London mental health crisis commissioning manual - South London ...

London mental health crisis commissioning manual

October 2014

ACKNOWLEDGEMENTS The London Mental Health SCN would like to thank all stakeholders and partners for their time and commitment in assembling the crisis mental health commissioning manual. A special thank you goes to the SCN crisis team members particularly Dr Sylvia Tang, David Monk, Dr Rhiannon England and Glen Monks for their valuable contributions to the manual. Individuals have provided insight and supporting information for each of the twelve different areas. Dr Phil Moore and Dr Ian Walton offered their expertise around GP support and education, Dr Steven Reid helped to shape the Liaison Psychiatry section, Michael Doyle and Carole Kaplan assisted with single point of access. Chief Inspector Dan Thorpe kindly dedicated his time and efforts to help write the policing and section 136 section, providing data and existing protocols to help develop the commissioning standards. Michael Partridge also kindly added to the policing and AMHP sections. A particular thank you goes to Dr Seema Sukhwal for completing the extensive literature review work. Seema’s dedication and hard work has been crucial to the development of the clinical commissioning standards, providing the evidence base behind the recommendations. The team also acknowledges Dr Gurleen Bhatia for her support and assistance. The team acknowledges Jim Symington for helping the project team network and liaise with others especially other Concordat partners. This enabled the team to collect case studies and build wider relationships across England. The team are extremely grateful to those who have submitted case studies which are listed in the Directory. The case studies provide national and regional best practice, a resource useful for commissioners and others to reference and learn from. The third sector has played a central role in the development of the manual. The team are really appreciative for the input and advice provided by Antonia Borneo and Paula Reid from Rethink Mental Illness, Alison Cobb from Mind and Sarah Yiannoullou and Naomi James from NSUN. Mind hosted a service user consultation on the SCNs behalf which was chaired by Naomi Phillips and Helen Undy. This was designed to sense check the commissioning standards and capture service user view points on existing crisis mental health services. We would like to thank all those who took part in the consultation, for their time and help with finalising the standards. A huge thank you goes to Vanessa Brunning for pulling together all the case studies, organising the service user consultation session and her continued support throughout the project. Thanks to Andrew Turnbull, Mental Health, Dementia and Neuroscience SCN Lead and Helen O’Kelly, Mental Health, Dementia and Neuroscience SCN Assistant Lead who have kept the project stay focused and delivered on time. Finally, special thanks go to Stefanie Radford, Mental Health Senior Project Manager, whose tenacity and enthusiasm have spurred her to drive this piece of work and bring together this huge amount of information into a coherent whole.

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TABLE OF CONTENTS PREFACE

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EXECUTIVE SUMMARY

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INTRODUCTION Defining mental health crisis Challenges facing mental health crisis services

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COMMISSIONING MENTAL HEALTH Commissioning principles

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DEVELOPING THE STANDARDS Policy context Standardising crisis mental health

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ACCESS TO CRISIS CARE SUPPORT Area 1: Crisis telephone helplines 16 Area 2: Self-referral 20 Area 3: Third sector organisations 23 Area 4: GP support and shared learning 27 EMERGENCY AND URGENT ACCESS TO CRISIS CARE Area 5: Emergency departments 32 Area 6: Liaison psychiatry 37 Area 7: Mental Health Act assessments and AMHPs 41 Area 8: Section 136: Police and mental health professionals 44 QUALITY OF TREATMENT OF CRISIS CARE Area 9: Crisis housing 48 Area 10: Crisis resolution teams / Home treatment teams 51 RECOVERY AND STAYING WELL Area 11: Crisis care and recovery plans 55 Area 12: Integrated care 58 REFERENCES 60 APPENDIX A - Glossary

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APPENDIX B-Questionnaire responses London mental health CCG leads 73 London mental health trusts 75 CASE STUDY DIRECTORY

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PREFACE In setting up London’s Mental Health Strategic Clinical Network it was clear that something different was needed; something that represented more directly the different narratives that exist around mental health and illness. The response to individuals in crisis has always been critical – when your mental health breaks down the pain is every bit as real as when you break your leg – and it is our responsibility as health and care professionals to respond as quickly. Dr Geraldine Strathdee, national clinical director for mental health, always reminds us that the best crisis is a crisis averted – and we can all think of cases where things could so easily have been prevented. But we will never eliminate every case and we must be prepared. Indeed we are, in many ways, at a moment of real possibility in relation to mental health. Increasingly, a body of ideas is being shared that together represent a coherent direction of travel. Care and support moving further out of hospital towards home; moving from prescription to partnership in working with empowered citizens and patients; seeing the development of resilience and health promoting communities as key ingredients for real population health; and working towards holistic approaches that bridge the mindbody divide that we have artificially created. I am grateful to all who have contributed to this work, particularly those people who have lived this experience which grounds us in why it is so important. As one participant reminded us “I actually say you’re never out of crisis, everybody’s in crisis it’s just how you cope with your life, and everyone’s different, everybody copes differently.” There is much in this manual that goes along with it to provoke us all to rethink our response to crisis, and a clear mandate from those who use our services to make some changes. We hope it provides inspiration to you all.

Dr Matthew Patrick Clinical Director, London Mental Health Strategic Clinical Network Chief Executive, South London and the Maudsley NHS Trust

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PREFACE Whilst the aim should always be to prevent individuals experiencing mental health crisis, the nature of mental disorders is such that, from time to time, and in response to the stresses that individuals can experience, people will experience a crisis. When this happens it is clearly essential that appropriate support and treatment is readily available. The Government’s commitment to parity of esteem should ensure that crisis services available for those with mental health difficulties, are comparable to the services available for individuals presenting with acute medical and surgical problems. This, unfortunately, is not the case. Across London in recent years we have seen a number of innovative services develop, and examples of high quality care. In addition, the relationship between the capital’s secondary mental health providers and primary care has undoubtedly improved. Practice, however, remains variable and the variety of crisis services currently being delivered has resulted in a landscape for service users and their carers which is often difficult to navigate. This document, which has been compiled following extensive analysis and consultation, contains standards for the future commissioning of crisis services and covers twelve key areas of service delivery. The aim therefore is to ensure the consistent delivery of high quality, responsive crisis care which reflects and meets the needs of all service users and their carers. The standards build on work already on going regionally and nationally, and in addition, reflect best practice identified across the world. London is committed to ensuring that the recommendations outlined in the Crisis Concordat are acted upon in order to deliver better crisis services. The standards we advocate form part of the London’s comprehensive response to the Concordat.

Dr Nick Broughton Chair of Urgent and Crisis Care, London Mental Health Strategic Clinical Network and Medical Director, West London Mental Health NHS Trust

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EXECUTIVE SUMMARY The Mental Health Strategic Clinical Network has produced a set of standards and recommendations for commissioning mental health crisis services across London. To develop the standards, the network has analysed existing mental health crisis provision, reviewed literature, cross referenced against other guidance such as that produced by NICE, identified case studies and consulted people with lived crisis experience. The commissioning standards therefore were devised to reflect what people should expect from London’s mental health crisis services. They are embedded within twelve subject areas, mirroring the Crisis Concordat approach including: »» »» »» »»

Access to crisis care support Emergency and urgent access to crisis care Quality of treatment of crisis care Recovery and staying well

The following standards are to be refreshed in the future and are our first initial step to improving mental health crisis.

Access to crisis care support

1. Crisis telephone helplines

2. Self-referral

3. Third sector organisations

4. GP support and shared learning

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»» A local mental health crisis helpline should be available 24 hours a day, 7 days a week, 365 days a year with links to out of hour’s alternatives and other services including NHS 111 »» People have access to all the information they need to make decisions regarding crisis management, including self-referral »» Commissioners should facilitate and foster strong relationships with local mental health services including local authorities and the third sector »» Training should be provided for GPs, practice nurses and other community staff regarding mental health crisis assessment and management

EXECUTIVE SUMMARY Emergency and urgent access to crisis care

5. Emergency departments

»» Emergency departments should have a dedicated area for mental health assessments which reflects the needs of people experiencing a mental health crisis 6. Liaison Psychiatry »» People should expect all emergency departments to have access to on-site liaison psychiatry services 24 hours a day, 7 days a week, 365 days a year 7. Mental Health Act Assessments and AMHPs »» Arrangements should be in place to ensure that when Mental Health Act assessments are required they take place promptly and reflect the needs of the individual concerned 8. Section 136, police and mental health profession- »» Police and mental health providers should follow als the London Mental Health Partnership Board section 136 Protocol and adhere to the pan London section 136 standards

Quality of treatment of crisis care 9. Crisis housing

10. Crisis resolution teams/ Home treatment teams

»» Commissioners should ensure that crisis and recovery houses are in place as a standard component of the acute crisis care pathway and people should be offered access to these as an alternative to admission or when home treatment is not appropriate »» People should expect that mental health provider organisations provide crisis and home treatment teams, which are accessible and available 24 hours a day, 7 days a week, 365 days a year

Recovering and staying well 11. Crisis care and recovery plans

12. Integrated care

»» All people under the care of secondary mental health services and subject to the Care Programme Approach (CPA) and people who have required crisis support in the past should have a documented crisis plan »» Services should adopt a holistic approach to the management of people presenting in crisis. This includes consideration of possible socioeconomic factors such as housing, relationships, employment and benefits

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INTRODUCTION

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ndividuals with mental health difficulties, particularly those who experience serious mental illnesses such as schizophrenia and personality disorders, may experience crises requiring urgent and at times emergency mental healthcare.

It has long been recognised that there is considerable variation in terms of the quality and accessibility of services. In addition it is recognised that services typically compare unfavourably to similar services for those requiring urgent and emergency care for physical health problems, and this is an important area to tackle if we are to achieve parity of esteem. Mental health crisis care encompasses a wide variety of services including primary care, secondary care, emergency and social services as well as services provided by the third sector. With such an array of services, a systemic and integrated approach is required to improve crisis provision. This must be provided in combination with high quality “planned” mental healthcare, (aimed at preventing individuals experiencing crisis) together with a comprehensive programme of public mental health promotion (aimed at building resilient communities). A whole systems approach such as this requires an integrated commissioning strategy that extends to social care, housing and employment support as well as substance misuse interventions. Whilst the best care is undoubtedly planned care, the aim should be to prevent individuals experiencing crises.

The nature of mental health, however, means that there will be a continuing need for high quality and responsive crisis services.

Defining mental health crisis Over the years, there have been many attempts to define what is meant by “mental health crisis”. A crisis can be described as a change in mental wellbeing that is likely to lead to an unstable or dangerous situation for the individual concerned. Terms such as ‘emergency care’, ‘urgent care’, ‘crisis care’, ‘unplanned care’ and ‘unscheduled care’ have been used to describe the services developed to support and treat those presenting in crisis. Varied terminology alongside differing interpretations of the terms has frequently led to confusion amongst providers, commissioners, service users and carers. Previous Department of Health guidance1 on telephone access to out of hour’s services clarified terms as: »» Emergency care - An immediate response to time critical healthcare need »» Urgent care - The response before the next in hours or routine (primary care) service is available »» Unscheduled care - Involves services that are available for the public to access without prior arrangement where there is an urgent actual or perceived need for intervention by a health or social care professional

The definition for urgent and emergency response is often different for mental health conditions compared to physical health conditions. Mental health response services need to be commissioned as part of urgent and emergency care pathways to both ensure quality of care for mental health problems and to address the significant number of crisis mental health presentations in primary and acute secondary care2.

“…crisis is a perception or experience of an event or situation as an intolerable difficulty that exceeds the person’s current resources and coping mechanisms...”4

Mind defines ‘mental health crisis’ when a person is in a mental or emotional state where they need urgent help3. Key challenges to designing crisis mental health services which incorporate a service user and carer perspective are that each person’s perception of what constitutes a crisis is individual reflecting their history and social support network5. People will respond differently to clinical situations which objectively appear similar, some finding the situation to be manageable, others finding it overwhelming.

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INTRODUCTION Challenges facing mental health crisis services The mental health crisis and urgent care pathway is often complex, characterised by multiple entry and exit points, and different mental health conditions being addressed by different teams and agencies. Problems often arise at the point where services meet in relation to transfers and communication. People experiencing mental health crisis may need to navigate their way through numerous services in attempt to find help. Navigation can be made unnecessarily difficult with differing names and roles of mental health teams depending on the locality.

“When someone is experiencing a mental health crisis, it is essential that they feel able to access the help they need and quickly... Without help, people may be at risk of causing harm to themselves and those around them... They often end up in police cells – completely inappropriately. They may even commit suicide... I hear tragic cases of suicide after someone has repeatedly been unable to access mental health crisis support.” - Norman Lamb, MP 21 February 20146

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The need for equality and nondiscrimination in regards to proportionality in the delivery of crisis care also applies to different cultures, religions and diverse groups. There are barriers to achieving better outcomes for black and minority ethnic groups. For example, there are higher levels of detention and higher admission rates to hospital. Black Mental Health UK states that there are higher use of control and restraint among UK’s African Caribbean population. Members of this patient group are also given higher doses of antipsychotic medication than their white counterparts and are less likely to be offered psychotherapy as the primary form of treatment7. The 2014 Crisis Care Concordat8, highlights the need for commissioners to focus on particular groups or sections of society which are reaching crisis point at a disproportionate rate, or accessing mental health services through the criminal justice system at a high rate. Many people are unclear on what services are provided locally and how to access them. Information and awareness of services varies by geography, organisation, the specific service and the individual’s experience and knowledge. Service users can be misdirected and told to go to emergency departments when in fact another more appropriate service was available. Analysis has revealed that referral to emergency departments from primary care is too often the default position in response to a crisis.

The reasons for this include: »» self-referral not accepted »» slow or no response from the appropriate service »» no alternative services made available »» a failure to provide a safe space out of hours (nowhere else to go) »» lack of knowledge of mental health services in primary care »» inadequate crisis plans in CPA documentation »» historical attitudes that emergency department is the default service for all crises »» limited capacity and availability of crisis services (under staffed, lack of resources) Initial analysis of research carried out by University College London regarding crisis teams has revealed that across the country, only 39 per cent of teams provide a 24-hour service seven days per week. In addition, only 55.5 per cent of teams accept self-referrals from known clients and 21 per cent from unknown clients9. Emergency departments are not the best place for people presenting in mental health crisis.

“I know I shouldn’t have gone to A&E, but I felt there was no alternative… I wish there was somewhere to go where there isn’t the fear of being judged, and that it’s acceptable to be there… Or if it’s OK to go to the A&E department for there to be more awareness about this.”3

INTRODUCTION Whilst emergency department capacity and ability to manage mental health crisis has increased significantly in recent years with the development of liaison psychiatry services, there is undoubtedly still a strong argument that such departments remain far from ideal environments for the assessment and management of those presenting in acute psychological distress.

Evidence given by the range of stakeholders clearly showed how current mental health crisis provision is characterised by lack of access and poor emergency departments care leading to poor and unacceptable outcomes for patients, so highlighting the immediate need for change.

Although there are many challenges facing mental health crisis services there are examples of excellent crisis and emergency The National Institute for Health mental health care. It is imporand Care Excellence (NICE) tant to capture good practice and guidelines for adult mental health10 state the assessment and share the benefits and impact of referral procedures for urgent and these services, interventions and crisis mental health should include studies. alternatives to emergency departments such as 24 hour helplines, 24 hour accessible crisis resolution and home treatment teams and the ability to self-refer. In March 2014, the All Party Parliamentary Group for mental health11 launched an inquiry into crisis mental health and emergency care. A national survey was circulated among service users, carers, families, health and social care professionals and the police which revealed that there are major inconsistencies in access to services, standards and models of service delivery. Negative experiences included overstretched and fragmented services, unclear routes into care, place of safety not within an appropriate setting (at police stations or emergency department), long waiting times, a postcode lottery regarding access, advice and services, no clear access route into services and repeated ‘bouncing’ between services.

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COMMISSIONING MENTAL HEALTH

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he process of ‘commissioning’ includes the evaluation, funding, planning and delivery of mental health services in a local area. Local commissioners have a responsibility to provide high quality and responsive mental health crisis services which are well suited to meet local population needs. Commissioners should have well established links with other agencies to enable an effective and integrated approach to a mental health crisis and urgent care. Various strategies are devised locally to ensure CCGs are engaged with wider partners and therefore able to offer a seamless service across the whole patient journey. Commissioning partners include other parts of the health sector (providers), the police force, ambulance service, criminal justice system, social care and local authorities. An example of this is the development of the Joint Strategic Needs Assessments (JSNAs) and Joint Health and Wellbeing Strategies (JHWS) which have been devised to align priorities based on local need12. The CCG’s commissioning intentions and strategic plans should incorporate the JSNAs and JHWS into their planning process. Issues such as staffing capacity, alternative options to inpatient hospital care together with the availability and accessibility of services especially in relation to minority ethnic groups should be addressed. Services should be designed to serve the needs of all ages, ethnic backgrounds and cultures.

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Parity of esteem should be reflect- Commissioning principles ed in how services are commissioned as well as the contribution 1. Anticipation and where of primary, secondary, community possible prevention of a and inpatient hospital care. mental health crisis Efforts should be taken to Evidence from NICE and other reduce the number of crisis guidelines should also be considincidents through preventative ered. Commissioning decisions measures including resilience have traditionally been steered interventions and early diagnoby ‘evidence based practice’ sis. Support should be acceswhich has relied on scientific and sible and available pre-crisis. research evidence however the views of people who have lived 2. In the event of a mental experience have equal weight and health crisis, provide a timely should therefore be included in and effective response every stage of the commissionEffective crisis management ing cycle13. Co-production and and control of a mental health service user engagement should crisis should be taken to prebe included to promote values vent further escalation. Individubased commissioning and take als should be in a safe environinto account the patient and carer ment, respected and receive perspectives and values. high quality treatment and care. There are three main commission- 3. Achieve the best patient ing principles which the Mental experience and outcomes Health Strategic Clinical Network Individuals who have experi(SCN) has adopted in the develenced a mental health crisis opment of this mental health crisis should feel reassured and commissioning manual and the content with the way the crisis commissioning standards. The was handled. Individuals should principles combined contribute to be given support following the delivering a whole system apincident, equipping them with proach to ensure individuals who recovery and self-management experience a mental health crisis tools. This is best achieved receive a high quality, effective through co-producing care and seamless service. packages which are integrated with their local community services.

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DEVELOPING THE STANDARDS Policy context

Mental health crisis care is commonly cited as a healthcare challenge which requires urgent attention. The NHS Mandate14 2014/15 highlights the need to improve mental health crisis to ensure services are accessible, responsive and of as high a quality as other health emergency services. Crisis mental health also features in NHS England’s business plan15 which has made parity of esteem (valuing mental and physical health equally) a key objective, this includes improving crisis care and waiting times.

Standardising crisis mental health

A uniform and standardised approach will produce less variability, enable service delivery comparison and ensure good practice is communicated and shared.

Stakeholders, partners and engagement

Clinical commissioners, mental health providers, social care, third sector, police representatives and service users have been consulted throughout the development of the mental health crisis manual. The SCN is ideally positioned to share resources, information and The need to improve outcomes connect to other improvement for people experiencing mental boards and wider agencies and health crisis was highlighted in the share best practice. The London mental health Crisis Care ConcorMental Health SCN has engaged dat8 published in February 2014. with Concordat co-ordinators as Twenty two signatories, representwell as NHS England colleagues ing key stakeholders involved in in commissioning assurance, the delivery of crisis care, have health in the justice system and committed to taking action to other London transformation improve the system of care and teams. The manual has been support for those in crisis. This informed by engagement with policy context means it is timely people who have needed crisis to address the mental health mental health services in the past pathway for patients presenting in coordinated by Mind. crisis across London. NHS England aims to support the delivery of the Crisis Concordat to ensure there is access to appropriate crisis services. This supports previous goals around assisting CCGs to understand and tackle unwarranted variation in mental health crisis provision.

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Excellence in commissioning requires a clear understanding of effective service responses as described and evidenced by the NICE and the Social Care Institute for Excellence (SCIE), with a focus on recovery which is demonstrated by measuring outcomes and clearly shown in service specifications. National guidance and recommendations have been researched to support the manual.

“Support the delivery of the crisis concordat so that we are working towards ensuring the access to crisis services, for an individual, are at all times as accessible, responsive and as high quality as other health emergency services. This includes ensuring the provision of adequate liaison psychiatry services in emergency departments and developing and implementing an access/waiting time standard for mental health services.” - Putting Patients First NHS England Business Plan 2014/15 - 2016/17

DEVELOPING THE STANDARDS Methodology

From March 2014, London-wide data was collated to explore current mental health crisis provision and understand the barriers to improvement. The manual provides a brief outline of London’s crisis and urgent care provision as well as identifying what good looks like for urgent care and crisis emergency pathways using a whole system approach. Tasks have included:

»» London Mental Health Trust website scoping exercise: Reviewing basic public information on services, teams, referrals, definition of a mental health crisis, public instruction and carer support. »» London Mental Health Trusts crisis questionnaires*: Scoping if there are trust policies/standards, procedures in crisis care (including out of hours), criteria of teams (emergency departments, walk in centres, crisis houses etc), confirmation of transformational programmes in operation and views on best practice. »» London CCG mental health crisis commissioning questionnaires*: Determining GP responses to patients presenting in mental health crisis, out of hours procedures, teams for referral, views on the ‘perfect’ crisis care, barriers to change and awareness of best practice models. »» Literature review: Researching models of best practice in crisis mental health internationally, nationally and regionally. Examining cost effectiveness of models and impact on patient outcomes. »» Mapping of NICE guidance and other existing national standards in place

»» Mental health service/referral mapping: Understanding the patient pathway, team composition, referral routes from entry to discharge per London region in an attempt to determine variation of London services »» Hosting a crisis service user engagement event: Consulting and engaging with people with lived mental health crisis experience from within London. To discuss draft standards, incorporate view points and real life experiences and to capture which aspects of the crisis pathway are good which are poor and where improvements are required. *To view questionnaire data see Appendix B. To note »» Nine of the 10 mental health trusts were surveyed and all nine responded. »» Twenty three CCGs mental health leads responded to the CCG questionnaire »» Answers provided to questions may be subjective as it is likely one person or one team would have completed the questionnaires and returned them based on their knowledge. There also may be variation in terms of ‘interpretation’ of the questions, as the questionnaires were circulated via email and not structured interviews etc.

Implementation

From the ‘scoping’ tasks, the variation and gaps in London’s local service provision became evident. This evidence alongside service user experience, led to a set of recommendations. The commissioning standards are embedded within twelve subject areas, mirroring the Crisis Concordat approach ensuring: »» Access to crisis care support »» Emergency and urgent access to crisis care »» Quality of treatment of crisis care »» Recovery and staying well The Crisis Concordat expects that in every locality, a local partnership of health, criminal justice and local authority agency agrees and commits to local mental health crisis declarations and an action plan outlining services that meet the principles of the national Crisis Concordat will be delivered. In response to this initiative, the London Mental Health SCN has developed this manual with pan London standards and recommendations which we hope will assist and direct commissioners in designing and shaping crisis mental health services.

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ACCESS TO CRISIS CARE SUPPORT Area 1: Crisis telephone helplines Commissioning standards and recommendations A local mental health crisis helpline should be available 24 hours a day, 7 days a week, 365 days a year with links to out of hour’s alternatives and other services including NHS 111 Crisis helplines should be staffed by qualified, competent and compassionate mental health professionals who are appropriately trained, supervised and supported Crisis helplines should be well publicised among people with mental health problems, carers, health and social care professionals, emergency services and the wider public Crisis helplines should be profiled within the Directory of Services and enabled to receive referrals from NHS 111 including electronic referrals where appropriate People should expect to have a single crisis helpline telephone number across London in the future

“Talking can help reassure you and the helpline does a great job.”11 16

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ingle point of access is a SCN findings departure from the traditional According to the London mental arrangement of GP referral to health CCG leads, 78 per cent individual specialists. had a crisis helpline service in place. When asked what a perfect The idea behind the service is to crisis would look like, the majority avoid inefficiencies created by of the leads stated a single point multiple assessments, referral of access service where a local 24 forms and client records. This type hour mental health crisis line can of service has been used by other refer patients to the appropriate medical disciplines, as well as service for advice and help. psychiatry including primary care and emergency care. For single The service was also identified point of access to practically work, as a tool to help break down practitioners need to have conthe crisis pathway into different fidence in the process and have types of crisis and prompted good communication systems in understanding local population place as well as a clear underneeds. This would certainly help standing of each other’s roles and shape services around patient skills. needs, mobilising the correct A single point of access to mental health care usually starts with a single telephone number. Crisis telephone lines offer a first point of contact for individuals experiencing a crisis or distress and requiring urgent or emergency support. According to the All Party Parliamentary Group for mental health11 many individuals have found them useful for immediate help, advice and signposting to the right mental health specialist support. Crisis lines have also been identified as a way of reducing emergency department admissions.

services accordingly.

“I think it is important to break down the crisis pathway into different types of crisis and causes. The biggest problem is having single point of access that work 24 hours and patients knowing what to do when they get into crisis. In our case we are starting to map out the pathway and improve access and treatment services but there is still work to do to improve services across the whole system.” “Ideally, I would like a service similar to the ‘Initial Response Team’ in Sunderland, where people in crisis are triaged by an experienced clinician and if the patient needs to be seen, a face to face assessment is carried out (usually at the patient’s home) within an hour. This would cover all areas of mental health crisis adults, CAMHS and dementia.”

ACCESS TO CRISIS CARE SUPPORT One CCG response stated that they had an interim mental health crisis line set up for a six month period, however reverted back to a generic number for a group of boroughs. This has been flooded with calls which have been unresponsive with an average waiting time of over 40 minutes. A minority of CCG leads stated that A&E was used as the default option when the crisis telephone line was not responsive. When asked “Under what circumstances do you refer patients to A&E?” one response included,

Service user engagement event

People with lived mental health crisis experience emphasised to the SCN the importance of responsive crisis telephone lines which are handled by compassionate staff that are able to signpost people to the appropriate services. “I want someone to be compassionate and kind, who cares about me rather than clinical and cold.”

