - GP Provision of GP support into “attached” care homes in order to support health, manage long-term 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 three years from April 2015.
Roll out the use of AUDIT tool in the emergency department Managing capacity within RUH and in community alcohol treatment. The team is respected for their 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. people will suffer avoidable harm. •Fewer 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 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 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.
consent) to inform that system of service users assessed needs and arrangements in place to meet those needs be that within or without of the criminal justice system. (We are currently working with SOMPAR to enable them to come up to Lord Bradley’s spec in Somerset also. I note some B&NES clients have been taken to Bridgwater super custody suite). 1 social worker band 6 7 mental health nurses band 5 1 OT band 5 1 social worker band 5 2 engagement workers band 4. mental health act transfers from prison. Criminal Justice system (we see people in police custody, we see voluntary attenders and see people in Courts) better informed and informed in a more cost effective and timely manner the mental health / learning disability needs of our clients (assuming capacitated consent). As AWP also provide the mental health and learning disability provision in the 5 prisons in our cluster, timely handovers of the needs of those coming into prison and a reduction in the need to re-triage those already screened out by CARS (unless presentation changes significantly once incarcerated). Challenges:
Mental Health adult of working age reablement team The Reablement service provides a pre and post crisis intervention – depending on where in the MH system service users are. It undertakes an initial assessment, develops a support plan and then implements the plan. The episode of support is normally completed within 6-8 weeks and the case is closed once the service user’s needs have been met and any onward signposting – i.e. to community networks or another provider – has been completed. Funded via Sirona’s main service contract Impacts: The service helps to prevent people escalating into acute clinical need. It also helps people who are recovering from an acute episode to reintegrate into the community. Challenges: In some cases support is required beyond the time-limited service – i.e. for more than 6-8 weeks. However this can be managed through signposting. There are also occasions when a client is registered with a GP but resident in another local authority area and so pathways of care can be complicated. The service has recently been redesigned (effective July 1) and so far it seems to be achieving its expected outcomes within the agreed timescales. Performance in relation to the redesign specification will be kept under review.
Respite beds pilot A respite house is being developed to offer short stays. The aim is to provide a therapeutic experience that will help people manage their mental health and keep them out of states of acute need. The respite pilot model will be developed in conjunction with the MH service teams to ensure there is a safe staffing model focused on supporting the individual pre or post crisis. Quality Innovation Productivity and Prevention (QIPP) investment funds. Impacts: The service will be one of the few of its kind in the country. Demand for it is expected to be high. to other services will be numerous. The scope for innovation is considerable. The therapeutic value of the service to the user should be substantial – which should result in reduced demand for other MH services. Challenges: The main challenge so far has been finding a suitable location for what is a sensitive service. However two viable options have now been identified. A further challenge may be the reception of the new service within its host community. The respite project is a pilot. Its continued funding is entirely dependent upon its performance during the pilot phase.
AMPH service LA recently agreed funding for increased AMHP staffing LA recently agreed funding for increased AMHP staffing. I team leader F/T; Ix Deputy F?T. All AMPHs rota-ed on during the week As above. Extra capacity is in line with national indicators Continued funding from the local authority. SWASFT – South West regional Mental Health Joint protocol The West Regional Mental Health Joint Protocol has been created and agreed with the 5 police forces that cover the South West region to allow for an agreed understanding with our emergency colleagues across the South West. The Mental Health Clinical Guideline is also attached. Challenges Integrating knowledge of this police/ambulance service agreement into practice. Review in 12 months.
Standard Operating Procedure for Mental Health A&E Liaison response times 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 terms of ensuring a shared understanding of protocol and practice. Review in 12 months.
Section 136 protocol facility and funding 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.
Work force development in the RUH – mental health training. The RUH and AWP recognise the need to increase competence and confidence in managing people’s mental health problems which has resulted in the training of emergency department staff, their development of a risk matrix and bespoke training for healthcare assistants across the hospital. Training was provided by the liaison team and for the HCAs gives skills for health accreditation. Delivered within the funded liaison service envelope. Impact Increased awareness and skills in managing mental health problems. Part of an on-going drive for workforce development (See action plan).
Production by service and community staff of the Hope Guide It was recognised that there was no single source of information on mental health services and points of contact. The service user and carer groups alongside community organisation have developed and distributed the Hope Guide which is updated quarterly. Funded via Local authority. The impact has been huge in terms of an increased awareness of what is available. Challenges The challenge is to keep it live and connected to other forms of information.
Oxford Health NHS Foundation Trust. CAMHS paediatric liaison service to the Royal United Hospital. All young people up to the age of 18 who present at the Royal United Hospital following an act of deliberate self-harm and who are admitted to either the Paediatric ward or the Observation Ward are assessed the following day by a clinician from the CAMHS Team. A full assessment of their mental health needs and mental state is undertaken and follow up assessment / intervention offered as appropriate to their needs. Where a child / young person does not live in BANES a referral on is made to the most appropriate agency to support the young person. This is in compliance with the RUH protocol. Liaison rota in place. Senior Mental Health Practitioner available each day to carry out assessment on the ward. Consultant Child and Adolescent Psychiatrist is available to offer consultation and joint assessment if needed All young people admitted to the RUH following DSH including alcohol / illicit drug poisoning are given a comprehensive mental health assessment and offered appropriate follow up / intervention. There are some times difficulties arranging follow up care when young people live outside the catchment area for Banes CAMH Services
136 Diversion Work has recently begun 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 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, 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 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
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. 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 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 A, D Recruitment of Band 6 with substance misuse expertise to provide OOH advice and support to the Police, Ambulance and B&NES Street Homeless project (run by Julian Recruitment – January/February 2015 Training Implementation: February/March 2015 Full implementation and review of service: March 2015 onwards JE Increase number of contact with services related to substance misuse. Increased confidence in local providers with providing advice and assisting with/ managing issues regarding dual diagnosis.
