Multi-agency 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, 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 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 clients needing a MH Act assessment – especially out of hours. Provision of a suitable environment for 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 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 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.
Alcohol liaison team in the RUH Alcohol Liaison Service was set up at the Royal United Hospital (RUH) from April 2013. The aim of this integrated (3rd sector/specialist) service is to stem the rise in alcohol related hospital admissions by reducing bed days and frequency of attendance and admission of high impact users as well as increasing detection of alcohol misuse across the hospital and engaging people in treatment services. Funded by Clinical Commissioning Group (CCG) and Wiltshire Drug and Alcohol Team: 2 Alcohol Liaison Nurses 2 Recovery Workers 0.5 FTE Hepatology Nurse funded by RUH An additional community detoxification bed for the sole use by the RUH is being piloted for 12 months. Within the first 6 months of operation the bed has had 60% occupancy. Impact 4.4% drop in the Alcohol Specific Hospital Admissions from 765 in 12/13 to 731 in 13/14 63% reduction in client hospital spells 3 months post contact with the service compared to 3 months before contact 1,315 fewer bed day usage amongst the client group 3 months post contact with the service. £399,134 tariff savings from the reduction in client hospital spells An alcohol withdrawal protocol has been introduced and training provided to staff. This has led to a reported reduction in aggression amongst patients. Significant rise in number of people accessing treatment. Challenges Recurrent CCG funding is in place. Sustainability more dependent on widening the preventative initiatives available to us and thinking nationally about how to manage the market.
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
The large geographical area we cover and being able to consistently provide practitioners often at short notice given PACE timeframes. To meet the Lord Bradley Spec the Team has been required to make a significant number of developments over a short period of time although the team is now fully compliant with the spec and so can now consolidate. Sometimes the prompt identification of Psychiatric beds for those detained under the mental health act while in police / court custody A potential challenge maybe working out how street triage and CARS interface in a way that ensures our criminal justice partners get a
clear and consistent message Julian Homeless Hospital Discharge Service, The JH service will be working with people who are likely to have and potentially crisis MH needs in addition to current physical health needs. Will work alongside the Liaison Teams (alcohol, A&E and Primary Care) Funded by the local authority Challenges are to ensure the service is well integrated into local provision. Funded on a 3- year basis Gypsy and Traveller Outreach and Engagement Pilot Service Pilot to find out the best ways of engaging with this client group – which include high numbers of “boaters” – in order that they can design service responses, the outcomes they want from services and how to ensure good out of hours access CCG funded To be determined with service users. Pilot project for 17 months until April 2016
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.
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 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.
Production by service users 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 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 Out Of Hours Service. CAMHS have a 7 day a week 24 hours a day service. Out of hours a Senior Mental Health Practitioner and Consultant Child and Adolescent Psychiatrist are available to offer advice to professionals who have urgent concerns about a child or young person’s mental health. Where necessary mental health assessments can be carried out in a place of safety. Senior Mental Health Practitioners, Consultant Child and Adolescent Psychiatrist, Team Manager, Service Managers, Directors. Professionals have access to mental health advice 24 hours a day ensuring that young people’s mental health needs are appropriately addressed.
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 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
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 teams to from named individuals is challenging in the context of reduced staffing levels. We recently recruited to a band 5 rotational 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 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: 2015 Full implementation and review of service: 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. 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. 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 Development of workforce in RUH C, D A sub group of the RUH nursing workforce group is meeting to discuss training and skill sharing January 2015 onwards Also optimising care for physical needs of patients in Sycamore and Ward 4 without having to ML/RR Increased confidence in physical healthcare staffs’ ability to manage mental health problems and vice versa.
Personality disorder community support (AWP – UJ ) A Investment bid to be submitted to CCG by December 1st Once approved staff 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. Ursula James Increased liaison with CAMHS 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 level of resilience through increasing initiatives in the community A Implement the Wellbeing College pilot 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 evaluate effectiveness. Project now linked to social prescribing initiative 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 before people need to use health services.
(local) and data integration project and funded by Innovate UK Mental health support in perinatal pathway B Improve the perinatal pathway Update 30/09/2015: Looking at developing the perinatal pathway to include mental health support. Still awaiting details of funding to support. Referrals to be accepted from midwives. Consideration to be given to how the pathway will look in a crisis situation and where would a crisis occur? To align with pathway developed in Wiltshire as shared services. AWP Improved services for women receiving perinatal services and support. CAMHS A, B Improve services for children and young people experiencing mental health problems. Update 30/09/2015: There is national funding available for CAMHS transformation. A ring-fenced proportion of this is to be spent on eating disorders and the rest is available for spending on other areas. Funding will be provided for 5 years. B&NES has a higher incidence of eating disorders than in neighbouring areas. Looking to develop both preventative and specialist work – including supporting children to eat in their own homes. Service will provide early intervention, including giving better advice to GPs and school education. Looking into joint commissioning a service with Swindon and Wiltshire. Margaret Fairbairn Improved services in line with national expectations. Liaison and crisis services in B&NES able to provide appropriately timed and high quality response. Improve early intervention and specialist mental health approaches in order to prevent or smooth out transition into adult services where able.
include 111 providers implementing control room triage. Also found that activity and need with s136 admissions, ED admissions and 111 calls in relation to mental health, is in OOH during weekdays. At the moment, most services are following the GP working pattern (opening 9-5pm). Rotas are being looked at by ED staff to reflect need. Services have been encouraged to think about changing their hours of working in accordance with service need. 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. We want to continue the DTOC review and action plan and December/Jan 2014-15 Update 15/05/2015: Improved flow through system though there are still issues with Ward 4, timescales for moving to community placements, patients being transferred out of area and placements for children and young people. AM/BB-J/ML/DC Improve the experience of people with dementia and mental health problems in both mainstream and mental health urgent care pathways. Reduce the number of delayed transfers of care. Reduce length of stay in
functions of intensive and more closely align the 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. Improvements to be made to joint working between PCLS and Recovery teams. and improve patient experience. Holistic approach taken to need therefore improvement in joint care planning and outcomes.
service users can apply to practice. 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 (adult)/ 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. JE/KG Parity of esteem for people with physical and mental health problems. More people treated by services with 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 appropriate patient Update 15/05/2015: Looking at how to link in EPCR with other systems. Implementation date: Autumn 2015 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 feedback into services will
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. 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 being 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 plans 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 which can support their needs. People 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 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.
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 identified by GPs as frequent attendees, or those identified where the involvement of the service may reduce future health service attendance. dependent on good outcomes and continued CCG funding. Update 15/05/2015: Service has now been implemented on a two year pilot. Update 20/10/15: uptake by GPs very positive. It is already clear that moving forward capacity will be an issue. Initially concentrating on high attenders at GP practices. Reduce the demand on costly health services and enable funds 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. Support the revised approach to addressing social isolation in people with mental health problems A On a general the Mental Health & Wellbeing Forum provides a opportunity for commissioners, providers, service monthly Service specifications were revised between April-July 2014, with commissions ending March 2016. It is the commissioners' intention at that point to AM, BW, Providers, community groups, service carers To develop networks of support for social interaction within the community, outside of services, in to improve health and wellbeing.
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 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 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.