The evidence

There are variations in the single point of access model with respect to who can refer and when the telephone line is available. Some services are dedicated to crisis and urgent care services and others for routine mental health care provision (for those aged 16-18).

There is limited evidence available evaluating the outcomes of these models. There have been reports regarding concerns over making contact via a telephone “Being patient and allowing the when in a crisis. Phone lines in person to talk. Understanding that existence have had criticism over “When unable to get through when your mind is in chaos it is the effectiveness of the service. to crisis line with significantly harder than normal.” Sometimes it is not always distressed patients” possible to provide help on the “Staff manning crisis lines should telephone, with a long call wait or This indicates that crisis telephone be trained by service users and awaiting a call back after leaving lines maybe in place however carers, in order to be competent. a message. Service users have their efficiency can be limited. Calls to be recorded and commented that call handlers monitored for further training.” are not always very helpful3 and Out of the nine London mental question the qualifications and health trusts, two stated that they “NHS 111 should have the local skills of the call handlers. Some do not currently have dedicated crisis line number.” service users would rather not use crisis helplines. Some trusts a telephone at all and prefer a text stated that the crisis helpline It was agreed that crisis telephone line instead. is used by service users out of helplines should be well publicised hours. One trust stated that the among emergency services as service they are most proud of well as the wider public. This will in their trust was their 24 hour inform people new to services mental health crisis support who are experiencing a mental telephone line which is operational health crisis for the first time. 365 days a year handled by clinical staff. Another trust is in “If I’m very ill, I’m getting in a the early implementation phase of crisis, if I’ve never had any contact launching their crisis support line. with mental health services before or my relatives never had, how Crisis helplines are useful in will I know that there is a crisis reducing unnecessary emergency line that I can call?” department admissions. “Approximately 16 per cent of callers feed back that having access to the line avoids the need to go to A&E or call their GP out of hours.”

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ACCESS TO CRISIS CARE SUPPORT Mental Health Direct (Case study 1) Mental Health Direct (MHD) evolved out of discussions with service users, carer groups, GPs and commissioner consultations following complaints about lack of out of hour’s provision. It was also highlighted that mental health services were difficult for non-professionals to navigate, leading to inappropriately high use of A&E. The service was incorporated into the existing switchboard and clinical support supplied by Access and Assessment Teams, clinical lead and in out of hours the home treatment team. MHD is available 24 hours to anyone who requires it. The biggest challenge was managing demand with an increase by 33 per cent in calls from 2012-2013. Benefits of the service include one recognisable number for all, reduction in unplanned A&E attendance and robust out of hour’s service. This is also a service which works closely with service users to deliver local needs.

Sunderland and South of Tyne Initial Response team (Case study 2) Northumberland, Tyne and Wear (NTW) trust designed a service to manage mental health crisis using the Sunderland and South of Tyne Initial Response Team. The team offers an efficient 24/7 response to urgent telephone requests for help from people of all ages and conditions and offer triage and routing/signposting to appropriate services within the region. The phone line is available 24 hours a day and calls are managed by trained handlers. The team is the first point of contact for the public, service users, carers and referrers. Early evaluations indicate: »» Improved response times (average 30 minutes from call to door) »» Improved telephone access (average nine second pick-up) »» Equality of access to urgent mental health services »» Improved service user, carer and referrer experiences »» Reduced avoidable harm - no “bounced referrals” (routed to the appropriate service) »» Reduced assistance required from emergency services »» Positive staff and service user feedback

“100 per cent of service users would recommend the service to a friend in need of similar help.”

- Sunderland and South of Tyne IRT

“Staff are polite, show kindness and empathy and behave in a professional manner.”

- Sunderland and South of Tyne IRT

This model requires further quantitative evaluation. The service is ageless and further work is being established to see if this service would be effective for children and adolescents in accessing appropriate interventions in crisis. Northumberland, Tyne and Wear trust has learned lessons and had to overcome challenges as the crisis service has become more established, refer to case study 2. An Evaluation of Southern Psychiatric Triage Service16 based in Australia was published in 2008. This service is similar to the Northumberland Tyne and Wear trust mental health crisis model Sunderland model, however includes referrals from police officers as well as healthcare professionals. The service includes telephone triage and then directs service users to the correct treatment provider – the service is not involved in providing treatment. It is a single point of entry to CAMHS community assessment and treatment service.

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ACCESS TO CRISIS CARE SUPPORT The need for high end telephony is emphasised in the evaluation to ensure calls were handled quickly, efficiency and to reduce the call abandonment rate. The evaluation made a comparison with other similar models and concluded that: »» Psychiatric Triage Service provides a more rapid and accessible initial response to clients in crisis. »» Since the implementation of the Psychiatric Triage Service, triage services improved in consistency and efficacy, particularly due to the implementation of an IT system and effective change management process undertaken by Southern Health »» Psychiatric Triage Service appears to field calls efficiently and appears to manage a higher client risk profile. The concept of a single point of access goes much further than mental health crisis advice, access and response – it creates a single front door to specialist mental health services. This has been successfully adopted by Northumberland, Tyne and Wear (refer to case study 3). There is a centralised ‘clinical intelligence hub’ providing 24/7 advice, support, assessment and rapid access to treatment. The hub is supported by multi-disciplinary staff who are located close by and therefore there is no elongated referral screening process ultimately creating a ‘slimmed down’ assessment approach. North West London Urgent Care Collaborative is currently developing paperless referral and communications systems such as

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e-referral screening, telephone triage with a ‘clinical intelligence systems interface’ e-directory of third sector services to inform signposting and advice on selfcare (refer to case study 4).

Supporting information

Examples of related existing standards

NICE Guidelines10

»» Health and social care providers should provide local 24 hour helplines staffed by mental health and social care professionals and ensure that all GPs in the area know the telephone number

References to case studies and contacts

»» Mental Health Direct – 24 hour mental health support and crisis line (Case study 1) »» Sunderland and South of Tyne Initial Response team (Case study 2) »» Northumberland, Tyne and Wear Initial Response service (Case study 3) »» North west London’s mental health transformation strategy 2012-15 (Case study 4) »» Integration of CAMHS into a single point of access for children (Case study 5)

ACCESS TO CRISIS CARE SUPPORT Area 2: Self referrals Commissioning standards and recommendations People have access to all the information they need to make decisions regarding crisis management including selfreferral A range of self-referral options should be available for people in mental health crisis Mental health crisis services provide information in various formats, detailing opening hours, referral procedures and eligibility criteria Mental health crisis information should be available in different languages and take into account different cultures and religious beliefs Mental health crisis information should be available and easy to obtain via provider trust websites; this should be accurate and up to date

“A GP must make a referral to the crisis team first and then aim to see you in four hours after that referral... impossible for me at the time. I couldn’t leave the house. People need to be able to self-refer.”11

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“People wanted their own definition of being in crisis respected as the first step in getting help and exercising choice and control.”3

A

ccess to services is known as to be one of the biggest concerns for those in crisis.

There are many accounts of individuals being turned away from services unable to access help for not being ill enough or not meeting the service criteria3. Self-referral offers advantages for improved access to services for those who would not otherwise receive services. More self-referral options could reduce the use of compulsory treatment if people are able to get timely support rather than crises escalating17. It can open up pathways to care enabling people to access services of their choice. In a time of distress, self-referral can also offer an easier option for people who do not know where to go especially out of hours. It also means that people who have used services would not have unnecessary repeat assessments, with the potential to escalate their mental health problem. This includes having the correct information when it is needed, the right support in being referred and some control at a time when they may not be able to exercise choice.

A sense of control and choice at the point of crisis may help prevent the crisis escalating further. (This is linked with crisis care plans, see Area 8.) Language, culture and health beliefs can be barriers to accessing appropriate care. Different cultures, health beliefs or a limited understanding of mental health may mean that mental health services are not seen as being relevant or helpful. Mind18 recommend that commissioners empower people from black and minority ethnic groups by providing appropriate information, access to advocacy services and ensure that they are engaged and have control over their care and treatment.

SCN findings

Some of the London mental health CCG leads stated that in a crisis, self-referral should be possible. Some stressed the importance of sharing information and improving communications throughout the referral process. “Good electronic patient record sharing. Clear and agreed quality markers (eg times from referral to being assessed and timely and clear communication).” Three of the nine London mental health trusts stated that local GPs advised self-referral or GP referral to community mental health team when presenting for the first time in a crisis. “Once known to their crisis service, they will be given the contact details, should they need to re-refer themselves.”

ACCESS TO CRISIS CARE SUPPORT All London trusts claimed to provide information regarding the available crisis mental health services and also indicated the different formats of information, usually: »» Crisis leaflets »» Website »» Crisis cards »» Crisis plans (see Area 11) »» Contact details of mental health professionals Two trusts specified that crisis information was available in different languages. Two trusts referred to their crisis telephone support line.

into some of the crisis houses in London. Seven of the nine mental health trusts provided detailed referral information on their websites to help inform services users on the process and what to expect. Four mental health trust websites publicised self-referral options. Five of the mental health trust websites include full referral route details, with four describing in detail the eligibility into each of the services.

Some of the mental health trusts have accounted for different languages and have designed their home page to make sure the “Mental health liaison services information is easily accessible provide verbal information and and the text is clear. Two menadvice 24 hours and puts informa- tal health trusts have provided a tion on the notice board in A&E language alteration button on their and with third sector organisations homepage, with many different like the Samaritans and Alcoholic languages to choose from. Two Anonymous.” have word bank options on the home page, which defines and “Welcome pack including informa- explains particular words, and one tion on in/out of hour services” mental health trust website has listen aloud choice. “Crisis cards, leaflets, GP newsletters, service user advocacy group Service user engagement newsletter” event “Leaflet, included in crisis plans available as crisis card in SMS service”

From discussions with people with lived mental health crisis experience, self-referral was seen as a good aspect of crisis care.

More information around what information is available to service users and those experiencing crisis for the first time was researched from the trusts’ websites.

Individuals shared positive experiences regarding self-referral back into services. Self-referral options, however, need to be widely and consistently communicated.

There are some crisis services which enable self-referral, such as crisis resolution and home treatment teams. This is variable across London and tends to be available only if the individual has used the crisis team in the past. It is now possible to self-refer

“Not enough information to understand decisions”

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The evidence

There is limited literature detailing self-referral to mental health services during a mental health crisis. People using services value being able to contact services when they experience a crisis as well as having choice and control over their treatment and how they access care during a crisis3. A small study19 showed those who had a contract for self-referral had come further in the recovery process, and expressed less resignation, hopelessness and powerlessness. Apart of self-management, NHS staff should respect people’s knowledge of their own needs and therefore there should be more self-referral options17. Mental Health Measure in Wales allows people direct re-access to secondary mental health services when they know their mental health is deteriorating. This could reduce the use of compulsion if people are able to get timely support rather than crises escalating to the point where the Mental Health Act is used. Self-referral routes are popular for IAPT services and can enable improved access to those who would otherwise not receive services. If self-referral is structured properly it can be extremely beneficial to improve access for those who may not have been able to get access before as well as those who have never thought of consulting20. Those self-referring to advertised psychological workshops have psychological problems in need of treatment were more representative of the population, in terms of ethnicity, than GP referrals21, 22.

ACCESS TO CRISIS CARE SUPPORT See Area 9 regarding information on the two crisis houses in Camden. Any adult resident in Camden who believes themselves to be at risk of being admitted to hospital due to a mental health problem can be referred by a crisis team, or can call and refer themselves during normal office hours. Further details on the Camden and Islington NHS Foundation Trust website.

Supporting information

Examples of related existing standards NICE Guidelines10 »» Health and social care providers should support direct self-referral to mental health services as an alternative to accessing urgent assessment via emergency department »» Give service users clear information about all possible support options available to them after discharge or transfer of care

Mental health in Scotland: National Standards for Crisis Service5 »» Info on crisis service organisation and contact details 24/7 »» Information and advice provided to service user/ carer on alternative support organisations »» Explanation and feedback for not meeting eligibility criteria for a programme »» Information for alternative services when not meeting eligibility criteria for a programme »» All service information and approaches take account of diversity issues London urgent quality standards24 All registered healthcare practitioners working in urgent care services to have direct access to urgent referrals to specialist on call services where necessary and the right to refer those patients who they see within their scope of practice.

NICE guidance: Psychosis and schizophrenia in adults: treatment and management23 »» Give carers written and verbal References to case studies information in an accessible »» Big White Wall digital mental format about: diagnosis and health service (Case study 6) management of psychosis and schizophrenia positive outcomes and recovery types of support for carers role of teams and services getting help in a crisis. »» When providing information, offer the carer support if necessary. »» As early as possible negotiate with service users and carers about how information about the service user will be shared.

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Big White Wall digital mental health service (Case study 6) The digital mental health service, Big White Wall, is offered on a self-referral basis to all adults in Southwark. With the aim that this will increase access to mental health services, particularly for people who are unwilling or unable to access other options. The service offers instant access, 24 hours a day crisis support from trained counsellors through the ‘Ask a Wall Guide’ function, safe and moderated peer support, and selfmanagement materials. The service is fully anonymous, meaning that it is more acceptable to people who are unwilling to access support due to stigma. Members are protected through clear house rules and real-time moderation. Big White Wall members frequently make use of the network at times of distress, to resist urges to self-harm or to cope with suicidal thoughts – many then continue to use it for support with longer-term issues.

ACCESS TO CRISIS CARE SUPPORT Area 3: Third sector organisations Commissioning standards and recommendations Commissioners should facilitate and foster strong relationships with local mental health services including local authorities and the third sector Commissioners should work with organisations representing black and minority ethnic groups to ensure that all services are delivered in a culturally appropriate manner

O

rganisations such as Mind, Rethink Mental Illness and the service user led network, National Survivor User Network (NSUN) strive to empower and support people with mental health conditions, and offer services which compliment and support the activities of the statutory services.

Voluntary bodies such as these are valuable in helping individuals get through a mental health crisis by providing advice, navigating and signposting people to services, offering up to date information The involvement of the third and also provide services locally. sector should be routinely They can advise or recommend considered in service design NHS services and also direct patients to use voluntary sector Local third sector services should services25. Their roles are varied be mapped relevant to the and they can provide a number of management and support of those interventions in mental health from in crisis and ensure that mental counselling, support and activities. health crisis teams are aware of Some are also involved in mental these health crisis helpline provision as well as providing alternatives An accurate and up to date to admission to hospital, such as database of local services should crisis houses. be available to people with mental health problems and their carers Telephone helplines are a useful resource for immediate support. Commissioners should ensure There are a number of national that third sector organisations are charities for certain mental health appropriately profiled within the problems which operate phone NHS 111 Directory of Services lines out of hours for example, the Samaritans, No Panic (for panic and anxiety) and Beat (for eating disorders). Rethink Mental Illness and Mind provide mental health services including housing, cri“If it wasn’t for the staff sis helplines, employment training, counselling and befriending in Mind or my family, I schemes.

wouldn’t be here today.”

- Event participant

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Local Mind offices provide drop in centres, day services as well as acute day hospital services – some of these (not all) are set up to help people to manage crisis.

Staff from a recognised voluntary organisation can access services more easily than an individual can alone. Staff are acquainted with mental health professionals making communication on behalf of the individual much easier and quicker. Online support can also be useful for crisis support including NHS Choices, Mind and Rethink Mental Illness, providing high quality advice and up to date information and links to support services including those created and maintained by people with mental health problems. The voluntary sector also have an important role in supporting commissioners and providers to develop services in partnership with people who use services, to ensure services are as effective at meeting the needs of those they serve as possible. NSUN have developed National Involvement Standards framed in terms of the principles and purpose for involvement. The standards also address the processes of involvement across health and social care at strategic, operational and individual levels and, for it to be meaningful, the impact of involvement. The 4PI framework can support people to make decisions about the care they need, which is vital in times of crisis and indeed may prevent it26.

ACCESS TO CRISIS CARE SUPPORT SCN findings

Thirteen per cent of London mental health CCG leads had voluntary sector involvement in mental health crisis or urgent care locally. CCGs with limited voluntary sector involvement recognised the need and importance for integrating services with the community and third sector. One CCG lead felt a barrier to improvements in crisis mental health was “no money to pay voluntary sector anymore.” Where voluntary sector organisations were engaged, they were described as ‘best practice’. “There is a very good voluntary sector-led service called CREST EVOLVE. They employ navigators and we have found that the star+ worker support seems to prevent crisis and support recovery. It also gets patients help quickly when they need it.”

“I was so low, I was having thoughts of not wanting to live anymore. The peer support from NSUN was vital to me finding my voice in distress, and just knowing I could share it with people who had been in a similar position. It reminded me that I was part of something bigger.” - NSUN service user

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to outcomes with consideration given to the monetary and nonmonetary value of co-production. Employment-related outcomes or prevention of more acute needs arising – therefore reducing the use of crisis services – has been It was raised that voluntary oridentified as a common feature ganisations should keep people within the literature. There were informed of the support available a number of studies that demonensuring websites are up to date strated the preventative impact and information is clear. of co-production whereby projects were preventing more acute The evidence needs in existing service provision The voluntary sector is well that provides support for people established in providing support and advice to people experiencing prior to reaching a crisis point. mental health problems27, 28. Although the preventative aspect was common, it was not quantiThere are three broad types of fied in a consistent way. Some peer support, including profespeer-based programmes such as sionally designed services which the Personalisation Forum Group are delivered by people who use and Croydon SUN, or the supservices (expert patient proport on offer through time banks, grammes), peer networks organsuch as that at Holy Cross, creised and run by service users ate alternatives to acute services, (clubhouse model and personmeaning that people don’t have alisation forum groups) and coto reach crisis point before they produced services (for example receive support. Evidence from Croydon service user network). the Croydon SUN programme showed a 30 per cent reduction The concept of co-production is in use of emergency department still relatively new, and thus the term ‘co-production’ is largely ab- services after six months of mem31 sent from literature searches. The bers being part of the network .

Service user engagement event

People with lived mental health crisis experience reported positive feedback on the role the third sector plays in crisis support.

evidence that does exist is promising and has good outcomes for the individuals who receive the service and who are involved.

Evidence reveals that co-production improves the health, confidence and skills of participants while creating more efficient services tailored to population needs. This leads to better outcomes, reducing hospital admissions and prescriptions and other expensive treatment interventions29,30. There have been studies that have explored the approach of co-production, identifying the links

There is a lot of literature focused on peer support networks. Literature reviews revealed thousands of descriptions of peer-led and peer-run mental health services around the world. Reviews32 have been published since 1999 which have shown that people with histories of mental illness (‘peers’) can provide services that are often comparable in effectiveness to those provided by mental health professionals. Studies33 have examined the feasibility and effectiveness of using peer support to reduce recurrent psychiatric hospitalisations.

ACCESS TO CRISIS CARE SUPPORT One study found that the use of peer mentors as a promising intervention for reducing recurrent psychiatric hospitalisations for patients at risk of readmission.

research is needed. Additional References to case studies peer support programmes should »» “Evolve” – A navigator service be implemented within the context (Case study 7) of high quality research projects to »» Leeds survivor led crisis service examine this in the future. (Case study 8) »» Solidarity in a crisis (Case study Investigations into how peer 9) Supporting information support relates to psychiatric »» Refer to Mind/NSUN values hospitalisation and crisis stabibased commissioning lisation have been performed in reference/standards (May “Evolve” - A navigator North America34. The likelihood 2014) | link service (Case study 7) of experiencing a psychiatric »» Refer to NSUN’s service hospitalisation or crisis stabilisauser and carer involvement ‘Evolve’ is part of CREST, tion was modeled for individuals standards (2013) | link a local voluntary sector using peer support services and a charity in Waltham Forest, control group of individuals using Examples of related existing and provides navigators to community mental health serstandards 10 establish the nature of the vices. Results showed a positive NICE Guidelines crisis, whether social or outcome as peer support was as- »» Local mental health services medical, and works with the sociated with an increased likelishould work with primary care individual to decide on the hood of crisis stabilisation and a and third sector including appropriate course of action decreased likelihood of psychiatric voluntary organisations to to minimise risks to a mental hospitalisation overall. ensure that all people with health relapse. mental health problems have In 2011, a literature review was equal access to services based Initial outcomes of the pilot performed focused on peer on clinical need and services have shown that the Evolve support workers employed by are culturally appropriate team has contributed to professionally led mental health »» Mental health services should 35 an overall reduction in services . The review showed work with local third sector, the number of individuals that there was potential to drive including voluntary, BME having a crisis where through recovery focused changand other minority groups to regular contact with a es in services; however, careful jointly ensure that culturally navigator is maintained, as training, supervision and manageappropriate psychological well as a reduction in the ment is required from all involved. and psychosocial treatments duration of a crisis episode The authors did propose that fuare delivered by competent through quicker access to ture research should concentrate practitioners. intervention and treatment. on establishing a robust evidence base for the effectiveness of peer Mental health in Scotland: support in mental health services National Standards for Crisis in the UK, with a focus on random Service5 controlled trials, where appropri»» Working partnerships are ate. established with service user led organisations for Despite the promotion and uptake input on practice and policy of peer support internationally, developments, with access to there is little evidence from curindependent advocates for info, rent trials about the effects of peer advice and support including support for people with severe assistance with advance mental illness. A recent systemstatement atic review and meta-analysis36 »» Promotion of shared working revealed some evidence that between wider health and peer support was associated with community organisations positive effect on hope, recovery through community partnership and empowerment, though further arrangements

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ACCESS TO CRISIS CARE SUPPORT Leeds survivor led crisis service (Case study 8) The Leeds survivor led crisis service is governed and managed by people with direct experience of mental health problems. The service is funded by three Leeds NHS CCGs, Leeds City Council and Leeds Personality Disorder Clinical Network and receives small amounts of charitable trust funding occasionally. Whilst working in partnership with local statutory services the service remains outside mainstream mental health services. It has been successful in providing a viable alternative to the medical model of care for people in acute mental health crisis. “It can be cheaper to locate crisis services in the voluntary sector, than it is to provide statutory services, including inpatient services. It is also a more positive experience to be in a community based homely environment.”

“The peace and quiet was a nice change from the noisy, hectic crazy ward.”

- Service user, Leeds survivor led crisis service

Solidarity in a crisis (Case study 9) Solidarity in a crisis is a peer support service which is codesigned and co-delivered by service users and carers in Lambeth. Crisis support is offered over the phone or in person out of hours during the weekends. It is an alternative service to NHS services or hospital. The aims of the service are to reduce isolation, support people using empathy and knowledge gained through experience and to help the person before reaching crisis point. Peer supporters are trained and have regular supervision. They provide advice in a non-judgmental manner and give people reassurance, a sense of belonging and hope to those who are in distress. The service accepts referrals from community mental health teams, inpatient wards, GPs, voluntary agencies and selfreferrals.

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ACCESS TO CRISIS CARE SUPPORT Area 4: GP support and shared learning Commissioning standards and recommendations Training should be provided for GPs, practice nurses and other community staff regarding mental health crisis assessment and management

G

Ps are often the first point of referral into mental health services. With the onset of a crisis, GPs can be a valuable source of support. GPs are in an ideal position to prevent the escalation of a crisis with an established relationship with their patients. They can play an important role in recognising a mental health problem at an early stage or identify any worsening of a mental health issue.

This should include all primary care professionals who have a responsibility to try to prevent crisis by understanding individual stressors, encouraging compliance with medication where appropriate and supporting carers and families.

An increased focus on training has been suggested, and may form part of the new four-year training regime being developed by the RCGP and Health EduEnsure out of hours services cation England. Chief Medical GPs can also help with the manknow referral routes for those in Officer, Dame Sally Davies said agement of a crisis to support mental health crisis self-management techniques that specific training is needed to raise awareness of the consemay have proven to work in the Commissioners should take steps quences of violence on mental past, including any personal copto further develop the skills of health throughout a patient’s life37. ing strategies. The GP can also CCG mental health leads in the The Mental Health Foundation38 recommend and refer the most commissioning of mental health suggests widening the scope of appropriate service for the indicrisis services vidual, taking into account of all of mental health education and traintheir needs and preferences. The ing to include all primary care staff Training delivered to primary care including GPs, practice nurses, GP also may already be aware staff should ensure that staff from administrative staff. Although of their personal circumstances all agencies receive consistent undergraduate training for doctors including housing, employment messages about locally agreed includes a mandatory psychiatry and any personal matters that roles and responsibilities could play a part in the escalation element, “the RCGP curricuof a crisis. Giving advice on wider lum for mental health makes no GPs should be routinely consulted mention of continuing training or lifestyle factors which may be afand involved in investigations fecting the person’s mental health, development”. following serious untoward such as diet and exercise, can be incidents related to crisis effective. presentations to ensure that learning is embedded systemically As individuals experiencing a mental health crisis can present GPs and other community staff with co-existing drug and alcohol should receive training regarding problems, it is important that all the potential precipitants for staff are aware of local mental crises, including the role of health and substance misuse substance misuse and social services and know how to enfactors, in order to ensure early gage with them8. GPs may also identification and intervention consider prescribing medication when possible for symptoms in the short term while investigating the underlying causes of a crisis. GPs should be aware of mental health crisis services within the locality

“I am lucky to have a great doctor who understands me.”11

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ACCESS TO CRISIS CARE SUPPORT SCN findings Crisis mental health guidelines/ standards

Fifty-seven per cent of mental health CCG leads said they did not have guidelines or protocols to follow when people present in crisis; 65 per cent do not have waiting time standards.

Crisis assessments

Eight of the leads said that they typically completed crisis assessments in the GP surgery, others within the community or at A&E. The majority occasionally undertake a Mental Health Act assessment at the GP practice.