ageless service which will include the Early Intervention service, Psychiatric Liaison and Intensive Services House) also provide assistance with referrals on appropriate pathways to other services. Update 15/05/2015: continuing to try and get funding. Researching and investigating how to evidence that service will pay for itself. Longer term reduction in the presentation of services 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 Development of workforce in RUH C, D A sub group of the RUH nursing workforce group is meeting to discuss training and skill sharing opportunities with AWP. January 2015 onwards Also optimising care for physical needs of patients in Sycamore and Ward 4 without having to transfer to an acute setting. A consultant physician will be available from to call and help with making decisions on ML/RR Increased confidence in physical healthcare staffs’ ability to manage mental health problems and vice versa.
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. champions within the Police service and this would allow for cascade training or offering a point of contact for advice. way. (We will enter into discussions about the possibilities of doing this for ambulance staff, although recognise their capacity to attend training is stretched). Section 2 - Access to support before crisis To include: A: Improve access to support via primary care; B: Improve access to and experience of mental health services Scheme Includes Action Timescales Led by Outcomes
Scheme Includes Action Timescales Led by Outcomes Street Triage (AWP – JE) A, D, F Submit bid for investment to CCG as the request to NHS England was unsuccessful. Learn from the Devon Partnership/SWASFT Partnership initiative in order to improve practice. Continue work with other commissioners to ascertain whether a single AWP/ SWASFT initiative can be developed in the longer term. To include 111 providers 2015/16 depending on funding agreement. Update 15/05/2015: Did not get targeted resilience monies. Continuing to try and get funding. Researching and investigating how to evidence that service will pay for itself. AM/JE Links to rapid response service redesign. 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 hands-offs and improve patient experience. Holistic approach taken to need therefore improvement in joint care planning and outcomes. Improve urgent care pathway A, F, D Although local SOP in place there remains work to be done supporting discharge especially in terms of locating appropriate placements as well as mental health acute bed provision. December/Jan Update 15/05/2015: Improved flow through system though there are still issues with Ward 4, timescales for moving to community placements, patients AM/BB-J/ML/DC
assessment functions across PCLS, intensive, with some linking to the intensive hospital liaison interface. Meeting timetabled for December to agree on final model. Pathway might look something like this: Also work to commence in 2015 to explore if we can increase productivity of assessment functions of access service though a reduction of the “burden” of RiO system. Holistic approach to need therefore improvement in joint care planning and outcomes. Working in collaboration with SWASFT B, C, D SWASFT want to be engaged with work in relation to conveyance of PoS. Currently in operation as green 2 response time. SWASFT This needs to be assessed in light of SWASFT ability to respond to all green 2
Have committed to 30min response time for section 136 requests. In addition we need to discuss with SWASFT the numbers of private transport conveyances for patients detained under section of the Mental Health Act. Update 15/05/2015: David Partlow has been in contact with Liz Richards at AWP. Scoping exercise is being carried out to look at demand and develop a model. priorities in the face of capacity demands. Section 5 - Recovery and staying well / preventing future crisis. To include: A: 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 implementation. December/January: Recruitment February onwards: Full implementation and review/evaluation 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.
Update 15/05/2015: Recurring funds received. Working in collaboration with SWASFT Plan to develop a facility to feedback into primary care and secondary mental health services with 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. Update 15/05/2015: Looking at how to link in EPCR with other systems. Implementation date: Autumn 2015 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 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 notes 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 2015-16 AM/CP/DP
via the SWASFT electronic record. Already being used in some instances. 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 which can support their needs. People referred to the service may have mental health needs, long term conditions or other practical issues which affect their mental and physical wellbeing. This service will operate mainly within GP practices, as well as links to, e.g. A&E and Health visitors. Priority will be given to people who are 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 to 31 March 2017 and any extension is dependent on good outcomes and continued CCG funding. Update 15/05/2015: Service has now been implemented on a two year pilot. AM/BW Be responsive in addressing health, practical and social issues that may negatively impact on the health and wellbeing of people who frequently make use of local GP practices. Reduce the demand on costly health services and enable to be better targeted on people whose needs are purely clinical rather than practical or social. Improve the patient’s quality of life Encourage and enable people to better manage their conditions, take up of prescribed health related activities and access to mainstream services and community resources.
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' 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 monthly to share views and experiences, discuss issues and developments. 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. 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 can be viewed as forerunners of the overarching commission, providing an opportunity in 2014-16 to gather evidence, experience and best practice in order to 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 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 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 pilot (2014-2016) with an independent evaluation spanning approximately 12 months. The college monitoring will take place over full 2 year period. All WC providers/LA/PH/CCG. People to self-manage 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.