GPs description of a “perfect crisis” service The perfect crisis service was described as a “service which works same hours as the general practice, ideally linked to out of hours services.” Other MH CCG leads stated: “Responsive to GPs in hours. Able to assess people in the home, GP surgery or community clinic. Good at sharing information when patient already known to services. Same team working in all settings (eg A&E as well as community). Known patients can seek help from the team that know them best if in-hours.”

to be triaged and either a) discharged and signposted onwards b) receive the crisis support required and admitted or transferred to a local team.”

Although some areas have a crisis line, the effectiveness may need re-addressing.

There was a request for more ‘out of hours’ crisis services and extended hours to the trusts access team. It was felt crisis services should work to agreed response times, preferably within four hours for crisis and 24 hours for urgent cases.

Resources and investment were also quoted particularly to fund 24 hour support. Organisational culture and resistance to change within the mental health trust were felt to be obstacles also. CCG leads also identified GP education, lack of clinical leadership and a disjoint between managers and clinicians as barriers to change.

“Extreme difficulty for groups getting through to crisis line. This is a Another CCG lead is working lolongstanding issue that we have cally with their local provider to set struggled to resolve over past two up a more responsive service that years.” visits a patients home if this is felt to be most appropriate. The main barriers identified were the availability of the assessment “Where people in crisis are triaged teams to provide phone triage and by an experienced clinician and if rapid home visiting, especially out patient needs to be seen, a face of hours, and to be able to arto face assessment is carried out range follow up appointments. (usually at the patient’s home) within an hour.” “Change fatigue and fear of change was another factor, esThe majority of CCGs suggested pecially whether there is capacity 24 hour cover, responsive serin the system to make change, vices and easier accessibility as belief that a more responsive through a single point of entry. service will open the floodgates.”

Generally there “needs to be better integration with the rest of the system”. Good electronic patient record sharing is essential and clear and agreed quality markers (eg times from referral to assessment).

Barriers to change

The most common barrier identified by CCG leads were finances “One assessment via the point of and resources. Lack of integracontact with rapid safe response tion of some services within the in the least restrictive environment provider was also suggested. which is culturally acceptable and includes carers and family.” One CCG said: “Resources. We particularly need “GPs and patients are aware of better liaison services and also a crisis pathway and are able to GP education and access in Lonpresent at a 24 hour service and don can be improved.”

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ACCESS TO CRISIS CARE SUPPORT cant effects on patient outcomes in routine clinical practice, howevWhen the leads were asked if er did not result in significantly imthey were aware of best practice proved recorded diagnostic rates in crisis management in primary The evidence of mental disorders in routine concare, 61 per cent of CCGs did not Various studies have taken place 42 feel they could clearly identify a to assess the impact of education- sultation . This intervention was a cluster randomised controlled gold standard model. However, al interventions. Agius and Butler trial carried out in Kenya, with the best practice models mentioned 2000, reviewed the management intervention group receiving a included: of mental health illness in the 39 40-hour comprehensive structured »» Northumberland and primary care setting . interactive mental health training Sunderland model »» North West London The study produced a series of ro- programme. collaborative bust educational initiatives to im»» Sandwell hub prove primary care psychiatry and Courses dedicated to crisis mental health that have been identified »» Crest Evolve/ use of navigators the joint working with secondary »» Catch 22 and family action in care mental health professionals. nationally and internationally. NHS Scotland has a mental health Wandworth It is believed that mental health crisis intervention and suicide »» South London and Maudley management in primary care is mental health trust – responsive reliant on the knowledge and skills prevention in primary care course suitable for staff in primary and psychiatrists assisting GPs and of the primary care team and the secondary care settings within the “very skilled A&E liaison links with their secondary care rural, remote and island settings team” colleagues. Almeida et al, 2012 reviewed the impact of an educa- (with limited access to specialist care). The virtual online course Service user engagement event tional intervention on depression 40 offers the necessary skills needed People with lived mental health and self-harm in older patients . to manage a mental health crisis crisis experience felt that frontline The intervention successfully primary care staff require further prevented the onset of new cases in line with the local psychiatric emergency plan43. training to understand their needs. of self-harm behavior and reThis included an understanding duced the two year prevalence Southern Australia Health run a of the impact of physical health of depression. Sikorski, 2012 is prescriptions. the first overview of a randomised one day workshop entitled The non-violent crisis intervention controlled study introducing GP programme, developed by Crisis “Physical health does come hand training for depression care41. It Prevention Institute44. The workin hand with mental health.” seems that training, if combined shop teaches staff to respond to with guideline implementation, the warning signs that someone Issues around referrals to inapcontributes to enhanced care for is beginning to lose control and propriate services and bouncdepression in primary care. addresses how staff can deal ing between services were also with their own stress, anxieties, raised. Time to Change launched a pilot training scheme in GP surgeries in and emotions when confronted “Not understanding the services Lewisham and North Staffordshire with these challenging situations. This programme focuses they are sign posting to – thereto improve healthcare profeson prevention, de-escalation, fore inappropriate signposting.” sional’s knowledge, attitudes and and the breakaway principles to behavior around mental health. assist staff to respond early to a “Lack of communication between The training was designed to adpotential mental health crisis. Staff services.” dress discrimination and stigma within primary care services (See will be clear on ways to intervene to help prevent an escalation of A bad experience included the Case study 13). anxiety and aggression as well lack of support once discharged from secondary care. There is limited literature evaluat- as develop and understanding of the impact their responses can ing the outcome of training in a “GP was my first point of call crisis intervention. A mental health have on a potentially aggressive incident. when discharged from mental training programme had signifi-

Awareness of best practice

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health services - then stated it’s not their field.”

ACCESS TO CRISIS CARE SUPPORT City and Hackney CCG mental health training (Case study 10) City and Hackney CCG have just launched a programme of training for all primary care staff offering free Mental Health First Aid Lite courses to all GP reception staff. The next phase of the programme will be to offer a two day course to those reception staff who would like further training. Practice nurses, district nurses and health care assistants are encouraged to attend the UCLPartner’s mental health and wellbeing training package for practice nurses (Case Study 12). This includes face to face and e-learning which ensure that nurses have a thorough and wide understanding of mental health in primary care including crisis management. For GPs, educational sessions and workshops continue to run. Mental health training has also been incorporated into this year’s locally enhanced service (LES). GP practices are required to ensure that all reception staff have children and adolescent mental health crisis training to be able to respond better to young people who need urgent access to primary care. City and Hackney have been awarded a grant to develop a community mental health education and training hub which will promote good mental health training across professions in the borough. Joint training opportunities between schools, workplaces, health, police and the local authority will be arranged and a virtual shared calendar of training will be set up. This will help to build a strong sense of community resilience so that more people are empowered to help people in crisis.

Kingston CCG advanced diploma in mental health (Case study 11) Kingston CCG has been awarded funding to provide training to advanced diploma level in mental health to 20 Kingston GPs. The programme is accredited by RCGP and to be delivered by PRIMHE, from autumn 2014 to summer 2015. There will also be training for nurses to follow and awareness training for all interested other GPs and their practice staff. The overall aim is that there will be enough GPs trained to this level to assist and support the delivery of mental health care in primary care across Kingston. There are 27 practices and this would mean ‘buddying up’ for some. Overall, each trained GP practitioner will cover a population of roughly 10,000 registered patients.

“I can’t believe how much of this stuff really works.” - GP, Sandwell

“Feeling heard and having your wishes considered by your GP is the most important thing.”11 30

ACCESS TO CRISIS CARE SUPPORT Supporting information

Mental health in Scotland: Examples of related existing National Standards for Crisis standards Service5 NICE Guidelines10 »» Immediately before assessment »» Support individuals who selfharm a service user who has been »» Have referral criteria agreed referred in a crisis, find out if that ensures self-harm is not a they have had experience of barrier to appropriate service acute/non acute mental health response services and consult any crisis »» Address childcare issues and plan and advance statements. needs of dependents to support Find out if they have an future management of crisis advocate and contact them if »» Outline roles/responsibilities service user wishes. between crisis service, and »» Assessment in crisis should services that most often form be undertaken by experienced first point of contact e.g. health and social care helplines, GPs, police, A&E professionals competent in departments crisis working and include assessment of the service user’s relationships, social and living circumstances and level of functioning as well as their symptoms, behaviour, diagnosis and current treatment »» When referred in a crisis the patient should be seen by specialist mental health secondary care services within 4 hours of referral »» To avoid admission aim to explore support systems (family, friends, carers), support service user in crisis in their home environment, make early plans to help service user maintain activities (work, education, voluntary work) where possible »» When communicating with service users use diverse media including letters, calls, emails etc

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References to case studies

»» City and Hackney CCG mental health training (Case study 10) »» Kingston CCG advanced diploma in mental health (Case study 11) »» Bespoke mental health training for practice nurses (Case study 12) »» Time to Change: mental health training for GPs (Case study 13)

EMERGENCY AND URGENT ACCESS TO CRISIS CARE Area 5: Emergency departments Commissioning standards and recommendations Emergency departments should have a dedicated area for mental health assessments which reflects the needs of people experiencing a mental health crisis Dedicated areas should be designed to facilitate a calm environment while also meeting the standards for the safe delivery of care Resources should be in place to ensure that people experiencing a mental health crisis can be continuously observed in emergency departments when appropriate

Arrangements should be put in place to ensure that crisis plans are accessible to emergency departments and ambulance staff Emergency departments should have immediate access to psychotropic medications routinely used in the management of mental crises including intramuscular preparations Although an intervention of last resort, intramuscular tranquilisation, when necessary, should be administered in emergency departments in accordance with accepted guidance

Mental Health Act assessments undertaken in emergency departments should be completed within four hours of the person’s presentation to the emergency departEmergency departments and local ment in order to ensure parity of esteem mental health providers should work closely to ensure safe effective care pathways between services All emergency department frontline staff should be trained in the assessment and management of mental health crisis

Systems should be in place to ensure that people who regularly present to emergency departments in crisis are identified and their care plans appropriately reviewed

Difficulties with long waits in busy areas were “enough to push me over the edge.”3

- Event participant

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large proportion of crisis and urgent mental health problems present to emergency departments. Primary mental health presentations account for around five per cent of emergency department attendances45. Between 13 and 20 per cent of admissions are associated with alcohol related problems, and selfharm is the most common reason for acute medical admissions. Self-harm is one of the top five reasons for admission to hospital for emergency medical treatment, accounting for up to 170,000 admissions in the UK each year46.

Lack of urgent care mental health services mean people default to emergency departments. Often such cases are not appropriate or eligible for secondary care home treatment teams2. Research has shown that people with mental health conditions attend emergency department services more frequently than the average. Mental health problems are common in frequent attenders with a significant proportion being linked to psychosocial exacerbations of underlying conditions. The prevalence of mental illness among people with physical health conditions is two to three times higher than in the rest of the population. People with depression are twice as likely to use emergency services as those with long term conditions without depression2. There have been many accounts of individuals presenting at emergency departments in distress, waiting for hours for assessment and treatment as there is no mental health professional available. Long waits in a chaotic, busy and unsettling setting such as emer-

EMERGENCY AND URGENT ACCESS TO CRISIS CARE gency departments can lead to more distress and unnecessarily escalate a mental health crisis or lead to the individual absconding. Individuals experiencing a mental health emergency need the same immediate medical attention as they would for a physical health problem. The All Party Parliamentary Group on mental health11 asked service users about mental health services at A&E and if appropriate care was provided their responses included: “Put separate emergency rooms in A&E departments for psychiatric patients staffed by consultants not junior doctors with very little experience of mental health.” “Encourage mental health care providers to have their own mental health A&E departments.” “I voluntarily took myself to A&E because I was afraid I would hurt myself. As soon as I arrived at reception I was immediately dismissed and told that I would have to wait, there are people with more serious problems here. I waited until 3am before I met with members of the crisis team. They were unhelpful and dismissive. I was sent home at 5am and told to just contact my GP.”

SCN findings Referring to emergency departments

Fifty-nine per cent of CCG leads said patients in crisis are referred to emergency department. The majority of the leads also said this especially out of hours. Fifty-six per cent stated that crisis assessments typically take place in emergency departments, which reveals the frequent use of emergency department admissions.

There were a range of reasons for GPs to refer patients to emergency departments. These included: »» Self-harm, overdosed or at risk to themselves or others »» Out of hours »» Patient not under mental health services »» Cannot access support (community crisis team, consultant or crisis line) not available, unresponsive or slow to respond, lack of capacity »» An associated medical need/ physical issue »» When crisis plan is not working The most popular responses by far were self-harm, overdosed, at risk and out of hours. There is frustration that there is limited response from mental health teams which finish or are unavailable after 4pm or 5pm – even when primary care services are still open at 5pm to 7pm. Some other responses included when there is no other option, GP unaware of crisis line or access services and when unable to get through on the crisis line with distressed patient. When asked ‘Does your GP out of hours provider know where to get help in an emergency?’ the majority of responses were “default to A&E”. Even in cases where the GPs think they know where to get home treatment from, they still claimed “patients still go to A&E or end up there”. Some stated that “A&E is the guidance they are given from their provider and is the current pathway”. One response noted, “There is no help other than A&E. Seven day working needs to address mental health!”

When asked ‘What would the ideal ‘crisis’ look like?’ several leads responded “not use A&E if possible”. Other responses included: “Same team working in all settings (eg A&E as well as community)” “Access times one hour in A&E” The majority of trusts stated that people experiencing mental health crisis present at emergency departments. In some areas of London, the majority of crisis referrals come through local emergency departments. Eight of the nine mental health trusts asked stated that local GPs are advised to refer the patient to emergency departments if experiencing mental health crisis for the first time. Two trusts specified that emergency department was necessary only if extremely urgent. “The decision as to whether to refer to A&E is dependent on the nature and severity of need. If there is an associated medical concern such as overdose which needs to be cleared then A&E would be used.” Within the community mental health team, the trusts were asked ‘What actions does the care coordinator/duty person take when managing a crisis?’ Five of the nine trusts said “ask patient to attend A&E” as one of their answers (alongside other actions, such as refer to home treatment team, arrange review by doctor etc). None of the mental health trusts have a walk-in centre dedicated to mental health crisis, although one

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EMERGENCY AND URGENT ACCESS TO CRISIS CARE trust considered their emergency department as a walk in centre facility.

the supported discharge service and could make contact with the team directly. A member of the team would then usually attend “Yes, individuals in crisis can the home of the young person or present to mental health liaison meet somewhere in the commuservices based within A&E depart- nity, or be seen on the ward. If a ments any time 24 hours a day, young person or child is on leave seven days per week.” from a CAMHS inpatient unit, they would return directly to that unit as per care plan.” Children and adolescent mental

health services (CAMHS)

When the mental health trusts were asked what arrangements were in place out of hours for under 18s presenting in crisis, most trusts claimed that A&E was used. One trust stated that under 18s presenting in crisis (known to the services) can contact the trust out of hours for advice. If they are not known, they could attend A&E for assessment by adult mental health staff who can notify the senior CAMHS staff on call. There was no out of hours home treatment team for under 18s in the trust at present. Another trust stated that they can access the mental health liaison teams based within A&E for assessment. Where required, support within A&E is also provided by healthcare assistants who are available to accompany the individual for the time they are there. In one area they are developing a specialist CAMHS nurse role to work within the mental health liaison team two shifts per week. Referral to CAMHS is made following assessment. Other comments included: “Any patients under 18 years old presenting through a section 136 or at A&E will be seen immediately by the adult mental health staff and referred to CAMHS’ on call staff. A small number of young people may be under the care of

“The CAMHS service director in one area is meeting with five of the local authorities to discuss what out of hours social work interventions are available. There is an out of hours CAMHS SPR contract serving nine boroughs who will come out and see any 16-18 year old if admission to hospital appears to be indicated. There are also triage facilities in all of the acute hospitals that sit behind A&E.”

Service user engagement event Individuals with experience of mental health crisis, raised concerns regarding emergency department setting, training of staff and accessibility out of hours.

“Why should mental health be different to physical health?” “Is A&E the best setting for crisis care?” “There should be dedicated, trained mental health nurses in all A&E departments – who have access to my current care plan” “More out of hours support that isn’t A&E.”

relative room which can be used by anyone at any time.” “I sometimes feel the staff make the assumption if you are married you already have support from your partner.” Positive experiences were captured: “I had a good experience in A&E. I had a really nice psychiatrist who helped me through my crisis and put me in a safe place where I was with experienced staff 24 hours and one to one.” “I think sometimes that we forget that non-mental health staff professionals can play an important role in how well we are treated in places like A&E as well.” “One of the staff escorted me to the A&E department, made sure I was safe, introduced me to the staff there, and then took me to a room that was secluded from the general A&E department. It was nice and airy and it had a lilac colour which was quite calming. The chairs were such that if I felt I wanted to lie down they weren’t uncomfortable.” “A&E can be quite disruptive, and when you’re in crisis you need to be somewhere where you can be calm, have access to water, if you want to read a book, and also having the staff coming in and checking in on you every so often, you know, that was very reassuring.”

Negative experiences included: “Left alone in cubicles” “Rooms not identified specifically for mental health – often uses

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EMERGENCY AND URGENT ACCESS TO CRISIS CARE calm environment and resulted in teams including; one registered reduced numbers of people leavmedical practitioner and at least Although there are current efforts ing prior to assessment due to the one other registered healthcare to reduce emergency departnoisy and busy surroundings. It practitioner ment presentations, enhancing also resulted in reduced numbers » » An escalation protocol is to be access to mental health services of hospital admissions, preventing place to ensure that seriously as alternatives and the avoidmental health crisis escalation49. ill/high risk patients presenting ance of emergency departments The Royal College of Psychiatrists to the urgent care service are being used as a default option, recommends: seen immediately on arrival some service users will continue “that every A&E department by a registered healthcare to present there. There have been should have at least one inpractitioner. toolkits and plans developed to terview room for psychiatric » » All patients are to be seen improve mental health services consultations, close to or part and receive an initial clinical within emergency departments. of the main A&E receiving area, assessment by a registered The College of Emergency Medito enable assessments to take healthcare practitioner within cine produced a toolkit for mental place in a setting that provides 15 minutes of time of arrival at health in emergency departments, privacy, confidentiality and urgent care service which supported getting timely respect.”50 »» Urgent care services to have access to appropriate specialist appropriate waiting rooms, services for all individuals47. It also Supervision is also required with treatment rooms and equipment highlights how a busy and chaotic observation from a central locaaccording to the workload and emergency department can be tion, with security, privacy, appatients’ needs detrimental and potentially escapropriate toilet facilities, lighting, late a mental health problem. furniture etc. reviewed, with staff References to case studies with the necessary competences » » Whittington integrated liaison Psychiatric emergency departand staff members, being conassessment team (Case study ments in other countries, such as 14) the US, have reviewed the impact siderate and trained to meet the 48 of an emergency department set- needs of individuals . ting48. The space is often the most vexing issue as well as the layout Supporting information Examples of related existing and design within a psychiatric standards emergency department. NICE Guidelines10 »» On arrival at mental health Construction of the psychiatric services for assessment, emergency service should considservice users should be greeted er the individual’s conditions and and engaged by reception needs, accounting for the and other staff in warm, »» Irritable/over stimulated friendly, empathic, respectful patient who requires a quieter and professional manner, environment anticipating possible distress »» Impulsive or paranoid patient » » Ensure that waiting rooms are who may leave/abscond comfortable, clean and warm »» Agitated patient who requires and have areas of privacy, constraint/seclusion especially for those who are »» Suicidal patient who requires distressed or who request this a safe environment free of or accompanied by children hazards48

The evidence

The CQC reported on an A&E department where an assessment lounge had been provided. Clinical staff reported this facility as “invaluable” as it provided a

London urgent quality standards24 »» During the hours that they are open all urgent care services to be staffed by multidisciplinary

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EMERGENCY AND URGENT ACCESS TO CRISIS CARE Whittington integrated liaison assessment team (Case Study 14) The integrated liaison assessment team has the following features: Consultant/specialty trainee follow-up clinic -The consultant and specialty trainee offer a follow-up clinic during the week for patients seen in the emergency department. This clinic is for cases where there are diagnostic difficulties or medication issues. Liaison follow-up clinic - The team provides a follow-up clinic seven days a week. This is typically offered to those who do not require admission or crisis team follow-up and who do not have easy access to community follow-up. This clinic may also be helpful for ‘new’ core trainee doctors, particularly on call at night, who are not yet confident with their management plan and would like a second opinion. The patients are seen in an interview room in emergency departments. This clinic is available to patients from any area regardless of whether they are already under the care of one of the community teams, and is not a replacement, but a support, to existing services. Direct referrals -The team has developed an initiative to identify patients who are more appropriately referred directly to psychiatry from the triage nurse using an agreed protocol. This is a joint agreement between A&E and the team. Direct referrals take place 9am to 8pm, 7 days per week. Parallel assessments - To reduce waiting times in the A&E and improve patient management, the team can carry out assessments in parallel with emergency staff before a patient is deemed ‘medically fit’. The key issue will remain whether an individual’s mental state is accessible. Parallel referrals can be made as soon as possible after the patient arrives.

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EMERGENCY AND URGENT ACCESS TO CRISIS CARE Area 6: Liaison psychiatry Commissioning standards and recommendations People should expect all emergency departments to have access to on-site liaison psychiatry services 24 hours a day, 7 days a week, 365 days a year Liaison psychiatry services should see service users within 1 hour of emergency department referral to ensure a timely assessment and minimise risk Clinicians in the emergency department should have rapid access to advice from a senior clinician following emergency department crisis assessments

“Only 40 per cent of general hospitals have a psychiatric liaison service.”3

“Locally we majorly need an investment in liaison services and for commissioners to support the work under way.”53

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L

iaison psychiatry addresses the mental health needs of people attending the general hospital in emergency departments, inpatient and outpatient settings.

»» Vulnerable groups such as the homeless, people with personality disorders, victims of domestic violence and abuse, children and young people at risk

People with acute mental health problems commonly present to emergency departments therefore liaison psychiatry has a key role to support those in crisis. For many, an assessment in emergency department will be their first experience of mental health services.

Liaison psychiatry services in a general hospital could generate savings of up to £5 million a year by improving the care offered to people in hospitals who have a mental health condition52.

Timeliness is also a necessity as emergency departments have a performance target requiring all patients to be discharged within four hours. Effective liaison psychiatry services should therefore be located in general hospitals, able to respond quickly to emergency situations, and well integrated with community mental health services and social care. Mind’s Listening to Experience report3, demonstrates that people who use services want to see liaison services in every emergency department. According to liaison psychiatry guidance51 there are six main patient groups who attend emergency or unplanned care at acute hospitals who stand to benefit from liaison psychiatry services. »» People who self-harm »» People with physical and psychological consequences of alcohol and substance misuse »» Frail older people »» People with known severe mental illness when in relapse »» People admitted with primarily physical symptoms which upon assessment have psychological or social causation

According to the liaison psychiatry guidance commissioned by the South West Dementia, Mental Health and Neurological Conditions Strategic Clinical Network there is evidence that for every £1 invested in liaison psychiatry services, up to £4 of value is returned to the local economy51. There remains however wide variation around the country both in the availability of liaison psychiatry services in general hospitals and in models of service delivery.52 Rapid assessment, interface and discharge (RAID) has been recognised nationally for its innovative approach to liaison psychiatry. Evaluations of the RAID model has shown to reduce admission, length of hospital stay, costs and revealed clinical benefits to service users54

EMERGENCY AND URGENT ACCESS TO CRISIS CARE SCN findings

When the mental health CCG leads were asked where patients are typically referred to when presenting in a crisis, a few mentioned liaison psychiatry at emergency departments as an option. “They go to a single point of access in secondary care mental health. This is backed up by liaison at A&E.” “Try to refer to community mental health but often have to resort to A&E for the liaison psychiatry team.” GP out of hours services do know about the assessment and liaison team but according to one source, are more likely to use emergency departments due to immediacy and availability. When asked how they would like mental health crisis provision to be different, a couple of responses included more capacity for the A&E liaison team, and there was support for better liaison services in one particular borough. When the trusts were asked where the majority of crisis referrals come from, three of the nine trusts asked stated A&E departments via the liaison psychiatry departments. Two of the trusts specifically claimed that people experiencing crisis out of hours go to liaison psychiatry or to the enhanced liaison service. All mental health trusts in London stated that they had a mental health liaison psychiatry team, with all but two having 24-hour coverage. It remains unclear how many teams a particular one trust has across all A&E departments. One trust has an operational liaison psychiatry service 9am-5pm

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Monday to Thursday, and 24-hour coverage Friday to Sunday. The other trust has a 8am-10pm daily service. Both trusts, however, had other services in place to cover the other hours. “Our experience has been that many people come to the attention of mental health services through mental health liaison services in A&E and once the crisis is resolved they disengage with services until they again reach a crisis. This allows little opportunity for interventions which might assist them in coping in the future.”

Service user engagement event

The main concern raised by people with lived experience of mental health crisis was the waiting times around liaison psychiatry. It was agreed that there should be a liaison psychiatry team with every emergency department. “Shorter waiting times when waiting for psychiatric liaison”

The evidence

The Centre for Mental Health report54 collected data from five sites across England. They found variation in the hours worked by hospital-based liaison psychiatry services. In the absence of 24hour liaison psychiatry, mental health crisis teams provide this service, which can be problematic as these teams are community based and therefore focus on home treatment. On site services respond quicker to referrals and therefore avoid the risk that priority will be given to community caseloads55. It is easier for services to be based in-house especially when based on a single point of access and the dynamics around multidisciplinary team working between emergency department staff and ward staff.

The RAID model has been shown to be cost efficient56. An economic evaluation estimated that cost savings were in the range of £3.4 to £9.5 million a year. Most of these savings come from reduced bed use among older patients.54 Studies57 have indicated that patients and staff are satisfied with the service. The RAID model reduces length of stay in hospital as well as reduces the admission rates. The Royal College of Psychiatrists and the Royal College of Physicians recommend that all acute hospitals have access to effective liaison psychiatry services58. The Mental Health NHS Confederation further evaluated five liaison services and included these recommendations: »» All services should be provided on an all-ages basis, which in many cases is likely to imply more work with older people and with children and young people »» Services should approach establishing a service in two stages: a rapid response generic service and then an outpatient clinic for the treatment of mental health problems59 The multidisciplinary psychiatric emergency service (PES) model can be beneficial to psychiatric emergency patients by providing timely rendering of care, improving access to care and ensuring safety and better assessment60. The use of dedicated in-house liaison psychiatry services is more likely to have much greater expertise in the types of mental health problems most commonly found in the hospital setting, for example medically unexplained symptoms, self-harm and delirium.

EMERGENCY AND URGENT ACCESS TO CRISIS CARE There is good evidence that liaison psychiatry services improve the quality of assessments especially in relation to self-harm61. Good quality assessments are in themselves therapeutic leading to improvements in health outcomes including reduced repetition of self-harm62.

Supporting information

Examples of related existing standards Quality standards for liaison psychiatry services (2014)63 Domain 2: Providing emergency mental health care to adults of all ages Standard 21: People with mental health needs are assessed within the appropriate timescales The following standards relate to the responsiveness of the liaison team within its usual operating hours and not the response of other services such as out-ofhours teams. »» Patients are referred for emergency* mental health care are seen within 60 minutes »» Patients referred for urgent** mental health care are seen within the same working day »» Referrers are satisfied with the liaison team’s speed of response to emergency* referrals »» Referrers are satisfied with the liaison team’s speed of response to urgent** referrals NHS Services: Seven Days a Week Forum: Clinical Standards64 Standard 7: Where a mental health need is identified following an acute admission the patient must be assessed by psychiatric liaison within the appropriate timescales

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24 hours a day, 7 days a week: »» Within 1 hour for emergency* care needs »» Within 14 hours for urgent** care needs Supporting information »» Unless the liaison team provides 24-hour cover, there must be effective collaboration between the liaison team and out-of-hours services (eg crisis resolution home treatment teams, on-call staff, etc.) *Emergency: An acute disturbance of mental state and/or behavior which poses a significant, imminent risk to the patient or others **Urgent: A disturbance of mental state and/or behavior which poses a risk to the patient or others but does not require immediate mental health involvement

References to case studies

»» Liaison psychiatry in north west London (Case study 15) »» The hospital mental health team: Hull and East Yorkshire Hospitals Trust (Case study 16) »» Rapid Assessment, Interface and Discharge (RAID), Birmingham and Solihull Mental Health NHS Foundation Trust (Case study 17)

EMERGENCY AND URGENT ACCESS TO CRISIS CARE Liaison psychiatry in North West London (Case study 15)

Hull and East Yorkshire Hospitals Trust: The mental health team (Case study 16)

Central and North West London NHS Foundation Trust and West London Mental Health NHS Trust, worked in partnership to establish pilot services at four acute trusts: North West London Hospitals NHS Trust (Northwick Park and Central Middlesex hospitals), Hillingdon Hospital NHS Trust, Ealing Hospital NHS Trust, and West Middlesex University Hospital NHS Trust. A working group involving mental health providers, acute trust staff, commissioners and service users developed an ‘optimal standard’ model for a hospital of 500 beds that provided an integrated multidisciplinary service with 24 hour input to emergency department and inpatient populations. There have been improvements in mental health diagnosis, treatment and care of patients in acute hospitals with co-morbid physical and mental health problems and a reduction in the overall lengths of stay for the same group.

The team is a multidisciplinary team which assesses patients with a range of mental health problems including acute mental illness; self-harm; attempted suicide; or extreme distress. Dependent upon the nature of the referral the response rates are 30 minutes the same working day or within 24 hours. A further aim is to educate staff within the acute trust to enable them to recognise mental health problems early and refer appropriately.

Birmingham Rapid Assessment, Interface and Discharge (RAID) (Case study 17) The Rapid Assessment Interface and Discharge (RAID) psychiatric liaison service operating in City Hospital, Birmingham operates 24 hours a day, 7 days a week and emphasises rapid response, with a target time of one hour to assess referred patients who present to A&E and 24 hours for seeing patients on the wards. An independent economic evaluation of the service reported that RAID saves 44 beds per day in a 600 bed hospital which equates to about £4 million per year.

“The team has expanded to integrate older people’s liaison service.” - HMHT Hull and East Yorkshire

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EMERGENCY AND URGENT ACCESS TO CRISIS CARE Area 7: Mental Health Act assessments and AMHPs Commissioning standards and recommendations Arrangements should be in place to ensure that when Mental Health Act assessments are required they take place promptly and reflect the needs of the individual concerned

A

ccording to the Mental Health Act 1983, if a person has a “mental disorder” (any disorder or disability of the mind), The provision of AMHPs across they can be admitted to hospital London should be increased in voluntarily as an informal patient order to ensure that Mental Health or be admitted to hospital against Act assessments are completed their wishes as a formal patient65. within the agreed timeframe

Assessing doctors and AMHPs An urgent assessment in the com- should have up to date knowlmunity, not necessitating police edge of what local alternatives to intervention, should be completed admission to hospital (eg crisis within a maximum of four hours houses) are available, these from referral whenever possible should be considered as part of the assessment Assessments should not be delayed due to uncertainty regarding Assessments should consider the availability of a suitable bed. the individual’s crisis plan when To assist in this it is recommended available including any advanced that a pan-London protocol for the directives management of psychiatric beds is developed For Mental Health Act assessments of children and young To ensure the prompt attendance people arrangements should be of AMHPs and section 12 apin place to ensure that at least proved doctors at Mental Health one of the assessing doctors has Act assessments, particularly out CAMHS expertise or that the asof hours, sector-wide rotas should sessing AMHP has expert knowlbe developed edge of this age group

The Act gives an approved mental health professional (AMHP) the power to make an application to admit a person to hospital under a section of the Act if they consider it necessary to ensure the best care and treatment for that person66. An AMHP is often a specially trained social care worker, community mental health nurse, occupational therapist or psychologist who has been approved by the local services authority to administer functions under the Act. The Act gives the nearest relative the right to request that an AMHP considers application for admission to hospital. The nearest relative is determined by section 26 of the Act and is usually the spouse or co-habitee67. The police maybe called to assist in some cases when detaining an individual is particularly problematic.

“About a quarter of people are in hospital without their agreement.”67

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EMERGENCY AND URGENT ACCESS TO CRISIS CARE Although local arrangements may differ, every borough should have a single point of contact where an AMHP can make contact with police to request help with mental health assessments. The reasons for police assistance include to manage risks and to promote cooperation. The Metropolitan Mental Health and Policing Briefing sheet69 describes the common pitfalls around the implications of attending mental health assessments both with and without a warrant.

Use of the Mental Health Act

The following must be considered by the AMHP when undertaking the Act: »» Age and physical health »» Wishes and views of the individuals needs including past wishes expressed by the patient »» Cultural background »» Social and family circumstances »» Impact of further deterioration or lack of improvement on children, carers, family and the individual In the case when a person belongs to a particular patient group, such as under 18 or has a learning disability, at least one of the professionals involved in the assessment should have expertise in this area.

not being met49. There have been reports of difficulties in locating and accessing beds and in some cases the appropriate beds. Evidence includes: »» Four to five hour delays in accessing beds »» Difficulties in locating a bed close to patient (sometimes the other side of the country) »» Repeat assessments under the Act due to beds becoming unavailable »» AMHPs spending additional time with patients in hospital while bed being sourced »» Admission of patients into psychiatric intensive care unit beds (a breach of the Mental Health Act Code of Practice) CQC identified a London trust admitting informal patients to a psychiatric intensive care unit due to lack of inpatient beds. There is an issue of finding a realistic alternative to detention in hospital for patients in crisis who could not remain in the community or within their home. Lack of alternative options increases the number of detentions and pressure on beds. London evidence also shows it can be difficult to access an approved mental health professional outside of office hours, with delays being more than four hours. Reasons for delays include incidents being outside of office hours, social workers providing both AMHP and children services and duty workers being tied up with children welfare issues49.

“AMHPs reported delays of four to five hours in getting a bed were not uncommon.”49

A systematic review on the use of the Act identifying the frequency of the Act, characteristics of patients detained under the Act and the outcomes of the use of the Act. Findings revealed that men are more likely to be detained than women. The most widely studied and important demographic variable was ethnicity, with black individuals more likely to be admitted formally than white individuals. On average, black individuals with psychiatric disorders were twice as likely to be detained against their will. Diagnosis associated with lack of insight, poor self-care and threatened violence to others appear more likely to lead to formal admissions70. There have been limited studies into training needs of practitioners, but senior registrars felt undertrained in the use of the Act, with less than half reporting ever received any formal training.

CQC reported in 2012/13 the highest number of uses of the Act ever reported nationally over 50,000 to detain patients not counting the use of short term holding powers49. In relation to The evidence Prior to 2008, the Act imposed crisis mental health, however, CCGs have a legal duty to desstatutory duty on local authoriadmissions on Section 4 were ignate an inpatient unit where ties to make sure they appointed patients can be admitted in “cases sufficient numbers of AMHPs. The reported to have fallen from 1.9 to 0.7 per cent of all psychiatric hosof special urgency” and tell local 2007 Act amendment removed pital admissions. Over time, many authorities about this. According this with local authorities having to patients admitted on this section to the evidence collated by CQC provide a 24-hour AMHP service were transferred on to Section 3 visits in March 2013, this duty is instead.

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EMERGENCY AND URGENT ACCESS TO CRISIS CARE (detained in hospital for treatment up to six months) with a decrease in the proportion of Section 4 patients whose sections were allowed to lapse to informal status.

Supporting information

Examples of related existing standards NICE Guidelines10 »» When a service user is admitted to a place of safety ensure they are assessed for the MH Act as soon as possible and within 4 hours Mental Health Act, 1983 in relation to crisis and emergency use of the MH Act65 »» Because a proper assessment cannot be carried out without considering alternative means of providing care and treatment, AMHPs and doctors should, as far as possible in the circumstances, identify and liaise with services which may potentially be able to provide alternatives to admission to hospital. That could include crisis and home treatment teams. »» A thorough assessment is likely to involve consideration of: contingency plans (should the patient’s mental health deteriorate) and crisis contact details. »» Especially in times of crisis, decisions about the use of the Act for people with personality disorders will often have to be made by professionals who are not specialists in the field. It is therefore important that approved mental health professionals and doctors carrying out initial assessments have a sufficient understanding of personality disorders as well as other forms of mental disorder. »» In an emergency, such as

Hackney 24 hour AMHP service (Case study 18) The London Borough of Hackney and East London Foundation Trust out of hours AMHP service aims to respond to requests for Mental Health Act assessments which arise outside usual working hours (5pm-9am week days and 9am to 9am on bank holidays and weekends).

Forty-two per cent of AMHPs (from 94 local authorities) said they did not have a ‘special urgency’ arrangement in their area; 45 per cent did not know whether there was one or not.49

The service aims to provide consistency and continuity of care to people requiring this intervention. Since July 2013, it undertakes approximately twenty five assessments out of hours per month. There has been improvement in response times with 100 per cent compliance with the four hour response target. Discussions with referrers has suggested that the service is more accessible and responsive than the previous emergency duty team arrangement and has also been able to undertake some planned assessments out of hours when circumstances are appropriate. There is now a single 24 hour phone number. The service operating costs are less than previously. when the patient is in crisis, as whether the patient can the important thing is that the mix with individuals of their patient is in a safe environment. own age, can receive visitors Once the initial emergency of all ages and has access to situation is over, hospital education. managers, in determining whether the environment References to case studies continues to be suitable, would »» Hackney 24 hour AMHP service need to consider issues such (Case study 18)

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EMERGENCY AND URGENT ACCESS TO CRISIS CARE Area 8: Section 136: Police and mental health professionals

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he interface that exists between crisis services and emergency services (such as the police, ambulance, fire People should expect appropriate Police and mental health probrigade and emergency departcontingency plans to be in place viders should follow the Lonments) is critical to the delivery in the event of multiple section don Mental Health Partnership and management of crisis supBoard section 136 Protocol and 136 assessments. If a trust has no port. In many cases, these servicimmediately available designated adhere to the pan London seces are the first point of contact for places of safety for a section tion 136 standards someone experiencing a mental 136 assessment arrangements health crisis and are responsible should be in place to access an The police should be provided for their transition to more specialalternative within the trust or by with a single number to access ised mental health support. arrangement with a neighbouring mental health professionals for advice and they should ideally use organisation Over the past decade, police this facility before using their secinvolvement in mental health Follow up should be arranged for tion 136 powers crisis has been recognised. Police people in their area of residence officers act as gatekeepers makwhen they are not admitted to When people are detained under ing critical and difficult decisions hospital following a section 136 section 136 they should be taken within local communities. assessment and their GP into a NHS place of safety. If under any circumstances police custody formed in writing regarding the criPolice teams have powers under is used as an alternative, arrange- sis presentation and the outcome section 136 of the Mental Health ments should be made to underAct to take someone to a place of stand why this has happened and safety for a mental health assessa full partnership review should ment. According to the Act, if the take place to avoid further inciindividual’s behavior is violent dents of this nature occurring or aggressive, police should be asked to assist and they should Organisations commissioned to be taken to a place of safety provide places of safety should by ambulance (or similar) even have dedicated 24 hours, 7 days a where police are assisting65. week, 365 days a year telephone Safety in Mind DVD numbers in place. The police or Individuals should be transported any other service transporting The Vulnerability Assessment in a safe manner as agreed locally people should always use these Framework has been between police, approved mental numbers to phone ahead prior to adopted by a number of health practitioners and health arrival at any place of safety partners in London already. services. Where police vehicles A partnership training DVD are used due to the risk involved it “On average across called ‘Safety in mind’ uses may be necessary for the highest the assessment framework. qualified member of an ambuLondon, 42 percent of The DVD has been jointly lance crew to ride with the patient. respondents reported developed by South London In this situation the ambulance and Maudsley Mental should follow directly behind to that where a patient is Health Trust, Metropolitan provide assistance. Where the denied access to a place Police Service and London person has a physical injury, of safety, a principal Ambulance Service and was illness or condition (including launched on 03 October intoxication) that requires medical reason for doing so is 2014. attention they should be taken to that the place of safety is More information: an emergency department. already in use.”33 http://bit.ly/slam-film

Commissioning standards and recommendations

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EMERGENCY AND URGENT ACCESS TO CRISIS CARE Only after the injury or medical requirement has been resolved should the person be taken to the designated health based place of safety.

are equipped to make the necessary decisions. This would then led to people receiving care more quickly and reduce the use of section 136.

Police involvement is sometimes appropriate and necessary “especially where a crisis could not be foreseen or prevented, but often they act as a default where mental health services fail.”71

SCN findings

It is frequently reported that the place of safety is police custody which should be used only in exceptional circumstances. Despite many accounts of compassionate police officers, police cells are not appropriate11 and officers do not have the right training or expertise to manage a mental health crisis. In some cases, the police cannot access or locate an available place of safety and lack support from other services. The role and responsibility of the police, emergency departments and ambulance services need to be closely examined especially in relation to their interaction with mental health teams. The London Mental Health Partnership Board action plan72 explores a number of solutions and recommendations regarding section 136 including around access to places of safety, police response, the role of section 12 doctors and training. Multi-agency approaches are now being considered between the police and the NHS. Street triage aims to respond to crisis at the earliest opportunity with a mental health nurse available for assessment before police officers potentially exercise their powers under section 136. With mental health professionals giving appropriate advice, police officers

Interaction with the police seems variable across London at borough level. London mental health trusts were asked if there was a liaison service provided between the trust and the local police. Six mental health trusts had one, two did not and one trust did not provide an answer. “This is delivered through different mechanisms across the trust. Local borough liaison meetings that have traditionally looked at section 136 have extended to include AWOL and AMHP interface issues” “Have local police liaison groups in place in each borough” One of the trusts which answered that they did not suggested good relations with the police were maintained. “No but have regular meetings with police in some boroughs” Two trusts mentioned the police as part of their transformation programmes which were currently in operation. One trust is currently piloting the mental health police street triage scheme. Another trust said that they were working closer with police through provision of liaison and diversion. When mental health trust websites were reviewed, places of safety do not seem to be available consistently across London. Two London scenarios clearly indicate the issues that can occur when locating and accessing

places of safety for service users experiencing a mental health crisis. It is important to note that when individuals are denied access, it is not recorded in a systematic way that is monitored and so the frequency and distribution of such cases remains unknown. To support the police and other emergency services in accessing places of safety, it is important that the correct information is available.

The evidence

Nationally, in 2011/12 the section 136 power was used at least 23,500 times49, with more than a third resulting in a police cell being used as a place of safety73. In 2012/13 there were 21,814 reported, of which 7,761 involved the use of a police cell74. In 2013, Metropolitan police cells were used 87 times in London, with a monthly average of 7.25. In 2014, so far, there have been 17 uses of a police cell with a monthly average of 2.2. This is a 70 per cent decrease. For use of section 136 studies show a high prevalence of schizophrenia, personality disorders and mania in individuals detained under section 136 and an over representation of black detainees.75

“In 36 per cent of cases those detained under section 136 of the Mental Health Act 1983 were held in police cells rather than health-based places of safety.”11 45

EMERGENCY AND URGENT ACCESS TO CRISIS CARE Behaviors precipitating section136 detentions included causing a disturbance, threatened or actual violence or self-harm and aggression or threatening behavior and drug or alcohol use has been shown to precipitate up to 29 per cent of referrals.76 Many individuals detained had previously been detained under section 136 at some time in the past and a majority of studies reported a strong correlation between police officers beliefs about a person’s mental state and corresponding psychiatric assessments.75 Borschmann et al, 2009 reported most of the studies were London based.75 It is likely that a high proportion of London based studies is representative of the fact that considerably more episodes of section 136 occur in London than anywhere else in the UK.77 A small rural study revealed a general dissatisfaction with the quality of care and treatment both from the police and professionals. Detainees recognised the need for police intervention but felt they lacked the mental health skills to meet the needs of the individual78. This report suggests the need for a place of safety other than emergency departments or police cells and reinforces the Mental Health Code of Practice 2008 stating that a police cell should be used on an exceptional basis.

Previous studies79 have reported a desire for training as well as multiagency section 136 agreements. About half of emergency department staff and the police in the study did not know that detainees were entitled to information and legal rights if requested. Police departments across North America have taken part in a programme altering police officers knowledge, perception and attitudes towards persons with mental illness called the Crisis Intervention Team. It is designed to improve officer’s ability to safely intervene, connect individuals to mental health services and appropriately manage crisis80. The training involves the police collaborating with mental health providers and community stakeholders and covers signs and symptoms, mental health treatment, co-occurring disorders, legal issues and de-escalation techniques80. An important element of the model is a central designated psychiatric emergency drop-off site with a no refusal policy81. This enables the police officer to transport the individual to emergency mental health services for assessment and then get back to other community duties. It has successfully been used in many law enforcement agencies worldwide80, 82, 83, 84, 85, 86.

“In 36 per cent of cases those detained under section 136 of the Mental Health Act 1983 were held in police cells rather than health-based places of safety.”11 Supporting information

Examples of related existing standards NICE Guidelines10 »» After application of mental health Act ensure that the police are involved only if the safety of the service user, family, carers, dependent children or health and social care professional is an important consideration and cannot be managed by other means such as involving more professionals

References to case studies

»» Vulnerability Assessment Framework training tool (Case study 19) »» London street triage pilot (Case study 20) »» Integrated mental health team based within police headquarters (Case study 21) »» British Transport Police (BTP) suicide prevention project (Case study 22)

Several studies also reported poor communication between different agencies and poor levels of knowledge regarding the implementation of the section. It is suggested that an increased level of training as well of collaborative training between police, ambulance staff and mental health professionals would contribute to more effective resources and implementation of section 136.

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EMERGENCY AND URGENT ACCESS TO CRISIS CARE Vulnerability Assessment Framework training tool (Case study 19) The Vulnerability Assessment Framework provides a simple tool for Metropolitan police officers to use to identify those that are vulnerable and possibly in need of further help. The tool was developed by the University of Central Lancashire, originally called the Public Psychiatric Emergency Assessment Tool. Since this system went live over 55,000 reports have been completed, enabling the police and partners to identify individuals that are becoming vulnerable far earlier and enabling early intervention.

London street triage pilot (Case study 20) NHS England (London Region) together with the Mayor’s Office for Police and Crime (MOPAC) have commissioned a Street Triage Project in London, piloted in the boroughs of Lambeth, Lewisham, Croydon and Southwark. The triage service consists of mental health practitioners accompanying police officers to mental health related call outs and/or providing dedicated telephone support to officers on the ground who are responding to people in crises. The mental health practitioners are deployed specifically to help officers decide on the best option for individuals in crisis by offering professional, on the spot advice and assessment, accessing health information systems and liaising with other care services to identify the pathways for those individuals in need of support. The project aims to reduce the use of section 136 of the Mental Health Act amongst the police and reduce the amount of time that officers spend dealing with people who are in crisis due to mental health problems.

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QUALITY OF TREATMENT OF CRISIS CARE Area 9: Crisis houses and other residential alternatives Commissioning standards and recommendations Commissioners should ensure that crisis and recovery houses should be in place as a standard component of the acute crisis care pathway and people should be offered access to these as an alternative to admission or when home treatment is not appropriate Crisis houses should be considered as an alternative to early discharge from wards Crisis houses should be appropriately staffed and supported; this should include regular psychiatric input and out of hours cover

“There is no single model for crisis houses.”3

“One of the world’s great mysteries is why we don’t have more [crisis houses].”3

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risis houses and residential alternatives are non-clinical areas, often smaller and less medically focused when compared to an inpatient ward that can meet the needs of people in mental health crisis who need short term support away from home.

The main focus is on ensuring people leave the crisis house with a range of personal wellbeing strategies and tools, coping mechanisms and have access to support networks in the community to ensure they build up resilience to reduce the likelihood of a future mental health crisis.

Alternatives to inpatient admissions have been used in the UK and worldwide. They may be provided within the NHS or the voluntary sector. There is no single model and they can vary as to how they are accessed and staffed3. Alternative approaches are strongly supported by people using services and crisis houses have often been set up in direct response to demand from local mental health service users as a preferred alternative to hospital treatment87.

SCN findings

Crisis houses enable people to recover in a community based, safe and therapeutic environment, which allows them to continue with their day to day routine but in the knowledge that emotional and practical support is available to help them recover from crisis and prevent relapse upon discharge. People using crisis houses are able to influence and provide feedback about how the houses are run through weekly house meetings, they are encouraged to state what could be changed or improved (more activities, group therapies) and are supported to develop and participate in peer led initiatives.

Crisis house provision

Two of the nine mental health trusts have access to crisis houses to manage people in crisis. One trust has access to one crisis house and the other runs three crisis houses, with another run by the voluntary sector. This makes a total of five crisis houses in operation currently to our knowledge in London. One trust who does not have crisis house provision was unclear as to how the service would operate if it was in place: “The current year’s commissioning intentions by the local CCG include provision of a crisis house service, this service is not yet in place and it is not yet clear how this service will operate.” Two trusts included crisis houses in transformation programmes that are in progress or planned. One trust mentioned that an additional crisis house had been opened on the hospital site, and this model was what they were most proud of. A trust stated that there would be “increased alternatives to hospital admission (crisis or recovery houses)” as part of its improvement agenda due to complete by March 2015. Three crisis houses are planned with Rethink Mental Illness and LookAhead.

QUALITY OF TREATMENT OF CRISIS CARE Service user engagement event

There were varying amounts of knowledge about crisis houses among individuals with lived experience of mental health crisis. Some were familiar with the “excellent service” and others did not know what the service provided, saying it sounded “scary” [sic]. Good experiences in mental health crisis included crisis houses “Crisis houses with trained staff and support workers/project workers, to have a minimum stay of one week and maximum of three weeks.” “I’ve been in the women’s service quite a few times, which I found very helpful.”

Community based service types

»» Clinical crisis houses (similar to hospital services but within community settings) »» Specialist crisis houses (like clinical crisis houses but aimed at specific group) »» Crisis team beds (integrated with crisis resolution teams) »» Non-clinical alternatives (managed by voluntary sector, strong links with crisis resolution teams) Reviews identify significantly greater satisfaction within residential alternatives88, 89, 91, 92. Three out of four studies suggest that residential alternatives were better than standard inpatient admissions. The fourth study looked at a service staffed by qualified professional which found it more expensive than a standard admission. The review concluded that some patients do not like inpatient admissions and that using alternatives could relieve pressure on inpatient beds for riskier patients. People reported experiencing less coercion and more autonomy.

More information should be made available to service users regarding alternatives to emergency departments and acute admissions. The criterion for referral and eligibility to crisis houses was unclear, support available within the crisis house was unknown and They also experienced less anger some people claimed “it doesn’t and aggression90. Positive user exist, not for men”. experiences of crisis houses and host families have been further The evidence documented3. Service users Inpatient and residential alternareported that crisis houses were tives to standard acute wards smaller, calmer and more perinclude: sonal. Some service users cited the higher staff to service user Hospital based service types ratio provided a different level of »» General therapeutic wards engagement. It reduced pressure (acute treatment therapeutic on families and reduced stigma of models) hospitalisation91. »» Wards for specific

demographics (e.g mother/ baby, hearing impairments) »» Therapeutic wards for specific groups (e.g personality disorder) »» Short stay wards

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Outcomes are also improved or similar. Alternative services such as crisis houses provide more psychological and less physical and pharmacological care than standard wards92.

Care provision may be more collaborative and informal in alternative services, although there was no significant different in intensity of staff patient contact. Staff patient contact is an important determinant of patient satisfaction so increasing it should be a priority for all services. A further review found that women within crisis houses received just as effective care in improving symptoms and functioning as compared to traditional settings but with higher satisfaction levels at no greater cost or expense93. Improvements in symptoms, social functioning, mood and activities of daily living and a reduction on risk issues can also be seen94. In terms of impact on the health system, crisis houses can avoid repeat admissions to hospital. Good staff satisfaction and low burnout rates can also be seen95. According to the Joint Commissioning Panel for mental health96 crisis houses have been unsuccessful when staffing is low and remote from inpatient units. Self-referrals are also important to people using services3. Day hospitals A Cochrane review identified that day hospitals are a less restrictive alternative to inpatient admission for people who are acutely and severely mentally ill, and one in five people currently admitted to inpatient care could feasibly be cared for in an acute day hospital97. Caring for people in acute day hospitals is just as effective as inpatient care achieving the same levels of treatment, satisfaction and quality of life.

QUALITY OF TREATMENT OF CRISIS CARE There is reasonable evidence to support the use of day hospital care to reduce inpatient care whilst improving patient outcomes. However, there are drawbacks, which include that they are less effective in reducing admission rates as more radical crisis intervention approaches (eg assertive community treatment), may not make cost savings (compared to crisis intervention) and where they fit with other types of care especially community care services97.

Supporting information

Examples of related existing standards NICE guidance: Psychosis and schizophrenia in adults: treatment and management23 »» Crisis houses or acute day facilities may be considered in addition to crisis resolution and home treatment teams depending on the person’s preference and need.

References to case studies

»» Highbury Grove crisis house (Case study 23) »» Camden crisis houses (Case study 24) »» West of Dorset recovery house (Case study 25) »» Hertfordshire Partnership NHS University Foundation Trust (HPFT): Host Families scheme (Case study 26)

“The centre acts for me a great safety network to create a pleasant quality of life. I feel the environment is safe and very pleasant staff of which I am very grateful.”

– Service user, Highbury Grove Crisis House

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Highbury Grove crisis house (Case study 23)

Camden crisis houses (Case study 24)

Highbury Grove in Islington provides an alternative service to hospital admission for people experiencing mental health crisis in a community setting. The service consists of three components including a twelve bed residential service; a crisis phone line provided seven days a week 5pm to 6am and the crisis night centre. The crisis night service is available seven days a week to provide a safe place for service users to meet and socialise therefore minimising social isolation, while providing support where necessary. Referrals to all three services can be made by acute mental health services, housing providers, GP’s, drug and alcohol services, recovery and rehabilitation teams, and service users can self -refer. The service also offers support with developing independent living skills, working towards achieving a full and healthy lifestyle, accessing social and community facilities, training, education and social development, accessing other specialist support and accessing local support groups.

Two crisis houses were established in Camden to provide an alternative to acute inpatient hospital admissions based on a person-centred recovery model. The Camden crisis house model includes a crisis team who support people in their homes and act as gate-keeper for admissions and a structured acute day treatment programme, where service users are encouraged to participate in therapeutic groups. A robust range of treatment and support is provided which can safely meet the needs of people experiencing a crisis, flexibility and responsiveness to individual needs and resources to enable people to manage their own crisis in a community setting where possible. People are admitted to the houses at the height of acute crises for brief stays of on average two to ten days. Most people (7478 per cent) are discharged to their own homes.

QUALITY OF TREATMENT OF CRISIS CARE Area 10: Crisis resolution teams / home treatment teams Commissioning standards and recommendations People should expect that mental health provider organisations provide crisis and home treatment teams, which are accessible and available 24 hours a day, 7 days a week, 365 days a year Assessment by the mental health team following a crisis referral should take place within: »» 4 hours in an emergency »» 24 hours if urgent In extreme circumstances, when the risks are immediate, flexible and responsive services will be required The eligibility criteria for crisis teams should be readily accessible and shared with referrers to ensure referrals are appropriate; this should include guidance as to what constitutes an emergency referral

Feedback should be provided to service users and referrers regarding the rationale in the event of a service user not meeting the eligibility criteria for a crisis team Feedback provided within 24 hours to all relevant agencies following assessment or following a decision being made not to assess Initial assessment must be undertaken by suitably trained and supervised mental health clinician A summary should be sent to the referrer within 24 hours of assessment completion which should include detail of all actions to be taken Mental health crisis teams should use the CORE Crisis Resolution Team Fidelity Scale criteria for benchmarking best practice

Information regarding alternative services (including, for example, how primary care can better support the individual) should be provided when a person is assessed as not meeting eligibility criteria for a crisis team

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risis resolution teams work within mental health services providing short term, intensive home treatment for people experiencing mental health crisis98. The teams treat patients at home when they would otherwise be considered for admission to acute psychiatric wards. The multidisciplinary teams consist of doctors, nurses, psychologists, occupational therapists and social workers. Terminology used in relation to such teams varies, often being referred to as intensive home treatment teams, mobile treatment teams (in the USA), home-based crisis services, crisis services, rapid response team etc. The common factor is that these teams deliver treatment both in and out of office hours in patients’ homes. The level of cover can vary, some teams are accessible for home visits 24 hours a day, others have other service input when visits are not available. These teams aim to minimise bed use by acting as gatekeepers preventing hospital admissions where possible and supporting people after a crisis as they plan to leave hospital. Research shows they are effective in reducing admissions to hospital and increasing the acceptability of crisis care98.

“Only 40 per cent of CRTs provide a full 24/7 service while 85 per cent provide some cover 24/7.”98

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QUALITY OF TREATMENT OF CRISIS CARE In practice, crisis resolution teams have a patchy gatekeeping role with involvement from trusts and communities differing. Only 35 per cent of teams have access to non-hospital beds98. Not all are readily available, staff report high caseloads, understaffing and a variable approach to delivering the gatekeeping role. Variation in role can also dilute their ability to focus on crisis home treatment, with some teams expected to fulfil other functions such as running psychiatric liaison services from emergency departments. Confusion over role boundaries and variability in job functions are understandable when these teams are designed to work in partnership with other mental health care services. In certain areas there are concerns about how well the teams are integrated with other services98.

SCN findings

tients experiencing crisis out of hours go through the local crisis resolution teams. One trust’s stated that crisis teams are required if “face to face” assessment is needed. “They [service users] contact the crisis resolution home treatment who will respond to where ever the person is – GP surgery, own home, A&E.”

Funding crisis resolution teams

As part of one trust’s transformation programme, some of the less well funded home treatment teams are receiving additional investment to increase the size of their teams, and others are reviewing the crisis care pathway to home treatment services as part of their ongoing service redesign programmes.

Service user engagement event

People with lived mental health crisis discussed the importance of having an accessible crisis mental health team. It was also clear that teams varied across the London boroughs in terms of service provision and staff knowledge.

Access to crisis resolution teams A quarter of London mental health CCG leads thought GP’s tend to refer patients to crisis resolution teams out of hours. Others referred to crisis telephone lines or emergency departments as an al- “Crisis care should be a 24 hours, ternative, mainly the latter at times day and night service, not 9am5pm Monday to Friday.” “when crisis teams were unavailable or slow to respond”. “Crisis teams should be available 24/7 not saying ‘Sorry we close at There seemed to be time restric5:30pm today, you’ll have to call tions on when crisis resolution an ambulance.’” teams are available, with one response stating that “they do not visit after 8pm”. One CCG lead stated that if an emergency department is not to be an option, crisis resolution teams need to be able to go to the patients’ homes out of hours. Two of the nine London mental health trusts indicated that pa-

The evidence

Prior to 2005 there had been no randomised trials to evaluate the service model of crisis resolution teams within the context of a modern community mental health system100.Evidence from London showed crisis resolution teams can reduce hospital admissions, and also increase patient satisfaction99. The study revealed that individuals with acute mental health emergencies which received care from crisis resolution team tended to be more satisfied with their care. There have been other studies which have shown a reduction in admissions following the introduction of crisis assertive outreach teams, particularly for short admissions. The impact differed according to gender (reduction in female bed occupancy)100. Other evidence suggests that specialised crisis resolution teams are successful in reducing duration of hospital stays with lower associated costs101. Follow up mean costs were £1,681 less than for post crisis resolution team patients implying that crisis resolution teams reduce costs.

“See all sorts of people, I want one familiar face. Can’t handle too many faces.” Good experiences were captured, with advanced decisions being followed by the crisis team, with helpful staff working together with the person.

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QUALITY OF TREATMENT OF CRISIS CARE The benefits of support within the home environment compared to hospital settings in a crisis includes102: »» Equal power between service user and professional »» More likely to understand the situation and incorporate social needs – performing a crisis intervention in the environment where crisis occurred »» Safety and comfort of own home for service user »» Time can be more flexible »» Easier for service user to accept and less disruptive »» More conducive to focusing on service user needs »» Home treatment helps to normalise crises »» Easier for service user to try out new skills »» Opportunity for professional to meet family and to relate to whole family »» Higher rates of satisfaction A 2010 literature review103 suggested that the key positive characteristics of help in a mental health crisis situation are embedded within the core values and principles of crisis resolution and home treatment services. The three themes which emerged through the review included commitment to community based services, the philosophy of partnership and user empowerment. Round the clock availability, telephone contact; flexible referral procedures and rapid response were rated as positive qualities (making patients feel safer)103. Dealing with a crisis within the person’s home helps normalise the crisis and strengthen coping mechanisms. Benefits and positive patient outcomes are dependent on effective implementation of the approach as poorly delivered crisis services could lead to detrimental effects on service users and increase

admissions to hospitals. A more holistic care package is favourable among service users which include medical, psychological, practical help as well as advice on housing and food issues3. To manage risk especially in a mental health crisis service, good communication, responsiveness and accessibility is key. Ideally teams should be accessible 24 hours, be flexible to accept referrals from a range of services and arrange a prompt assessment. Service users and carers continue to state the importance of having access to 24-hour support.

the CORE team can assist with this. (link)

Examples of related existing standards NICE Guidelines10 »» Health and social care providers should ensure that crisis resolution and home treatment teams are accessible 24 hours a day, 7 days a week and available to service users in crisis regardless of their diagnosis »» Health and social care providers should ensure that service users: can routinely receive care and treatment from a single multidisciplinary There are new innovations includcommunity team. That they ing: are not passed from one »» Linking crisis resolution teams team to another and do not with 24 hour residential facilities undergo multiple assessments »» Integration with day services unnecessarily to reduce patient isolation and »» Ensure have timely access to increase occupational activity psychological, psychosocial »» Rotating staff between acute and pharmacological inpatient units and the teams interventions recommended for may improve continuity104 their mental health problem The North of England Strategic Clinical Network have developed a set of clinical standards describing the interventions used in crisis resolution and home treatment services105. The CORE study106 has performed a national audit, reviewing crisis resolution teams to develop a benchmarking tool for teams to review their performance and developing online resources to support service improvement and achieving excellent practice (due 2015).

Supporting information

»» Refer to the North England SCN CRT106 commissioning standards (link) »» Use CORE CRT fidelity scale107 and scoring guide for producing CORE CRT fidelity review. Resource packs produced by

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QUALITY OF TREATMENT OF CRISIS CARE NICE guidance: Psychosis and schizophrenia in adults: treatment and management23 »» Offer crisis resolution and home treatment teams as a first-line service to support people with psychosis or schizophrenia during an acute episode in the community if the severity of the episode, or the level of risk to self or others, exceeds the capacity of the early intervention in psychosis services or other community teams to effectively manage it. »» Crisis resolution and home treatment teams should be the single point of entry to all other acute services in the community and in hospitals. »» Consider acute community treatment within crisis resolution and home treatment teams before admission to an inpatient unit and as a means to enable timely discharge from inpatient units.

Redbridge home treatment team (Case study 27) North East London Foundation Trust provides multi-disciplinary home treatment as an alternative to admission which enables wards to target those who require an inpatient stay. The team consists of social care staff, psychologists and occupational therapists. All referrals to acute services are initially assessed by a mental health practitioner - referring teams are guaranteed an immediate telephone response and physical assessment when needed within two hours. The teams have a 100 per cent gatekeeping role to their wards and are also 100 per cent involved in inpatients discharge: arranging same day home visits for service users discharged from hospital and daily follow up until the end of the acute phase to ensure patients are well-supported in their home environments which better facilitates recovery. The home treatment team works closely with acute wards identifying outstanding practical issues, including service users who are not ready to be discharged at that point. The co-location of the team within the wards at one central base facilitates this integrated way of working. South Tyneside crisis resolution and home treatment team (Case study 28)

References to case studies

»» Redbridge home treatment team (Case study 27) »» South Tyneside crisis resolution and home treatment team (Case study 28)

»» »» »» »» »»

Northumberland Tyne and Wear NHS Foundation Trust provides a crisis resolution home treatment team with the capacity to visit service users up to three times daily, providing a range of psychological and physical interventions including support and psycho-education for carers and families. The team works extensively with the inpatient units, gatekeeping all admissions and providing early discharge planning. The team provides a 24 hour mobile workforce inclusive of nurses, doctors and support workers with access to specialist clinical advice. The mobile team has improved performance in record keeping and reduced time spent completing documentation by using digital dictation via mobile phones, sending records to a transcription service. Access to the team is via the South of Tyne initial response service, which provides 24 hour telephone access for all referrers who require urgent mental health support. Positive outcomes include; collaboration with service users to provide robust packages of care working within a recovery based model a reduction in clinical administrative workload; providing a more timely response to referrals and allows the clinical staff to focus more on clinical interventions the initial response service manages telephone referrals this team provide the face to face response; avoiding disruption to care and providing improved access for referrers maintaining an individual’s care in the community, reducing the adverse effects of hospital admission, a significant reduction in hospital admissions and bed usage and improved financial efficiency

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RECOVERY AND STAYING WELL Area 11: Crisis care and recovery plans Commissioning standards and recommendations Crisis care plans should: All people under the care of secondary mental health servic- »» include information regarding the 24 hour help line and how es and subject to the Care Proto access crisis care services gramme Approach (CPA) and out of hours people who have required crisis support in the past should have »» be accessible to health professionals immediately a documented crisis plan when a service user presents in a crisis (including GPs, ED Those people not on CPA should staff, LAS, NHS 111, GP out of have a crisis plan as part of their hours) primary care local care plans for vulnerable people where appropri- »» focus on individual strengths, networks of support and ate service user defined recovery outcomes Arrangements should be put in »» be reviewed regularly and kept place to ensure that crisis plans up to date, particularly following are accessible to GPOOHs and any crisis presentation, NHS 111 teams admission or significant change in an individual’s circumstances Crisis care plans should be »» identify factors which potentially co-produced by the person with could precipitate a crisis and mental health problem, his/her what steps can be taken to carer(s) and the mental health reduce the likelihood of a crisis professional(s) in such circumstances Mental health professionals should understand the use and purpose of crisis care plans and be trained in their design

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he care programme approach is the national framework which ensures that individuals with mental health problems under the care of specialist mental health services have their needs assessed and an appropriate plan of care then formulated in response. This should then be regularly reviewed and updated as circumstances change. The care plan should include a detailed crisis plan outlining the interventions necessary to prevent and manage potential crises. The Crisis Concordat8 highlights care planning as an essential component of recovery, as well as key in the prevention and management of a mental health crisis. Planning can be used to help plan treatment and used effectively can play an important role in preventing a crisis escalating. The term ‘crisis plan’ is used to refer to multiple plans including joint care plans, crisis cards, treatment plans, wellness recovery action plans, and psychiatric advance directives. Advance directives reflect a person’s preference for treatment should they lose capacity to make decisions in the future (eg when they are in the midst of a mental health crisis). The Mental Health Capacity Act entitles adults who have capacity to do so, to make advanced decisions to inform their care plan when unwell including how they wish to be cared for in times of crisis. Advanced directives have the potential to improve clinical outcomes through an increase in provision of preferred services during crises and improved service user engagement107.

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RECOVERY AND STAYING WELL A joint crisis plan aims to empower service users while facilitating early detection and treatment of relapse108,109.

“Use a support and recovery plan for patients with long term psychotic presentation. Piloting an integrated assessment format including self-assessment and Joint crisis plans are an applicaallows for closer integration with tion of the shared decision making personalised care/personal budmodel107, developed after widegets – aimed at managing crisis.” spread consultation with service user groups109. The joint crisis “All patients have a crisis and plan is formulated by the indicontingency plan which should vidual in collaboration with staff detail the sources of crisis support and aims to increase their level of available to the patient.” involvement. It is kept by the individual and allows them to express “Care plans including crisis and their treatment preferences for contingency plans are provided to any future crisis, when he or she give information specific to their may be less able to express clear needs and both formal and inforviews110. mal support available including family and social networks.” Crisis cards contain key information from an individual’s crisis plan Service user engagement event including who they would want to People with lived mental health be contacted in an emergency. crisis experience valued having a Good crisis planning, including ac- crisis care plan, with some inditive involvement and service user viduals unaware of advanced diengagement reduces the frequen- rectives. It was agreed that crisis cy of relapse and the likelihood of care plans should be developed crisis admission111. together with mental health professionals and carers. Crisis care plans should look at the individual SCN findings as a whole person with a realistic Care planning is used for advanced crisis planning (advanced approach. directives) across all London “Every service user should have mental health trusts. Trusts gave a crisis management plan, shared the following insights: with GP, social worker etc. and the “Advanced directives are used but triggers should be recorded.” patchily.” Benefits of crisis care plans included: “The trust has pioneered a new collaborative crisis and contingen“Not having to repeat yourself to cy plan that is completed in partevery individual you meet.” nership between service users, carers and care coordinators. This Individuals were passionate about forms the basis of the crisis plan what happened to their loved and a ‘hard copy’ plan is given to ones and dependencies when the user and carer and uploaded they have a mental health crisis. on to patient record system so Their wishes should be included, can be accessed by psychiatric respected and followed up as liaison, home treatment teams stated in their crisis management and crisis line.” plans.

“Somewhere within our care plans or crisis management plans we need to have provision made for the care of our pets, in my case my pet is what keeps me well, and we need to plan ….have names, phone numbers, addresses of people who can be contacted either to take the pet and look after it, or who could come and stay in our place, somebody we trust, … the care co-ordinator having the authority, from us through the care management plan.” It was highlighted that service users should be given accurate information and support to understand their rights and entitlements so they can make informed decisions.

“Advanced directives give [service users] control in times of vulnerability.”107

The evidence

Use of joint care plans was found to reduce the number of compulsory admissions under the Mental Health Act together with the number of overall admissions112. Other studies have found less of a direct link but found that patients with joint care plans do feel more respected and engaged in their care. One study found that clincal staff gained a better understanding of the patient’s illness when they have a joint care plan group however implementation requires all team members to be involved. There were also some cases where care plans were not accurately followed when put into action111.

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RECOVERY AND STAYING WELL System level policies and interventions are needed to embed facilitation of advance directives and institute ways to identify patients in crisis, retrieve information and respond appropriately107. Awareness needs to increase and clinicians need to be trained to enquire, access and use advance directives effectively. Discharge planning interventions were noted as effective in reducing rehospitalisation and improving adherence to aftercare among people with mental health problems113. Discharge planning interventions were carried out during the patients’ treatment in hospital with a view to organising care and preparing patients and treatment providers for a smooth transition114. Comprehensive discharge planning can result in reduced readmissions to both acute and community mental health services. Communication between health professionals, service users, their families and carers was found to improve the efficacy of discharge planning115.

Supporting information

Examples of related existing standards NICE Guidelines10 »» Develop advance statements and advance decisions with the person using mental health services. Ensure copies are held by service user and in primary and secondary care records »» Develop care plans jointly with service user »» A crisis plan should be developed by service user and care co-ordinator which should be respected and implemented and incorporated into the care plan.

What makes a good crisis plan? (Case study 29) In 2013/14, one of South West London and St George’s Mental Health Trust’s CQUIN targets was to review the crisis plans of people on care programme approach and implement a programme to improve the quality of crisis planning. The first action has been to co-produce what is considered to be an exemplar crisis plan and good practice standards for the crisis planning process. A three-stage process was used. Stage one, a literature review, stage two a workshop with service users, carers, friends, families and professionals to identify what makes a good crisis plan and stage three a Delphi exercise to identify areas of consensus. 78 out of 94 statements reached positive consensus within the Delphi exercise. 10 per cent of service users and 25 per cent of carers and families in comparison with 49 per cent of mental health professionals disagreed or strongly disagreed with the statement that crisis plans will not work because services will not honour them. The process for coproducing an exemplar crisis plan and good practice standards appears to have worked well. Crisis plans should include: »»Early warning signs/coping strategies »»Support available to help prevent hospitalisation »»Where the person would like to be admitted in event of hospitalisation »»Practical needs if admitted to hospital »»Details of advanced statements »»Degree to which families/ carers involved »»Information about 24 hour access to services »»Named contacts »» Ensure discharge, discussed and planned carefully beforehand with the service user and are structured and phased »» The care plan supports effective collaboration with social care and other care providers during endings and transitions, and includes details of how to access services in times of crisis »» When referring a service user for an assessment in other services (including for

psychological treatment), they are supported during the referral period and arrangements for support are agreed beforehand with them. »» Agree discharge plans with the service user and include contingency plans in the event of problems arising after discharge. Ensure that a 24hour helpline is available to service users so that they can discuss any problems arising after discharge. »» When plans for discharge are initiated by the service, give service users at least 48 hours’ notice of the date of their discharge from a ward. Mental health in Scotland: National standards for crisis service5: »» Be specific with service plans including level and duration of any planned intervention »» Plans are developed in collaboration with and incorporate views of service users and their carers

References to case studies

»» What makes a good crisis plan? (Case study 29)

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RECOVERY AND STAYING WELL Area 12: Integrated care

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Welfare rights problems are a major cause of stress which can precipitate a mental health crisis or worsen diagnosable mental health conditions. People with severe mental illnesses are at higher risk of experiencing a wide range of welfare issues. They are at a much higher risk of homelessness and in some cases this is preventable. Severe mental illness and low income can result in social isolation where an individual can cut themselves off from friends The wider, holistic model embedand family which can be source ded within social prescribing, has of help and support. People with an emphasis on personal experipoor mental health living on low ences, relationships and social incomes or who are unemployed circumstances can be more conare more likely to run into financial sistent with lay concepts of mental or housing difficulties and may wellbeing and mental distress have less capacity to cope or deal than a medical model118. with these problems. In particular, those who are not employed Social prescribing, normally depend on state benefits and if delivered in primary care, links advice is not provided there is risk individuals to sources of support of financial problems including the within the local community. This accumulation of debts and arcan include promoting or recomrears. One problem can aggravate mending opportunities for arts and the other leading to a downward creative activities, physical activspiral into mental health crisis121. ity, learning new skills, volunteerEngagement with advice services ing, mutual aid, befriending and and local partners is therefore cruself-help, as well as support with, cial if people are to access wider for example, employment, benadvice and support. efits, housing, debt, legal advice, or parenting problems119. SCN findings

ntegrated care, for the purposes of this manual, is defined as joined up mental health care, adopting a coordinated approach Services should adopt a holistic between health and social care, approach to the management ensuring all the individual’s needs of people presenting in crisis. are considered. It describes the This includes consideration of coordinated commissioning and possible socioeconomic factors delivery of mental health services such as housing, relationships, to support those in crisis or those employment and benefits who have experienced a crisis, maximising their independence, Provider trusts should work closehealth and wellbeing116. ly with local authority partners

Commissioning standards and recommendations

Bridging support should be provided between crisis services and wider community services e.g. mentoring, befriending, mediation and advocacy Provider trusts should work with partner agencies to compile and maintain a directory of local services which can provide support for service users in crisis e.g. women’s aid, drug and alcohol services and welfare advice services

“Around half of all people with debts have a mental health problem.”117

This approach is reliant on frontline health professionals having access to information about local services and possessing good links and contacts which extend beyond the health sector, and to be aware of the influence social, economic and cultural factors can have on mental health outcomes. A holistic approach takes into account an individual’s background including housing, income, employment, status and welfare.

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Service user engagement event

People with lived mental health crisis experience expressed the need for holistic care which has a whole person approach. This should be based on integrated health and social care model, not on a medical model of care. It was believed that support of this kind would help to prevent future reoccurrences and maintaining wellbeing.

RECOVERY AND STAYING WELL Individuals felt it was important particularly for people without support networks to pursue personal interests and to take part in activities which maybe spiritually or intellectually stimulating. Suggestions included: “Spiritual care delivered by trained (by mental health services staff, eg spiritual or pastoral care staff/ psychologist), especially on safeguarding vulnerable adults. To visit whilst in hospital and then continue in community.” “Art therapy and crafts clubs (eg photography, knitting/crochet, knit and natter groups) led by service users, within community settings.” “Faith groups.” It was also highlighted that advice around practical daily issues were important such as transport, employment and housing issues, this could help prevent mental health crisis triggers. More information on direct budgets and personalised budgets would be useful too. Alignment and coordination of services could be helpful in addressing these issues. Positive experiences were shared:

lems125. A study found a third of people were getting their correct entitlement, the rest were underclaiming. The study also revealed that many had previously been given incorrect or inadequate information in the past by social workers or other mental health professionals126. Debt advice services for people with mental health problems were cost effective127. There is also evidence that face to face services is associate with increased likelihood of debt becoming more manageable compared to telephone advice lines128. Investment in targeted programmes such as debt advice for people with mental health problems is linked to improving their financial circumstances and mental health129. There is an established link between mental health and unemployment, and this is heightened at times of economic downturn127, 130, 131, 132, 133 .

Interventions to combat economic exclusion and to promote social participation of individuals with mental health problems are extremely important in these times, and these efforts should target support to the most vulnerable groups. In 2004, a report “Alzheimer’s Society works with and is based in the same building was published to examine social as the memory clinic and the older exclusion and the lack of support that blights the daily lives of people community mental health people with mental health problem team in (name of hospital). This in the UK. This included lack of works.” support around basic tasks such as claiming benefits and paying The evidence bills which can lead to poverty and Welfare advice services in GP surgeries can increase the uptake social exclusion as well as issues 125 of social security benefits122, 123, 124. around mental health stigma . However due to a range of reasons, including lack of knowledge Social prescribing has been most successful for individuals with among eligible claimants, the mild to moderate mental health uptake is particularly low among problems, and has shown a range people with mental health prob-

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of positive outcomes, including emotional, cognitive and social benefits. It is also a way of reducing social exclusion, both for disadvantaged, isolated and vulnerable groups and for people with enduring mental health problems134, 135. Social prescribing can therefore be a supportive intervention among individuals who are at risk of being socially excluded as a result of experiencing emotional distress. Once a person has reached crisis point, it is much more difficult and costly to restore their employment and social status, with a subsequent exacerbation of economic and health inequalities119. A local commissioner stated the following: “The introduction of social prescribing both as a concept and a service in our locality has been a catalyst for enabling us to think much more creatively and holistically about addressing people’s wide-ranging mental health and social care needs within a non-stigmatising and empowering approach. The principles associated with social prescribing now underpin our developing commissioning intentions for mental health.”119 Factors which facilitate good integrated care for people with mental health problems include co-located services, multi-disciplinary teams, reduction of stigma and navigators116. The benefits of having a coordinator are to assist people in navigating their way through complex systems including health, social care, housing, employment and education (among other services) to help pulling together integrated care packages.

RECOVERY AND STAYING WELL Ways to wellness: Social prescribing for people with long term conditions in Newcastle West CCG (Case study 30) This project developed a single cohesive approach to social prescribing in primary care to improve the quality of life for adults with a range of long term conditions and mental health issues. This includes link workers to provide focused support to help patients identify and access community activities and where necessary specialist advice to help improve their wellbeing. GPs refer and encourage people to take up activities instead or alongside medical prescription. This approach recognises the wider determinants to bring about long term behaviour change increasing social networks and promote staying well.

According to the National Collaboration for Integrated Care and Support136; “Many people with mental and physical disabilities, complex needs, long-term conditions and terminal illness also need to access different health care, social care, housing and other services, such as education, and often simultaneously. The evidence is clear, however, that these services can be fragmented, and those who need to rely on them often find that they are hard to access and that there are inadequate links between them.” A knowledgeable key worker, or ‘navigator’, who can work across boundaries and has connection within housing, employment and education, has been identified to have a positive impact. Care coordinators need to be senior enough within the team to pull together effectively the contributions of all the different members137.

The Sandwell Esteem Team (Case study 31) The aim of the esteem team is to support people with mild to moderate mental health conditions and complex social needs at an early stage to prevent deterioration and admission to secondary care services. It aims to empower patients to take control of their own lives by offering guided therapies and tools for self-help. The esteem team is part of an integrated primary care and wellbeing model, developed to work in close partnership with statutory agencies to offer a seamless primary care service without barriers. The team works closely with welfare rights, talking therapies, advocacy, to ensure clients get the right services and help to access services. The team consists of gateway and link workers who act as care coordinators and navigators for those with complex needs. The service provides support, improves and maintains wellbeing.

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RECOVERY AND STAYING WELL and adherence »» addressing cultural, ethnic, Examples of related existing religious or other beliefs standards 10 about biological, social and NICE Guidelines »» familial influences on the »» Inform service users of their possible causes of mental right to a formal community health problems care assessment (delivered »» conflict management and through authority social conflict resolution. services) and how to access this »» Health and social care »» Before discharge or transfer providers’ boards should work of care, discuss arrangements with local authorities and all with any involved family or other local organisations with carers. Assess the service an interest in mental health user’s financial and home (including social services, other situation, including housing, hospitals, third sector, including before they are discharged from voluntary, organisations, local inpatient care. press and media groups, and »» Health and social care local employer organisations) professionals working to develop a strategy to combat with people using mental the stigma in the community health services should have and in the NHS associated with competence in: mental health problems and »» assessment skills and using using mental health services. explanatory models of illness » » If they are eligible, give service for people from different users the option to have a »» cultural, ethnic, religious or personal budget or direct other diverse backgrounds payment so they can choose »» explaining the possible and control their social care causes of different mental and support, with appropriate health problems, and care, professional and peer support »» treatment and support as needed. options »» addressing cultural, ethnic, religious or other differences in treatment expectations

Supporting information

Mental health in Scotland: National Standards for Crisis Service5: »» Take holistic approach including physical assessment, socioenvironmental factors including relationships, housing, employment

References to case studies

»» Ways to wellness: social prescribing for people with long term conditions in Newcastle West CCG (Case study 30) »» The Sandwell Esteem Team (Case study 31) »» Manashanthy: Cognitive Behavioural Therapy (CBT) for Tamil people in south west London (Case study 32)

“Unmanageable debt is a risk factor for selfharm.”120

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References 134. Bates, P. (Ed.). (2002). Working for inclusion: Making social inclusion a reality for people with severe mental health problems, London, Sainsbury Centre for Mental Health. 135. Gask, L., Rogers, A., Roland, M. and Morris, D. (2000). Improving quality in primary care: A practical guide to the national service framework for mental health, Manchester: National Primary Care Research and Development Centre, University of Manchester. 136. National Collaboration for Integrated Care and Support. (2013). Integrated Care and Support: Our Shared Commitment. [Online] Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198748/DEFINITIVE_FINAL_VERSION_Integrated_Care_and_Support_-_Our_Shared_ Commitment_2013-05-13.pdf 137. Goodwin, N. and Lawton-Smith, S. (2010) Integrating care for people with mental illness: the Care Programme Approach in England and its implications for long-term conditions management. [Online] Available at: http://www.ijic.org/index.php/ijic/article/view/URN%3ANBN%3ANL%3AUI%3A10-1-100855/0

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APPENDIX A - Glossary APPG AMHP CAMHS CCG CQC CPA CRT ED EDT HTT JHWS JSNA NICE PES RCGP SCN SCIE SPOA

All Party Parliamentary Group Approved Mental Health Practitioner Children and Adolescent Mental Health Services Clinical Commissioning Group Care Quality Commission Care Programme Approach Crisis Resolution Team Emergency Department Emergency Duty Team Home Treatment Team Joint Health and Wellbeing Strategies Joint Strategic Needs Assessment National Institute for Health and Clinical Excellence Psychiatric Emergency Service Royal College of General Practitioners Strategic Clinical Network Social Care Institute for Excellence Single point of access

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APPENDIX B - QUESTIONNAIRE RESPONSES | LONDON MENTAL HEALTH CCG LEADS No

Question

Answer

1

Are there crisis mental health guidelines/protocols to follow?

NO (57%)

2.

Are there crisis waiting time standards?

NO (65%)

3.

Where are crisis assessments completed?

In the community

GP practice

A&E

Other

CMHT (in hours, OOHs and SPOA)

Assessment and liaison team

A&E (in hours, OOHs and if unknown)

Rapid response team

MH inpatient ward (OOHs)

Trust access/crisis team

Crisis helpline

SPOA in secondary care

4.

Where refer patients in crisis?

S136 5.

The same patients presenting in crisis?

YES (100%)

6.

Collect socio-demographic data?

NO (48%)

7.

GPs undertake Mental Health Act assessments locally?

YES (70%)

8.

Voluntary sector involved?

NO (87%)

9.

Is there a crisis helpline?

YES (78%)

10.

GP OOHs know where get emergency mental health help from?

YES (87%) 22% of the yes’s referenced A&E

Default to A&E

Contact crisis response team

GP OOH in A&E with home treatment team

Clear protocol

Single point of access

Access to appropriate services

24/7 cover-psychiatric team on call

Self-referral, self-management

Rapid response

A&E mental health liaison

Integration between services

Standards

Least restrictive environment

Raised awareness of crisis pathway

Triage system

Culturally acceptable

Include carers and families

Electronic patient record sharing

One assessment via point of contact

More OOHs crisis service with HTTs

Expanded hours to access team

Community based

24 hour cover

SPO entry/access

More capacity in A&E liaison team

Distinguish types and causes of crisis

Patient engagement

Voluntary sector involvement

Access to clinicians

11.

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What does the perfect crisis look like?

APPENDIX B - QUESTIONNAIRE RESPONSES | LONDON MENTAL HEALTH CCG LEADS No 12.

Question What are the barriers to improvement?

Answer Money

Resources

Commitment

Lack of leadership

Complexity of service

GP education

Disjoint between primary and secondary care

Provider blocks

Culture in Trust

Lack of clinical leadership

Availability of assessment teams OOHs

Lack of patient engagement

Lack of interoperable records

Change fatigue

Slow to address policy change

Organisational boundaries

Effectiveness of crisis helpline

No local research e.g. who patients are and their needs

Lack of local authority 13.

Know of where is best practice happening?

NO (61%)

Trust A&E mental health liaison team

CMHT responsive and refer to HTT as necessary

Catch 22 and Family Action

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APPENDIX B - QUESTIONNAIRE RESPONSES | LONDON MENTAL HEALTH TRUSTS No

Question

Answer

1.

Have an organisational mental health crisis policy/protocol?

YES (67%)

2.

Where do patients go experiencing crisis OOHs?

24/7 helpline

A&E

Community team (duty worker)

24 hr MH Liaison team

Urgent care centre 3.

Where do crisis referrals come from?

Community services

GP practice

Aand E (liaison psychiatry services)

Police

Primary care services

Self-referral

4.

Have a service user helpline?

YES (78%)

5.

Do you provide A&E liaison psychiatry service?

YES (100%)

6.

A&E liaison psychiatry service available 24/7?

YES (89%)

7.

What are local GPs advised to do for patients presenting first time in crisis?

Go to A&E

Use helpline

Self-referral or GP referral to CMHT

Refer to crisis team

Other : Urgent referral to local CAMHS

Other: Signposted for social care needs e.g. housing department or Citizens Advice Bureau

Other: MH assessment team 8.

CMHT: A duty person/team available?

YES (100%)

9.

CMHT: Actions the care duty person takes at this stage?

Arrange review by doctor or other MHCP

Ask patient to attend A&E

Other: Attend home clinic, visit A&E, helpline support, signpost for social care needs (eg housing or citizens advice)

Refer to HTT/CRHT

Community MH team

Anyone

GP

A&E

136 suite

Social workers

Self-referral

Carer referral

MH Act assessments

Internal referrals from secondary care (eg inpatient, assessment and brief team, early intervention, forensics CMHT and joint homelessness team)

10.

CRT: Who can refer to CRT?

Out of area hospitals

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APPENDIX B - QUESTIONNAIRE RESPONSES | LONDON MENTAL HEALTH TRUSTS No 11.

Question CRT: What are the acceptance criteria?

Answer Diagnosis of acute MH crisis requiring immediate/ high intensity support

To prevent admission

Facilitate safe discharge from ward

HTT is not a frontline service, works with adults over 18 who have been assessed as needing hospital admission

At risk of informal or compulsory psychiatric hospitalisation 12.

Do you have a walk in centre for crisis mental health?

NO (78%)

13.

Access to crisis houses for mental health crisis?

NO (78%)

14.

POLICE: Liaison service provided to the local police?

YES (67%)

15.

Crisis services vary across trust catchment area?

YES (56%)

16.

Does crisis mental health pathway exclude any groups? Learning difficulties without MH problem HTTs – if outside area, not have MH disorder, under 18s, primary problem alcohol or substance misuse

Under 18s Cognitive impairment and dementia

CAMHS 17.

Arrangements in place for under 18s presenting in crisis Not known to services or OOHs – attend A&E OOHs? Known young people can ring for advice

18.

19.

20.

If no T4 CAMHS bed available where are 16-18s admit- Other NHS providers (neighbouring) ted?

What info is available for patients presenting in crisis?

Care plans used for advanced crisis planning?

CAMHS consultant on call 24hrs S136 suites Private sector

Admitted to paediatric ward then transferred with 1.1 nursing

A&E

Assertive home treatment

Admission to adult bed

Leaflets (different languages)

Website

Carer welcome pack

Third sector

Notice board in A&E

Crisis cards

YES (100%)

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APPENDIX B - QUESTIONNAIRE RESPONSES | LONDON MENTAL HEALTH TRUSTS No 21.

22.

Question Undertaking a transformation programme?

What is your organisation proud of?

Answer Expansion of HTTs

Street triage (police)

Service model re-design across community and inpatient services

Extension of assessment services OOHs

Trust Acute Care Pathway Redesign

AMH transformation

Home based emergency and urgent response

Improved earlier intervention pre-referral, screening and fast track to treatment

Alternatives to hospital admission

Improved follow up to staying well

Continual improvement and innovation

Management of complexity/demand

Positive service user feedback

Good feedback on HTTs

Partnership work via transformation programme across patch

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CASE STUDY DIRECTORY LONDON-WIDE AND NATIONAL CASE STUDIES - Compiled by the London Mental Health Strategic Clinical Network No Title Description Location Contact name(s) Contact details 1 Mental health direct offers 24 hour mental health support via a single North East Lon- Gavin Mess, Mental [email protected] Mental Health Direct – 24 hour recognizable crisis telephone number. The switchboard element is oper- don Foundation Health Direct Manated by non-clinical staff who apply an algorithm process to callers to Trust ager, mental health support and crisis ensure they are directed to the appropriate service or given the correct advice. The service ensures earlier intervention for people in crisis and line aims to reduce unplanned A&E admissions.

2

Sunderland and South of Tyne Initial Response team

A single point of access for urgent mental health requests including signposting to relevant services. Objectives are to offer a 24/7 response to telephone requests for help for all ages and conditions; offer triage and routing to services including local services. Call handlers and clinical triage provide rapid response and advice on care and treatment. Team works alongside the crisis team and service specialties.

Northumberland, Tyne and Wear NHS Foundation Trust

Denise Pickersgill, [email protected]. Service Manager uk Access and Treatment Service, NTW

3

Northumberland, Tyne and Wear Initial Response service

Initial Response Service (IRS) is a key development within the Principal Community Pathways (PCP) programme. The service provides a single point of access to NTW to ensure service users (urgent and routine) are referred to the right service and placed on the right pathway without delay, keeping them fully informed of this process. If service user needs cannot be met by one of the services they and their referrer are signposted to the appropriate service elsewhere, with an informative explanation.

Northumberland, Tyne and Wear NHS Foundation Trust

Denise Pickersgill, [email protected]. Service Manager uk Access and Treatment Service, NTW

4

North west London’s mental health transformation strategy 2012-15

The aim of the transformation programme is to improve the experience North west Lonof, and outcomes from, mental health urgent assessment and care don across North West London, including increasing the management of the health and wellbeing of people with mental health problems in primary care. Improvements include: a access and care standards policy; review of the local skill mix, competency and training needs of staff; extension of home visiting for crisis resolution work, providing 24/7 cover every day of the year and a single point of access available 24/7 every day of the year.

Glen Monks, Mental [email protected] Health Programme Director, North [email protected] West London

Integration of CAMHS into a single point of access for children

To develop the existing single point of access to improve assessment and triage so that appropriate referral is made to Tier 2 Primary Mental Health Services, Tier 3 services or redirected to Tier 1 services. The new service will have a single access point for all children’s emotional and behavioural services. The child will reach the most appropriate service first time around reducing waiting time.

Dr Brinda Paramothayan, Children’s Clinical Lead, Richmond CCG

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Richmond CCG

Michael Doyle, Head of Urgent Care Programme, North West London brinda.paramothayan@nhs. net

CASE STUDY DIRECTORY LONDON-WIDE AND NATIONAL CASE STUDIES - Compiled by the London Mental Health Strategic Clinical Network No Title Description Location Contact name(s) 6 The digital mental health service, Big White Wall, is offered on a selfSouthwark CCG Carol-Ann MurBig White Wall referral basis to all adults in Southwark. The service offers instant ray, Senior Mental digital mental access, 24 hours a day crisis support from trained counsellors through Health Comhealth service the ‘Ask a Wall Guide’ function, safe and moderated peer support, and self-management materials. The service is fully anonymous, meaning that it is more acceptable to people who are unwilling to access support due to stigma. Big White Wall members frequently make use of the network at times of distress, to resist urges to self-harm or to cope with suicidal thoughts – many then continue to use it for support with longerterm issues.

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‘Evolve’- a navigator service

‘Evolve’ is part of CREST, a local voluntary sector charity in Waltham Forest, and provides navigators to establish the nature of the crisis, whether social or medical, and works with the individual to decide on the appropriate course of action to minimise risks to a mental health relapse. Initial outcomes of the pilot have shown that the Evolve team has contributed to an overall reduction in the number of individuals having a crisis where regular contact with navigator is maintained, as well as a reduction in the duration of a crisis episode through quicker access to intervention and treatment.

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Leeds survivor led crisis service

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Solidarity in a crisis

Contact details [email protected]

missioner, NHS Southwark Clinical Commissioning Group

Waltham Forest

Chris O’Sullivan, Evolve Team Leader, CREST Waltham Forest

[email protected]. uk

The Leeds survivor led crisis service is governed and managed by peo- Leeds ple with direct experience of mental health problems. It runs a telephone helpline Connect, offers a place of sanctuary for people in acute mental health crisis called Dial House and provides person centred group work. It has been successful in providing a viable alternative to the medical model of care for people in acute mental health crisis.

Fiona Venner, Service Manager, Leeds survivor led crisis service

[email protected]

Solidarity in a crisis is a peer support service which is co-designed and co-delivered by service users and carers in Lambeth. Crisis support is offered over the phone or in person out of hours during the weekends. It is an alternative service to NHS services or hospital. The aims of the service are to reduce isolation, support people using empathy and knowledge gained through experience and to help the person before reaching crisis point.

Patrick Nyikavaran- [email protected] da, Peer Involvement Coordinator, Certitude

Lambeth

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CASE STUDY DIRECTORY LONDON-WIDE AND NATIONAL CASE STUDIES - Compiled by the London Mental Health Strategic Clinical Network No Title Description Location Contact name(s) 10 City and Hackney CCG have just launched a programme of training for City and HackRhiannon England, City and HackGP Mental health ney CCG mental all primary care staff offering free Mental Health First Aid Lite courses to ney CCG all GP reception staff. The next phase of the programme will be to offer lead, City and health training

[email protected]

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Kingston CCG advanced diploma in mental health

Kingston CCG has been awarded funding to provide training to advanced diploma level in mental health to 20 Kingston GPs. The programme is accredited by RCGP and to be delivered by PRIMHE, from in autumn 2014 to summer 2015. There will also be training for nurses to follow and awareness training for all interested other GPs and their practice staff. The overall aim is that there will be enough GPs trained to this level to assist and support the delivery of mental health care in primary care across Kingston.

Kingston CCG

Phil Moore, GP Lead clinical commissioner for mental health, Kingston CCG

[email protected]

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Bespoke mental The project was funded by the Health Education North Central East health training for London (HENCEL) to establish a sustainable network of nurse educators, develop a 10 module training and train the trainer programme practice nurses

North east and north central London

Sheila Hardy, Education Fellow, UCL Partners

Sheila.hardy@uclpartners. com

Time to Change: mental health training for GPs

London

Leigh Wallbank, Mental Health Promotion Manager, Rethink Mental Illness

[email protected]

a two day course to those reception staff who would like further training. Practice nurses, district nurses and health care assistants are encouraged to attend the UCLPartner’s mental health and wellbeing training package for practice nurses (Case Study 12). For GPs, educational sessions and workshops continue to run. Mental health training has also been incorporated into this year’s locally enhanced service (LES).

and educate practice nurses in the region. A bespoke mental health and wellbeing package for practice nurses has been developed. The practice nurses are taught to understand the patients’ mental, physical, emotional, spiritual and social needs. This has the potential to prevent crisis and when a crisis occurs, increase recognition with appropriate and effective response.

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The BIG Lottery funded a focused training programme for GPs and primary care staff. This funding was awarded to create an opportunity to learn from the Education Not Discrimination (END) targeted training element of Time to Change phase 1 (Sept 2007 – Sept 2011) and seek to develop a training model that is targeted and aligned with the needs of GPs and primary care staff, as well as meet the objectives of the new commissioning framework. This project was designed to try and improve attitudes and behaviours in GP practices towards people with mental health problems through improving knowledge.

Contact details

Hackney CCG

CASE STUDY DIRECTORY LONDON-WIDE AND NATIONAL CASE STUDIES - Compiled by the London Mental Health Strategic Clinical Network No Title Description Location Contact name(s)

Contact details

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Whittington integrated liaison assessment team

The integrated liaison assessment team has the following features: North central consultant/specialty trainee follow-up clinic for cases where there are di- London agnostic difficulties or medication issues; liaison follow-up clinic typically offered to those who do not require admission or crisis team follow-up and who do not have easy access to community follow-up; direct referrals - the team has developed an initiative to identify patients who are more appropriately referred directly to psychiatry from the triage nurse using an agreed protocol.

Stuart Shepherd,

[email protected]

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Liaison psychiatry in north west London

Central and North West London NHS Foundation Trust and West LonNorth west London Mental Health NHS Trust, worked in partnership to establish pilot don services at four acute trusts: North West London Hospitals NHS Trust (Northwick Park and Central Middlesex hospitals), Hillingdon Hospital NHS Trust, Ealing Hospital NHS Trust, and West Middlesex University Hospital NHS Trust. An ‘optimal standard’ model was developed for a hospital of 500 beds that provided an integrated multidisciplinary service with 24 hour input to ED an inpatient populations. There have been improvements in mental health diagnosis, treatment and care of patients in acute hospitals with co-morbid physical and mental health problems and a reduction in the overall lengths of stay for the same group.

Dr Steven Reid, Consultant Liaison Psychiatrist and Clinical Director, Central and North West London NHS Foundation Trust

[email protected]

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Hull and East Yorkshire Hospitals Trust: The mental health team

The team is a multi-disciplinary team which assesses patients with a range of mental health problems including acute mental illness; selfharm; attempted suicide; or extreme distress. Dependent upon the nature of the referral the response rates are 30 minutes the same working day or within 24 hours. A further aim is to educate staff within the acute trust to enable them to recognise mental health problems early and refer appropriately.

Dr Stella Morris, [email protected]. Consultant in Liaiuk son Psychiatry, Hull and East Yorkshire Hospitals Trust

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Birmingham and Solihull Mental Health NHS FT: Rapid Assessment Interface and Discharge (RAID)

The service aims to meet the mental health needs of all patients over Birmingham the age of 16 including those who self-harm, have substance misuse issues or mental health difficulties commonly associated with old age including dementia. With an emphasis on rapid response, it has a target time of one hour within which to assess referred patients who present to A&E and 24 hours for seeing referred patients on the wards. The service puts an emphasis on diversion and discharge from A&E and on the facilitation of early but effective discharge from general admission wards.

Hull

Michael Preece, RAID Operational Lead, Birmingham and Solihull Mental Health Foundation Trust

Michael.preece@bsmhft. nhs.uk

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CASE STUDY DIRECTORY LONDON-WIDE AND NATIONAL CASE STUDIES - Compiled by the London Mental Health Strategic Clinical Network No Title Description Location Contact name(s) 18 Hackney Gill Williams, City Hackney 24 hour The London Borough of Hackney and East London Foundation Trust out of hours AMHP service aims to respond to requests for Mental and Hackney AMHP service Health Act assessments which arise outside usual working hours. There has been improvement in response times with 100 per cent compliance with the four hour response target. There is now a single 24 hour phone number. The service operating costs are less than previously.

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Vulnerability As- The Vulnerability Assessment Framework provides a simple tool for sessment Frame- Metropolitan police officers to use to identify those that are vulnerable work training tool and possibly in need of further help. The tool was developed by the

Centre for Mental Health, East Lonodn Foundation Trust

London

University of Central Lancashire, originally called the Public Psychiatric Emergency Assessment Tool. Since this system went live over 55,000 reports have been completed, enabling the police and partners to identify individuals that are becoming vulnerable far earlier and enabling early intervention.

Contact details gill.williams@eastlondon. nhs.uk

DI Frankie [email protected]. by, National Mental police.uk Health Policing Portfolio Staff Officer to Commander Jones and Metropolitan Police Service Central Mental Health Team

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London street triage pilot

NHS England, London Region together with the Mayor’s Office for London Police and Crime (MOPAC) commissioned a Street Triage Project in London, piloted in the boroughs of Lambeth, Lewisham, Croydon and Southwark. The triage service consists of mental health practitioners accompanying police officers to mental health related call outs and/or providing dedicated telephone support to officers on the ground who are responding to people in crises. The project aims to reduce the use of section 136 of the Mental Health Act amongst the police and reduce the amount of time that officers spend dealing with people who are in crisis due to mental health problems.

Sinéad Dervin, [email protected] Commissioning Manager, Health in the Justice System, NHS England

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Integrated mental health team based in police headquarters

The aim of the project is to have an integrated mental health team based within the control room at police headquarters in Norfolk in order to improve safeguarding for those suffering from mental ill health and introduce and provide early access to services for those with mental health issues before they reach crisis point.

Terri CooperBarnes, Lead mental health Nurse, NSFT Amanda Ellis, Chief Inspector, Norfolk Police

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Norfolk

terri.cooper-barnes@nsft. nhs.uk [email protected]. uk

CASE STUDY DIRECTORY LONDON-WIDE AND NATIONAL CASE STUDIES - Compiled by the London Mental Health Strategic Clinical Network No Title Description Location Contact name(s) 22 London Mark Smith, Head British Transport In February 2013 a suicide prevention project (Operation Partner) was of Suicide PrevenPolice (BTP) sui- set up between BTP, NHS London and 2 London mental health trusts. This involved BTP staff and community psychiatric nurses working tion and Mental cide prevention together to implement and review suicide prevention plans for people Health, British project at risk. During 2013/14 631 people received life-saving interventions on the railway. During Operation Avert 1 and 2 the daily life saving intervention rate doubled and the numbers of fatal and injury suicide events reduced.

Contact details [email protected]. uk

Transport Police

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Highbury Grove crisis house

Highbury Grove in Islington provides an alternative service to hospital admission for people experiencing mental health crisis in a community setting. The service consists of three components including a twelve bed residential service; a crisis phone line provided seven days a week 5pm to 6am and the crisis night centre. The crisis night service is available seven days a week to provide a safe place for service users to meet and socialise therefore minimising social isolation, while providing support where necessary.

Islington

Sara Kelly, Team Manager, One Housing Group

skelly@onehousinggroup. co.uk

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Camden crisis houses

Two crisis houses were established in Camden to provide an alternative to acute inpatient hospital admissions based on a person-centred recovery model. The Camden crisis house model includes a crisis team who support people in their homes and act as gate-keeper for admissions and a structured acute day treatment programme, where service users are encouraged to participate in therapeutic groups. People are admitted to the houses at the height of acute crises for brief stays of on average two to ten days. Most people (74-78 per cent) are discharged to their own homes.

Camden

Kate Clayton, Operational Manager, Camden and Islington Mental Health Trust

[email protected]

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West of Dorset recovery house

The service provides an alternative to acute psychiatric inpatient admis- West Dorset sion, which allows care and support to be delivered in a safe environment that promotes recovery. The crisis and home treatment team offer a stay at the recovery house to people whose needs can be safely and effectively met there and who would otherwise require hospital admission.

Deborah Rodin, Services Manager, Rethink Mental Illness

[email protected]

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CASE STUDY DIRECTORY LONDON-WIDE AND NATIONAL CASE STUDIES - Compiled by the London Mental Health Strategic Clinical Network No Title Description Location Contact name(s) 26 The Host Families scheme is an alternative to hospital admission or fol- Hertfordshire Sarah Biggs, HertHertfordshire lows on from inpatient care and aims to offer intensive intervention and fordshire PartnerPartnership support to service users in a crisis. The scheme is an integral part of the ship University NHS University Foundation Trust Foundation Trust Crisis Assessment and Treatment Team providing a supportive, therapeutic alternative to inpatient care. Host families are recruited to offer a (HPFT): Host Families scheme supportive family environment to mental health service users. North east LonPete Williams, 27 Redbridge home North East London Foundation Trust provides multi-disciplinary home treatment as an alternative to admission which enables wards to target don Assistant Director treatment team those who require an inpatient stay. The team consists of social care staff, psychologists and occupational therapists. The teams have a 100 per cent gate-keeping role to their wards and are also 100 per cent involved in inpatients discharge.

NELFT MHS Acute Services Lead

Contact details [email protected]

[email protected]

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South Tyneside crisis resolution and home treatment team

Northumberland Tyne and Wear NHS Foundation Trust provides a crisis Northumberland resolution home treatment team with the capacity to visit service users up to three times daily, providing a range of psychological and physical interventions including support and psycho-education for carers and families. The team works extensively with the inpatient units, gatekeeping all admissions and providing early discharge planning. The team provides a 24 hour mobile workforce inclusive of nurses, doctors and support workers with access to specialist clinical advice.

Emma Bailey, Team [email protected] Manager, CRHT Sunderland and South Tyneside

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What makes a good crisis plan?

In 2013/14, one of South West London and St Georges mental health London trust’s CQUIN targets was to review the crisis plans of people on care programme approach and implement a programme to improve the quality of crisis planning. The first action has been to co-produce what is considered to be an exemplar crisis plan and good practice standards for the crisis planning process

Miles Rinaldi, Head of Recovery and Social Inclusion, SW London and St Georges Mental Health Trust

[email protected]. uk

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Ways to Wellness: social prescribing for people with long term conditions in Newcastle West CCG

This project developed a single cohesive approach to social prescribing Newcastle West in primary care to improve the quality of life for adults with a range of CCG long term conditions and mental health issues. This includes link workers to provide focused support to help patients identify and access community activities and where necessary specialist advice to help improve their wellbeing. GPs refer and encourage people to take up activities instead or alongside medical prescription. This approach recognises the wider determinants to bring about long term behaviour change increasing social networks and promote staying well.

Sandra King, Project Director Ways to Wellness

[email protected]

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CASE STUDY DIRECTORY LONDON-WIDE AND NATIONAL CASE STUDIES - Compiled by the London Mental Health Strategic Clinical Network No Title Description Location Contact name(s) 31 The aim of the esteem team is to support people with mild to moderate Sandwell and Ian Walton, IAPT The Sandwell mental health conditions and complex social needs at an early stage to Birmingham lead, Sandwell and Esteem Team prevent deterioration and admission to secondary care services. It aims to empower patients to take control of their own lives by offering guided therapies and tools for self-help. The esteem team is part of an integrated primary care and wellbeing model, developed to work in close partnership with statutory agencies to offer a seamless primary care service without barriers.

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Manashanthy: Cognitive Behavioural Therapy (CBT) for Tamil people in south west London

The aims of this project were to identify needs in the Tamil community, raise awareness of existing IAPT services and offer interventions to meet their needs. A culturally adapted CBT model has been established: Tamil speaking CBT therapists were employed and trained to provide workshops at the Wimbledon Shree Ganapathy temple to the Tamil community, as well as via other local temples and churches.

Contact details [email protected]

Birmingham CCG

South west London

Meera Bahu, Psychological Therapies and Wellbeing Service, South West London and St Georges Trust

[email protected]. uk

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1. Mental Health Direct – 24 hour mental health support and crisis line Aims

»» To offer everyone a single recognisable telephone number they can contact to gain advice and support about any mental health issue or mental health service »» To offer signposting to local access and assessment team for advice, support or telephone triage and to offer out of hours support »» To offer out of hour’s advice and support to all professionals

Rationale

Benefits and outcomes

Mental Health Direct (MHD) was set up in 2011 by North East London Foundation Trust (NELFT) at an initial cost of £197,300 (14 band 2 switchboard staff and 1 band 7 clinical lead). MHD evolved out of discussions with service user and carer groups and GP and PCT consultation following complaints about lack of out of hour’s provision. It was also highlighted that mental health services were difficult for nonprofessionals to navigate, leading to inappropriately high use of A&E. The service was incorporated into the existing switchboard and clinical support supplied by access and assessment teams, clinical lead and home treatment team staff.

»» »» »» »» »» »»

Clarity and equity of service One recognisable telephone number for all Stakeholder and service user engagement Reduction in unplanned A&E attendance Robust out of hour’s clinical advice and support Level of calls successfully answered remains at 100 per cent »» Number pro-actively promoted to all services: all known, new service users and carers are given number »» Earlier intervention and access to most appropriate services

Development

MHD is available 24 hours to anyone who requires it. The switchboard element is operated by non-clinical staff who apply an algorithm process to callers to ensure they are directed to the appropriate service or given the correct advice. Telephone triage referrals will be completed by the relevant borough’s access and assessment team Monday - Friday 09:0017:00 hrs; during Monday - Friday 17:00-21:00 hrs (audited as peak time) calls will go through to MHD clinical lead; outside of these hours clinical support is supplied by the home treatment team.

»» Engage with providers and key stakeholders »» Be involved in promotion of service via Clinical Commissioing Group/PTI »» Have one dedicated number for all boroughs/ areas »» Appropriate customer care and algorithm training (e.g. Samaritans) »» Email messaging service to alert appropriate teams/service of caller »» Call recording system to maintain quality, governance, supervision and any conflict/ complaint resolution

Challenges

Contact

Top tips for commissioners

Initially, promoting the service and ensuring service Gavin Mess, Mental Health Direct Manager cohesiveness was a challenge and then as people [email protected] have become more aware of the crisis line, the challenge has been to manage the increase in demand (between October 2012 and October 2013 there was a 33 per cent increase in calls).

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2. Sunderland and South of Tyne Initial Response team Aims

»» The primary aims of the Initial Response Team (IRT) are to offer an efficient 24/7 response, through a single point of access, to urgent telephone requests for help from people of all ages and conditions, and to offer triage and routing or signposting to appropriate services within and without Northumberland, Tyne and Wear (NTW)

Rationale

Benefits and outcomes

Development

Service users receive a timely response to urgent requests for help and are now being seen and routed to the most appropriate service. Feedback from service users has been very positive, clearly indicating that IRT staff are polite, show kindness and empathy, and behave in a professional manner. Remarkably feedback from service users has shown that 100 per cent would recommend the service to a friend in need of similar help.

NTW is one of the largest mental health and disability trusts in England serving a population of approximately 1.4 million and providing services across an area totalling 2,200 square miles. Sunderland was chosen for the development of a new access model following discussions with service users, carers, GPs and commissioners.

Working collaboratively with commissioners and other partners the transformation of access to NTW for urgent referrals was implemented and tested, developing telephone triage and a rapid response function as a first point of access for the public, service users, carers and referrers, supported in its first year through the imaginative use of the CQUIN attached to the contract.

Challenges

Lessons learned were primarily in relation to stakeholder communication. GP feedback suggested a lack of awareness of IRT and suggested that more PR work would be beneficial. Operationally, there were initial issues with data collection which made activity monitoring challenging. Also some of the training offered to staff needed to cover a broader spectrum of topics or be delivered in greater depth to realise the intended benefits.

IRT reduces clinician administration burden in the crisis response and home treatment teams, freeing time to care for service users with the greatest need, while also improving personal and clinical outcomes for people in crisis with mental ill health by reducing harm and premature mortality, improving safety and experience.

Contact

Denise Pickersgill, Service Manager Access and Treatment Service, NTW [email protected] Ian Holliday, Head of Joint Commissioning, NHS Sunderland CCG [email protected]

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3. Northumberland, Tyne and Wear Initial Response service Aims

»» The Initial Response Service (IRS), providing a single point of access to Northumberland, Tyne and Wear NHS Foundation Trust (NTW), will ensure service users are referred to the right service and placed on the right pathway without any delay, keeping them fully informed of this process. If service user needs cannot be met by one of our services they and their referrer are signposted to the most appropriate service elsewhere, with an explanation as to why this is happening.

Rationale

NTW is one of the largest mental health and disability trusts in England serving a population of approximately 1.4 million and providing services across an area totalling 2,200 square miles. IRS is a key development within the Principal Community Pathways (PCP) programme. PCP will design and implement new, evidence-based community pathways for adults and older people.

Development

NTW’s strategic direction is one of transforming services in order to ensure a sustainable future of higher quality services and clinical effectiveness, reducing overall costs of delivery by 20 per cent. This will be delivered through the PCP programme, funded through transition reserves and incentivised through CQUIN.

Challenges

The volume and complex design of existing teams made accurate baseline measurements difficult. Adapting the wider organisation’s culture to embrace the lean approach will take time and there may be a delay in fully realising benefits while the new ways of working are embedded. Public sector financial pressure will continue. This must be considered when developing a new model which must be sustainable in the medium to long term.

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Benefits and outcomes

Services will be easier to access. This new “front door” to NTW will be available 24/7 and receive requests for help for both urgent and non-urgent referrals as well as providing advice and information. This new front end will be more integrated with partner organisations to ensure that residents receive the help and support they need. Where appropriate, previous patients needing to re-engage with services are quickly and easily put back in touch with the support team they are familiar with.

Tips for commissioners

Acknowledge that every system has inefficiencies and that your support is needed to identify and address these. Form relationships in which providers can be honest about difficulties around these challenges. Make imaginative use of CQUIN to incentivise innovative developments attached to the contract.

Contact

Denise Pickersgill, Service Manager Access and Treatment Service, NTW [email protected] Ian Holliday, Head of Joint Commissioning, NHS Sunderland CCG [email protected]

4. North west London’s mental health transformation strategy 2012-15 Aims

»» The aim is to improve the experience of, and outcomes from, mental health urgent assessment and care across North West London, including increasing the management of the health and wellbeing of people with mental health problems in primary care. There is a need for rapid access to assessment and care for those in crisis, to be provided when and where the service user most needs it.

Development

Initial approaches to improve crisis assessment and care include: »» Rolling out and embedding of a common access and care standards policy »» A review of the local skill mix, competency and training needs of staff »» Progress to align mental health services to those in primary care - covering the period 8am – 8pm as a minimum. Extension of home visiting for crisis resolution work, providing 24/7 cover every day of the year »» Simplification of the ‘route in’, with a single telephone number, available 24/7 every day of the year

Projected outcomes

»» A single phone number for accessing urgent mental health assessment and care. Accessible 24/7, with access to clinical consultation and advice, including telephone advice, especially for people who are experiencing crisis »» Facilitate rapid access to specialist mental health assessment for those most in need complimented by mobile clinical response, delivering urgent response including home based urgent response »» Reduced reliance on MHA assessments via the EDT as the only alternative means of urgent assessment out of hours if service users are unwilling or unable to attend A&E. Much needed support for colleagues in police and probation services to help identify mental health issues, refer for and receive support »» Increased home visiting for crisis resolution, 24/7/365, reducing the likelihood of inpatient admissions and the distress of visits to A&E »» Direct access to the treatment team for those known to the service removing multiple assessment layers that exist currently

(Projected outcomes, cont’d) »» Prioritise people who cannot be managed within the primary care mental health teams setting because of need complexity or a lack of necessary resources »» Continue to be available to the primary care team after care has been returned to the primary care provider, to maintain continuity of care for both the primary care provider and the individual »» Provide information on available community resources and assist with access to these services through mapping local 3rd sector, voluntary and statutory provision into a single web based directory of services to promote recovery and self-management »» Promote ‘Recovery’ and enablement through co-produced service design, delivery, and review. The service user, their carer, family and friends at the centre of care and support planning, with treatment provided to those most in need as close to home as possible in the least restrictive environment »» Discharge from specialist mental health services to local GPs for on-going management and monitoring, based on a comprehensive plan that has been developed in consultation with the person’s GP »» Interface with the acute care pathway (including crisis teams and recovery houses) and support adherence to the urgent care standards

Contact

Glen Monks, Mental Health Programme Director, North West London [email protected] Michael Doyle, Head of Urgent Care Programme, North West London [email protected]

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5. Integration of CAMHS into a single point of access for children Aims

»» To develop the existing single point of access (a council led initiative) to improve assessment and triage so that appropriate referral is made to Tier 2 Primary Mental Health Services, Tier 3 services or redirected to Tier 1 services

Rationale

The background is one of dissatisfaction of current services, long waits, bounce back of referrals to GPs or bouncing of patients from one service to another. The aim was that no child should fall through the net and that the child is directed to the correct service first time around.

Benefits and outcomes

The new service has not been implemented yet but the aim is to have a single access point for all children’s emotional and behavioural services. The referral will be assessed by a psychologist from Tier 2 with input from a Tier 3 psychologist and a plan made as to the best management of that child. The child will therefore reach the most appropriate service first time around reducing waiting time and Development (in progress) bounce around. The GP would have the knowledge The development is a joint collaboration between the that their referral has been accepted and the child Clinical Commissioning Groups and local authorities will be seen by the correct service – there will be of of two boroughs (Richmond and Kingston) and feedback to the GP to this effect so that all parties South West London and St Georges mental health are kept fully informed. trust (the provider). Still at the negotiation and implementation stage the principles of the service have been agreed and all participants are supportive. A Tips for commissioners number of ‘Emotional Wellbeing Forums’ were orCommunication and honesty is key. What is it you ganised for consultation, with attendees from a wide want and what can you afford. Look at your own range of backgrounds and services. Similar local data and look at other local services to see what models were also considered to give an indication their experience has been. of likely numbers going through the service, costing and possible pitfalls.

Contact

Challenges

The main pitfall so far has been through lack of communication and a failure to clearly specify from the outset what was required from the provider. This resulted in the provider proposing a ‘gold standard’ service which was unaffordable and impractical. The availability of data from existing services enabled agreement of a more appropriate level of service.

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Dr Brinda Paramothayan , GP Lead for Children’s Health and CAMHS, Richmond CCG [email protected]

6. Big White Wall digital mental health service Aims

»» Big White Wall, the digital mental health service, is being offered on a self-referral basis to all adults in Southwark, with the aim that this will increase access to mental health services, particularly for people who are unwilling or unable to access other options. This includes supporting people who are in crisis and require immediate support, as well as those who need support on a longer-term basis.

Rationale

Unplanned admissions due to mental health crises are hugely expensive for the NHS and very distressing for individuals, family and carers. Out of hours, many people use A&E services for mental health emergencies, which will often not be the most supportive place for them. Many people experiencing acute mental distress are not in contact with mental health services and will not have a crisis plan. There is therefore a need for alternative models to support people with immediate mental health need.

Development

NHS Southwark CCG has received funding from the NHS England Regional Innovation Fund to provide Big White Wall to 500 local residents in 2014/15, plus evaluation from UCL.

Desired outcomes

NHS Southwark CCG hope that the use of Big White Wall will help identify unmet need in the local population, provide a self-referral service which is attractive to service-users and reduce unplanned mental health admissions to A&E and mental health services. In addition it is hoped that feedback from this pilot will inform the scope and design of future services in the area.

Contact

Carol-Ann Murray, Senior Mental Health Commissioner, NHS Southwark CCG [email protected]

Although not exclusively a crisis service, Big White Wall offers instant access, 24/7 crisis support from trained counsellors through the ‘Ask a Wall Guide’ function, safe and moderated peer support, and selfmanagement materials. The service is fully anonymous, meaning that it is more acceptable to people who are unwilling to access support due to stigma. Members are protected through clear house rules and real-time moderation. Big White Wall members frequently make use of the network at times of distress, to resist urges to self-harm or to cope with suicidal thoughts – many then continue to use it for support with longer-term issues.

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7. “Evolve” – a navigator service Aims

»» Support adult service users with a serious mental illness in their discharge from secondary to primary care »» Ensure service users attend appointments - GPs/practice nurses to monitor mental and physical health »» Using a person-centred recovery focus, support clients to reduce any social isolation they may be experiencing by increasing access to a variety of local opportunities/services

Rationale

‘Evolve’ is part of CREST, a local voluntary sector charity in Waltham Forest and was commissioned to provide 4 navigators and a team leader in April 2012 by Waltham Forest Clinical Commissioning Group for the annual sum of £187,000.

Development

Working with a designated navigator for a period of 12-18 months, clients attend 3 to 4 20-minute appointments where GPs and practice nurses monitor their mental and physical health. Taking a personcentred recovery focus builds a solid and trusting relationship between client and navigator and enables the navigator to detect early signs of crisis and prevent relapse. During periods of crisis, clients have increased contact with their navigator and GP; for those needing specialist input protocols for re-referral to secondary care have been developed. Where the discharge period is within 6 months the navigator makes a direct referral to the respective clinic for an urgent out-patient appointment. Navigators also encourage clients to complete a Wellness Recovery Action Plan (WRAP) as part of their recovery. Resources: team leader and 4 full-time navigators; installation of a shared drive; 10 2 hourly weekly education workshops for GPs and staff on mental illness including psychotropic medication protocols; GPs paid £200 per client for undertaking 3 to 4 20-minute assessments including a discharge meeting.

Challenges

Ensuring communication between primary and secondary care practitioners is firmly established requires continual monitoring by the navigators.

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Benefits and outcomes

Initial outcomes of the pilot have shown that the Evolve team has contributed to: »» An overall reduction in the number of clients in crisis where regular contact with navigator is maintained »» A reduction in the duration of a crisis episode through quicker access to intervention and treatment »» A reduction in time spent back in secondary care if a client has required input/re-referral »» Reduced stigma associated with receiving a depot injection at a mental health venue through clients accessing a practice nurse in generic setting

Tips for commissioners

Establish regular dialogue between primary and secondary care practitioners to ensure effective management of these clients in the community and reduce risks of mental health crisis.

Contact

Chris O’Sullivan, Evolve Team Leader, CREST Waltham Forest [email protected]

8. Leeds survivor led crisis service Aims

»» To provide an alternative to statutory services within a homely environment »» Provide services both for those in crisis, at the point of crisis and for those seeking to prevent the onset or escalation of crisis »» Provide a place of sanctuary at times of immediate crisis

Rationale

The Leeds survivor led crisis service was set up in 1999 by a group of service users, who had campaigned for an alternative to hospital admission for people in acute mental health crisis. Initially, the service was run in partnership with social services, becoming a registered charity in 2001.

Development

The service was established, and continues to be governed and managed by people with direct experience of mental health problems. The service therefore has been developed based on this knowledge and experience, while responding to the needs articulated by visitors and callers. It is funded by the three Leeds NHS clinical commissioning groups, Leeds City Council, the Leeds Personality Disorder Clinical Network and also receives small amounts of charitable trust funding from time to time. It runs a telephone helpline Connect (also available online), offers a place of sanctuary for people in acute mental health crisis called Dial House and provides person centred group work including peerled support, a men’s group, hearing voices, LGBT, self-harm and a ‘coping with crisis’ group. The team consists of people trained in the person-centred approach, some of whom are counsellors or therapists. The helpline receives around 5,000 calls a year and supports people in crisis, as well as preventing crises by supporting people before they reach crisis point. All services are accessible to deaf people. Dial House @ Touchstone is a partnership between Leeds survivor led crisis service and Touchstone supporting people from BME groups. The project opened to new visitors on 1 October 2013 and has received £500k in lottery funding for five years. It is available for anyone from a BME group, including refugees and asylum seekers.

Challenges

Managing the huge surge in demand with existing resource and capacity: call numbers have doubled.

Desired outcomes

»» Successfully worked with people in acute states of crisis who have been excluded from other services or who have been difficult to engage with services »» Reducing risk / preventing suicide »» Supporting people to resolve or better manage their crisis »» Reduced use of statutory crisis and emergency services »» Service monitors against the 6 outcomes in ‘no health without mental health’

Tips for commissioners

It can be cheaper to locate crisis services in the voluntary sector, than providing statutory services, including inpatient services. For service users it is a much more positive experience to be in a community based homely environment.

Contact

Fiona Venner, Service Manager [email protected]

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9. Solidarity in a crisis Aims

»» To reduce isolation during out of hours by providing support that is respectful and non-judgemental »» To support people using the empathy and knowledge gained through lived experience »» To support the person in distress before they reach crisis point and help guide them towards appropriate professional support

Rationale

Certitude launched ‘Solidarity in a Crisis’ on 1 April 2012. It is a peer support service for Lambeth residents over 18. Co-designed and co-delivered by service users and carers in Lambeth; by sharing their experience and providing social support to people in distress, peer supporters aim to promote recovery, enhance feelings of belonging and hope to those in distress, whilst helping to prevent people reaching crisis point.

Development

The service operates out of hours (Monday - Friday 8pm to 12am, Saturday and Sunday 8pm to 2am) with peer supporters providing crisis support over the phone and through meetings in the community to help them move on from the acute stage of their mental health crisis, in a mutually agreed location (public place). It is an alternative service to conventional medical services or hospital. Peer supporters have gone through a training programme and receive regular supervision and support.

Challenges

Finding activities and services that are open out of hours.

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Benefits and outcomes

»» »» »» »» »» »» »» »» »» »» »»

Less reliance on A&E for some individuals Less hospital admissions for some Preventing suicides Helping people stay in work who would have normally struggled Confidence building Resilience in facing long term crisis Connectivity with the wider community through signposting as well as supporting to make new friends and re connect with family Confidence for the peer supporters Peer support opportunities for those being supported Employment and volunteering prospects for the peer supporters New skills and training attained

Tips for commissioners

Use the same people you aim to support in the design, implementation as well as assessment of the services.

Contact

Patrick Nyikavaranda, Peer Involvement Coordinator, Certitude [email protected]

10. City and Hackney CCG mental health training Aims

»» To improve mental health care provided by primary care professionals by addressing the 3C’s’ – confidence, competence and capacity

Rationale

Good crisis management in primary care needs a rapid assessment for those people presenting there, referral with comprehensive information, rapid response by the crisis service and fast communication back to the referrer. Primary care thus needs to have the confidence and competence to identify crisis and know how to manage it well to ensure optimal outcomes. Primary care also has a responsibility to try to prevent crisis by understanding individual stressors, encouraging compliance with medication where appropriate and supporting carers and families.

Development

City and Hackney CCG have begun a comprehensive training programme for all primary care staff. All GP reception staff have been offered free Mental Health First Aid Lite courses and more than 100 have completed this training to date. Reception staff who would like further training will be offered the 2 day course. Practice nurses, district nurses and healthcare assistants have been encouraged to attend the mental health training offered by UCLP (see case study 12, Bespoke mental health training for practice nurses). The course includes face to face modules and e-learning, ensuring that nurses completing this have a thorough and wide-ranging understanding of mental health in primary care, including crisis management. Forty nurses have completed this training. GPs have continued the usual education sessions that have been running for many years but the CCG have also run additional workshops and will offer mental health master classes again next year. Mental health training has also been incorporated into the current locally enhanced service (LES). Practices are given bursaries - £0.45 per patient - and have to complete a number of hours of mental health

training according to list size. GPs are also required to follow up all episodes of self-harm in under 18s by offering an appointment to all patients identified from A&E attendance, this enables early identification of stressors and offering interventions before crisis point is reached. GP practices are required to ensure that all reception staff have child and adolescent mental health crisis training to be able to respond better to young people who need urgent access to primary care. The CCG have received a HENCEL grant to develop a community mental health education and training hub which will promote good mental health training across professions in City and Hackney. Joint training opportunities will be available between schools, workplaces, health, police and the local authority with the aim of building a strong sense of community resilience, empowering more people to help those in crisis.

Tips for commissioners

»» Ask people what training and at what level is needed »» Use voluntary sector expertise »» Contact local resources, schools, faith groups, community workers »» Involve pharmacists in primary care mental health prescribing and compliance initiatives »» Consider better use of peer support or expert patients for crisis management in primary care

Contact

Rhiannon England, GP Mental health lead, City and Hackney CCG [email protected]

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12. Bespoke mental health training for practice nurses Aims

»» For patients seen in primary care to be treated by a health care professional who understands their mental, physical, emotional, spiritual and social needs and can respond appropriately and effectively »» To create a sustainable model of capacity building through the creation of a community of nurse educators engaged with improving the capability for mental health in primary care »» To improve integration between primary and secondary care for mental health patients

Rationale

To understand the training requirements of practice nurses regarding mental health and wellbeing, a national needs assessment was undertaken in the format of a survey. Responses were attained from 390 nurses. The key findings were that 82 per cent of practice nurses have responsibilities for aspects of mental health and wellbeing in which they have not had training with 98 per cent of these nurses stating they would like to undertake at least one aspect of training in mental health and wellbeing.

Development

The project was funded by the Health Education North Central East London (HENCEL); £250,000 was secured to establish a sustainable network of nurse educators, develop a 10 module training and train the trainer programme and educate practice nurses in the region. A steering and expert reference group (ERG) were set up with representatives from all participating partners (HENCEL; the Academic Health Science Network, UCLPartners; the Mental Health Trusts, Barnet, Enfield and Haringey Mental Health NHS Trust, Camden and Islington NHS Foundation Trust, East London NHS Foundation Trust, North East London NHS Foundation Trust; and GP practices). Practice nurses views from the survey have been used to help shape the programme of learning (consisting of 10 RCGP accredited modules, five of which are available as eLearning through the BMJ), developed by Dr Sheila Hardy, with the support of the ERG. Mental health nurses from the four trusts were trained to become Nurse Educators and they delivered the programme. These Nurse Educators have been supported by UCLPartners to develop a network, which has initially been achieved through creation of action learning sets. In doing so, they have created a system of support and ongoing learning. To create a sustainable solution to capability and capacity building for mental health in primary care, this network is being supported to form a community of practice (COP) to help practice nurses and nurse trainers to continue their development in mental health.

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To achieve implementation at pace and scale, a tool kit has been developed to enable replication. This includes: train the trainer and educational materials; a guide to creation of the COP; operational guidelines and evaluation tools.

Benefits and outcomes

A bespoke mental health and wellbeing package for practice nurses has been developed. A community of nurse educators has been trained to deliver the package to improve both the capability for mental health in primary care and integration between primary and secondary care for mental health patients. The practice nurses are taught to understand the patients’ mental, physical, emotional, spiritual and social needs. This has the potential to prevent crisis and when a crisis occurs, increase recognition with appropriate and effective response.

Tips for commissioners

Use of the adoption tool kit enables creation of a highly cost effective, sustainable approach to building capacity for mental health in primary care, while improving integration, through building relationships between primary and mental health trusts nurses.

Contact

Dr Sheila Hardy, Education Fellow, UCLPartners [email protected]

13. Time to Change: Mental health training for GPs Aims

»» To improve healthcare professional’s knowledge, attitudes and behaviour towards mental health

Rationale

The BIG Lottery funded a focused training programme for GPs and primary care staff. This funding was awarded to create an opportunity to learn from the Education Not Discrimination (END) targeted training element of Time to Change phase 1 (September 2007 – September 2011) and seek to develop a training model that is targeted and aligned with the needs of GPs and primary care staff, as well as meet the objectives of the new commissioning framework. This project was designed to try and improve attitudes and behaviours in GP practices towards people with mental health problems through improving knowledge.

Development

The programme saw the delivery of bite-size, face-to-face training for all staff in GP practices to improve knowledge and understanding of mental health and how to support patients with mental health problems. The training was intended to fit into a 10 minute appointment slot and was delivered by a trainer with direct experience of receiving mental health care from their own local GP. At the end of the 10 minutes, trainees were given learning materials to support the session and a link to the website where they could access e-learning materials and ‘talking head’ films. The website had three core modules: »» Being mental health aware »» Making adjustments within the practice (Equality Act) »» Meeting people’s mental and physical health needs

Challenges

The key consideration was developing a model that would align with the availability of staff within a GP surgery. This is why the 10 minute ‘bite size’ model was so effective.

Benefits and outcomes

The face to face training yielded positive results. There was a statistically significant improvement in attitudes following the training across all groups of training attendees: there was an increase in knowledge and 35 per cent of people felt more confident about working to promote mental health following the training.

Tips for commissioners

The main reasons the training was positively received were due to the duration i.e. short enough to incorporate into general practice and the trainers sharing their personal stories.

Contact

Leigh Wallbank, Mental Health Promotion Manager, Rethink [email protected]

The training website can be found online: www.ttcprimarycare.org.uk

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15. Liaison psychiatry in north west London Aims

»» Improve the delivery of integrated care for patients with mental health needs in the acute hospital setting »» To provide a rapid response for people presenting with urgent mental health needs »» To provide training and supervision for non-specialist acute hospital staff in the identification and management of mental health needs

Rationale

A quarter of acute trust inpatients have mental health problems. Mental health problems account for 30 per cent of acute inpatient bed occupancy and 30 per cent of acute readmissions. Early identification and treatment of the mental health needs of this group has a direct impact on recovery. As well as improving patient outcomes, there is a growing body of evidence which shows that liaison psychiatry services in acute hospitals can lead to savings as a result of reduced length of stay and fewer re-admissions.

Challenges

The challenge has been determining an appropriate and sustainable funding mechanism. Liaison psychiatry is currently excluded from the mental health tariff proposals. The estimated cost savings leave open the question of whether savings are mainly of financial benefit to the acute trusts or to the CCGs.

Benefits and outcomes

»» Improvement in the mental health diagnosis, treatment and care of patients in acute hospitals with co-morbid physical and mental health problems »» Improvement in response times (1 hr in A&E; 24 Development hrs inpatients) The benefits of effective liaison psychiatry have »» Reduction in A&E waiting time breaches spurred the recent development of services across »» Contribution toward reductions in overall lengths the UK but availability remains patchy and where such services exist, there is no consistent model. In of stay on wards for people with dementia, comorbid mental health problems and alcoholNW London there are six acute hospital trusts but related admissions only two had established liaison psychiatry services. »» Improved patient experience and referrer Two providers working in partnership, Central and satisfaction North West London NHS Foundation Trust and West »» Increase in capacity and capability of all hospital London Mental Health NHS Trust, secured ‘winter staff in managing MH needs effectively pressures’ funding at the end of 2011 which enabled the establishment of pilot services at four acute trusts: North West London Hospitals NHS Trust Tips for commissioners (Northwick Park and Central Middlesex Hospitals), Engagement with both acute and mental health Hillingdon Hospital NHS Trust, Ealing Hospital NHS commissioners is essential. Trust, and West Middlesex University Hospital NHS Consideration of long-term funding from the start of Trust. A working group involving mental health proany pilot project is key to future viability. viders, acute trust staff, commissioners and service users developed an ‘optimal standard’ model for a hospital of 500 beds that provided an integrated Contact multidisciplinary service with 24-hour input to A&E Dr Steven Reid, Consultant Liaison Psychiatrist and and inpatient populations. Clinical Director, CNWL [email protected]

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16. Hull and East Yorkshire Hospitals Trust: The mental health team Aims

»» To offer a full psychosocial assessment to patients referred from either Hull Royal Infirmary or Castle Hill Hospital, who have presented with acute mental illness, self-harm, attempted suicide or extreme distress. Dependent upon the nature of the referral our response rates are 30 minutes the same working day or within 24 hours. A further aim is to educate staff within the acute trust to enable them to recognise mental health problems early and refer appropriately.

Service description

The team is multi-disciplinary and assesses patients with a range of mental health problems, but principally self-harm, within the acute care pathway. The team also assesses patients who have self-harmed and present to minor injury units throughout Hull and East Yorkshire, in the first instance via a telephone triage. The team provide an ageless service to patients who have self-harmed. They offer specialist psycho social assessment to all patients and follow up where appropriate.

Development

The team has developed incrementally since 1997. Today it consists of 15 practitioners and assesses approximately 3,700 people per year. Good working relationships with commissioners have enabled further developments to occur. For example, in 2006, it was recognised that the service received by young people attending A&E who had self-harmed was inconsistent with the adult service and a business case was submitted to enable the team to provide an ageless service for patients who self-harm. In 2012, the team expanded to integrate the older people’s liaison service. More recent developments include extended hours with the aim of becoming 24 hours. Another significant development is an extension from only seeing self-harm patients, to assessing all patients aged 18 and above presenting with mental health problems.

Challenges

»» Different commissioning arrangements for aspects of the service, for example the team see patients below the age of 18 for self-harm but not for other acute mental health problems. »» Potential for burn out of staff due to demanding, high risk nature of work. »» Service providers and stakeholders may have different agendas, which can create tensions. »» Accommodation within the hospitals

Benefits and outcomes

The team is seeking PLAN accreditation and hopes to have collated extensive feedback from patients, carers, acute colleagues and liaison practitioners. This information will be used to inform future developments and make service improvements.

Tips for commissioners

It is essential to establish good dialogue with clinicians in the acute and mental health trusts; also close working relationships with commissioners and acute staff; accommodation within the general hospital setting is paramount; regular meetings between liaison, acute and community colleagues.

Contact

Dr Stella Morris, Consultant in Liaison Psychiatry [email protected] Kerrie Harrison, Team Leader [email protected]

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17. Birmingham rapid assessment, interface and discharge (RAID) Aims

»» The service aims to meet the mental health needs of all patients over the age of 16 including those who self-harm, have substance misuse issues or mental health difficulties commonly associated with old age including dementia. With an emphasis on rapid response, it has a target time of one hour within which to assess referred patients who present to A&E and 24 hours for seeing referred patients on the wards. The service puts an emphasis on diversion and discharge from A&E and on the facilitation of early but effective discharge from general admission wards.

Rationale

The inception of the RAID model of liaison psychiatry – initially as a pilot at City hospital in December 2009 – saw a paradigm shift in the liaison model. Overnight, all patients of the acute hospital were offered access to mental health clinicians irrespective of the type of mental disorder, the department where the patient was treated or the time of day. RAID also embedded itself in the acute hospital 24 hours a day, 7 days a week.

Development

The pilot was evaluated internally1 and externally2 by academics from the London School of economics, who found that RAID saved 4 times what it cost. RAID was then rolled out across Birmingham. Clinicians work in partnership with acute hospital clinicians to assess, diagnose, formulate and plan treatment for those who are 16 years of age and above suffering with a mental health problem. Using an extensive knowledge of the broader primary and secondary care support services available, patients are placed on the correct pathway upon discharge from the hospital.

Benefits and outcomes

RAID saves money as well as improving the health and well-being of its patients. The London School of Economics reported that RAID saves 44 beds per day in a 600 bed hospital which equates to about £4 million per year. It also reported that in discharging more older people back to their homes rather than to care homes the service has saved the wider economy £60,000 per week.

Tips for commissioners

A RAID specific cross city commissioning group was set up to manage the commissioning of RAID enabling partnership working between the acute trusts and the mental health trust.

Contact

Michael Preece, RAID Operational Lead [email protected]

Challenges

There have been challenges in the roll-out of the RAID model across Birmingham and Solihull. These include the recruitment and delivery of a multidisciplinary team with the clinical experience and balance of skills required as well as practical issues such as finding accommodation within the acute hospital and becoming embedded in organisational structures and systems.

1 George Tadros, Rafik A. Salama, Paul Kingston, Nageen Mustafa, Eliza Johnson, Rachel Pannell and Mahnaz Hashmi. Impact of an integrated rapid response psychiatric liaison team on quality improvement and cost savings: the Birmingham RAID model. Available at http://pb.rcpsych.org/content/37/1/4#BIBL, accessed 8/10/13

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2 M Parsonage and M Fossey 2011; Economic evaluation of a liaison psychiatry service; Centre for Mental Health. Available from www.centreformentalhealth.org.uk

18. Hackney 24 hour AMHP service Aims

»» The London Borough of Hackney (LBH)/ East London Foundation Trust (ELFT) out of hours Approved Mental Health Professional (AMHP) service aims to respond to requests for Mental Health Act assessments (MHA’s) which arise outside usual working hours. That is, between 5pm and 9am week days and 9am to 9am on bank holidays and weekends. The service aims to respond in a timely manner usually within 2 hours, and to provide consistency and continuity of care to people requiring this intervention.

Rationale

Reliance on an emergency duty service (EDT) out of hours service to respond to any urgent situation which arises, including safeguarding children and crises in adult social care, has led to MHA assessments being deemed low priority and consequently people waiting in 136 suites for several hours, on occasions up to the 72 hour duration of a section 136. LBH were concerned to address this and to provide a service staffed by AMHP’s familiar with the people using services and with local arrangements. As well as benefitting the service user and colleagues in the other emergency services, it was also likely to lead to a better use of alternatives to admission.

Development

The service was developed over 10 months and involved a comprehensive scoping exercise and consultation with various stakeholders. The development included the decommissioning of the EDT service and the need to ensure that adult social care referrals out of hours received a prompt and robust service. Hackney already had a children’s out of hours service in place. Discussions with AMHP’s in Hackney were focused around the boundaries of the service, the interface with the daytime rota, payment and risk management.

Challenges

The challenges were to ensure that all tasks previously undertaken by the EDT were covered, that pathways for referral were clear and understood by all stakeholders and users of the service, and that staff were properly supported to do this work out of hours safely and professionally. As the provision of an AMHP service is a legal responsibility of the local authority delegated to the trust, LBH needed to give assurance to senior management in both organisations that this service was professionally robust and would lead to better outcomes.

Benefits and outcomes

The service became operational in July 2013 and undertakes approximately 25 assessments out of hours per month. There has been improvement in response times with 100 per cent compliance with the 4 hour response target. Discussions with referrers has suggested that the service is more accessible and responsive than the previous EDT arrangement and has also been able to undertake some planned assessments out of hours when circumstances are appropriate. There is now a single 24 hour phone number. The service operating costs are less than the previous EDT.

Tips for commissioners

A 24 hour AMHP service staffed by professionals employed in the day time service is generally more responsive and consistent in service delivery than EDT arrangements. It is also frequently less expensive. Robust planning and consultation with all stakeholders is essential, the service should have a single manager and have clear operating boundaries. It is essential that AMHP’s working at night have access to a manager on call.

Contact

Gill Williams, City and Hackney Centre for Mental Health [email protected]

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19. Vulnerability Assessment Framework training tool Aims

»» To enable and support the Metropolitan Police and partners to identify individuals who are becoming vulnerable far earlier and thereby enable early intervention and prevent crises.

Rationale

Police officers and other emergency services encounter individuals on a daily basis for which they may have concerns for and identify as vulnerable. The Vulnerability Assessment Framework (VAF) provides a simple tool to use to identify those that are vulnerable and possibly in need of further help. A report is completed and if appropriate shared with partners.

Development

(Development, cont’d) Since this system went live over 55,000 reports have been completed, this figure in itself speaks volumes about the success of the VAF. Once the report is on the system it is further assessed by officers working within the Multi Agency Safeguarding Hub/Public Protection Desk and where appropriate the report is shared with partners. Many of the reports that have been shared the individual is already known to partners, and may add additional information which enables the individual to get help before they reach crisis.

The VAF was introduced in April 2013 within the Metropolitan Police. The tool used within the framework was developed by Dr Karen Wright and Professor Ivan McGlen at University of Central Lancashire Benefits and outcomes (UCLAN), originally called the Public Psychiatric The VAF is enabling the Metropolitan Police and Emergency Assessment Tool (PPEAT). The tool cov- partners to identify individuals who are becoming ers 5 areas: vulnerable far earlier and enabling early intervention. The PPEAT also has further uses as a communicaA. Appearance and atmosphere: what you see first tion tool between partners as it gives a structure including physical problems such as bleeding. when passing information between services. The B. Behaviour: what individuals in distress are doing, PPEAT is used within a Partner Training DVD on and if this is in keeping with the situation. section 136 Mental Health Act “Safety in Mind” which C. Communication: what individuals in distress say is to be launched in October 2014. The DVD is the and how they say it. result of the hard work of South London and MaudD. Danger: whether individuals in distress are in sley Mental Health Trust, the Metropolitan Police danger and whether their actions put other people and London Ambulance Service. The DVD1 tells the in danger. story of a young man’s journey through the section E. Environment: where they are situated, and 136 process, and details what each partners’ role is whether anyone else is there. within this journey. The Metropolitan Police Service (MPS) have furthered its use in conjunction with UCLAN so that it is used by officers in every encounter they have, if the officer identifies three or more of the areas or on professional judgement the minimum they must do is complete an Adult Coming to Notice Record on a computer system known as Merlin. This is the same system on which we record vulnerable children. For those that are identified as needing immediate care, the appropriate legislation would be used to assist that individual, such as section 136 Mental Health Act and a report would also be completed. UCLAN continue to work with the MPS in the assessment of the tool.

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Contact

DI Frankie Westoby [email protected]

1 http://www.slam.nhs.uk/media/films/safety-in-mind. Contact: [email protected]

20. London street triage pilot Aims

»» ‘Street Triage’ aims to improve the experience of people who are in crisis and come into contact with the police. The project also aims to reduce the use of section 136 of the Mental Health Act (MHA) amongst the police and reduce the amount of time that officers spend dealing with people who are in crisis due to mental health problems.

Rationale

The Secretary of State for Health established an innovation fund to support a programme of work with other government departments, as part of the Department of Health’s (DH) contribution to the government’s growth agenda. The DH set aside £15 million to fund three distinct projects as agreed with Home Office and Ministry of Justice. One of the key programmes funded was street triage projects in nine English police forces across the country.

Development

NHS England (London region) together with the Mayor’s Office for Police and Crime (MOPAC) have commissioned a street triage project in London. The street triage project has been piloted in the boroughs of Lambeth, Lewisham, Croydon and Southwark. These boroughs were chosen as the local mental health trust serving the 4 boroughs – South London and Maudsley - showed to have the highest rates of detention under section 136 of the MHA across London.

Challenges

»» »» »» »»

Speed of engagement Staffing capacity Data collection Police/Clinical Commissioning Group/NHSE geographical boundaries »» Sustainability

Benefits and outcomes

The aim is for better outcomes for these individuals as well as achieving a substantial cost saving for police services.

Tips for commissioners

»» Strong partnerships between local commissioners, the police and police and crime commissioners »» Common understanding of the use of section 136 »» Shared vision of the desired outcomes for each partner »» Plan for sustainability

The triage service consists of mental health practitio- Contact ners accompanying police officers to mental health Sinéad Dervin, Commissioning Manager, Health in related call outs and providing dedicated telephone the Justice System support to officers on the ground who are [email protected] ing to people in crisis. The mental health practitioners are deployed specifically to help officers decide on the best option for individuals in crisis by offering professional, on the spot advice and assessment, accessing health information systems and liaising with other care services to identify the pathways for those individuals in need of support. The objective of street triage is to demonstrate that this approach can lead to more timely intervention by mental health professionals which will help reduce unnecessary detentions for people, particularly in police stations and ultimately reduce the time officers spend dealing with people in mental health crises.

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21. Integrated mental health team based within police headquarters Aims

The aim of the project is to have an integrated mental health team based within the control room at police headquarters in Norfolk. The objectives of the project are to: »» Improve safeguarding for those suffering from mental ill health »» Introduce and provide early access to services for those with mental health issues before they reach crisis point »» Provide an improved police response to those in mental health crisis by identifying appropriate intervention and referral pathways »» Provide an improved response to repeat callers with mental health issues and thereby reduce demand on the police services »» Improve joint working between Norfolk Constabulary and Norfolk and Suffolk Foundation Trust (NSFT), East of England Ambulance Service and Norfolk County council when responding to mental health issues due to co-location and sharing of expertise »» Reduce demand across NSFT and Norfolk constabulary. This will be evaluated by randomised controlled trials and the University of East Anglia are doing a full academic evaluation

Rationale

Benefits and outcomes

Challenges

Amanda Ellis, Chief Inspector, Norfolk Police [email protected]

As Norfolk is a large rural county it was felt that street triage would not have as much of an impact as having a mental health team based within the control room. A funding request was sent to the Police Innovation Fund who approved funding for a trial period to scope the project and its value.

The scoping project has shown many benefits such as cost reductions for the Constabulary and the NSFT as a result for example a reduction in S136 detentions. The welfare of service users was enhanced by them being able to obtain a more appropriate and timely service with early referrals made to more suitable agencies. There has been improved confidence and skills of staff when responding as Development first contact within the control room. Other police The project is a joint partnership between NSFT. The forces are showing interest in this project as we NSFT seconded a senior nurse to scope the project, have demonstrated real time benefits. Police officers which provided many benefits and efficiencies (see have direct access to a mental health professional ‘outcomes’). Following the success of the scoping whilst at the scene of incidents enabling an imbid a full bid has been submitted to the Police Innoproved response by the police, a reduction in harm, vation Fund for 1 x Band 7 Clinical Team Leader and threat and risk in the most vulnerable communities, 3 x Band 6 Mental Health Practitioners. The bid has improving professional understanding across the requested funds of £170,000 to enable the project to police and the NSFT leading to an enhanced workbe implemented. Due to the success of the pilot, the ing relationship and finally increased confidence and Chief Constable has agreed to release money from knowledge of mental health by police officers and the constabulary ahead of the bid results to enable staff. the project to be implemented. A band 8a Nurse has continued to be seconded to the project with the funding coming from the NSFT and the ConstabuContact lary. Year 2 funding has been applied for and the Terri Cooper-Barnes, Lead Mental Health Nurse, project is engaging with commissioners about the NSFT longer term funding. [email protected]

The development phase has been very successful. There have not been any pitfalls or significant challenges. Norfolk is the only Police force to have an initiative such as this and it has forged strong partnership links with NSFT and other agencies.

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22. British Transport Police (BTP) suicide prevention project Aims

»» »» »» »»

“From Crisis to Care” To prevent public access to known vulnerable areas of the railway Proactively look for people in distress To have a joint approach between police and health

Rationale

In February 2013 a suicide prevention project (Operation Partner) was set up between BTP, NHS London, Barnet Enfield and Haringey and West London Mental Health Trusts with Department of Health and Royal College of Nursing support. This involved BTP staff and community psychiatric nurses working together to implement and review suicide prevention plans for people at risk.

Development

In 2014 the project secured ongoing funding from NHS England and London Underground and is commissioned by the Health in the Justice team at NHS England. The pilot scheme provided: »» Medical operational review of BTP Suicide Prevention Plans »» MHPs working in the custody suite to provide screening »» Deployment of mental health practitioners (MHPs) to provide outreach assessment »» Fast access to information -MHPs have access to NHS national systems and can respond to police queries in relation to vulnerable people in real time »» A specific MHP with social care skills in two boroughs (Hillingdon and Ealing) One of the key objectives in this joint working was to get to the stage where the BTP Suicide Prevention Plan is succeeded by an NHS agreed care plan, ensuring the individual has access to the right type and level of service. Some recent research in Sussex1 has revealed that 50per cent of people assessed following detentions under section 136 are not followed up after release despite this being a code of conduct standard.

(Development, cont’d) Following significant rises in the number of suicide events on the railway, BTP gave a national directive to local offices to proactively look for people in distress under ‘Operation Avert’ with BTP, network rail operating staff and local police working together to reduce suicide on railways. Railway staff account for 20 per cent of the intervention and are trained by Samaritans. Operation Avert was launched for the third time on 10 September 2014. In attempt to reach those who are not already known to services there is a suicide prevention hotline – 0300 123 9101, for use by rail staff, health workers and volunteers who may have concerns for someone’s safety.

Challenges

Tackling the perception that railway suicide is lethal: of suicide events on the main line railways of the UK 75 per cent will result in death and 25 per cent in serious injury; whilst on the London Underground network, 50 per cent will be fatal and 50 per cent result in serious injury. The majority of victims usually live near the railway therefore it is a part of their daily life.

Benefits and outcomes

During 2013/14 631 people received life-saving interventions on the railway. During Operation Avert 1 and 2 the daily life saving intervention rate doubled and the numbers of fatal and injury suicide events reduced.

Tips for commissioners

Partnership working and collaboration between police and health is essential.

Contact

Mark Smith, Head of Suicide Prevention and Mental Health, British Transport Police [email protected]

1 http://www.sussexpartnership.nhs.uk/gps/policies/finish/2339/9034

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23. Highbury Grove crisis house Aims

»» Provide an alternative service to hospital admission for people experiencing mental health crisis in a community setting »» Support with crisis resolution or crisis prevention together with a personalised, solution focussed recovery plan to help prevent possible future crises »» Provide 24 hour access for people in a mental health crisis

Rationale

The service was established in 1996 by the mental health charity Umbrella following a survey by the King’s Fund to establish the needs of service users in Islington experiencing mental health issues.

Development

Challenges

»» Managing and re-assuring service users anxieties during cycle of change »» Increased demands of the NHS in providing much valued bed spaces »» As a voluntary sector provider we have restricted access to the NHS RIO system

Highbury Grove crisis project was commissioned in 1995 after the closure of the Friern Barnet Hospital. Service users were consulted as to what type of crisis services they felt they needed and suggested a non-medical model residential project and a drop-in ‘out of hours’ service at night. In 2011 the mental health charity Umbrella merged with One Housing Group, and the crisis house service joined the One Support Mental Health services portfolio.

»» The residential service supported 242 customers »» The crisis night centre conducted 4464 interventions with services users »» Crisis phone line received 1033 calls »» Increase in complex cases with higher needs, including self-harm and substance misuse issues »» Excellent partnership working especially with the crisis pathway

Based in Islington Highbury Grove crisis service consists of three components:

Tips for commissioners

12 bed residential service: Supporting people with their primary mental health needs and secondary support needs including drug and alcohol dependency. One to one support for 2 weeks offers regular structured morning programmes and activities; support with developing independent living skills; accessing social and community facilities. Post-discharge, 6 “in reach” meetings are offered as follow up support to the service user.

Contact

Crisis night centre: In 1999 a nine month service review was commissioned, as a result the service was re-launched as the crisis night centre. Now the evening service remains available 7 days a week to provide a safe place for service users to meet and socialise therefore minimising social isolation, while providing support where necessary. Crisis phone line: The service is provided 7 days a week 5pm to 6am. The crisis phone line is provided by staff at the crisis house and is the only phone line available to those who experience mental health problems within the borough of Islington.

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Benefits and outcomes

The critical success factor in the up-scaling of the crisis service has been formal joint working with the Camden and Islington NHS Foundation Trust acute services and crisis teams, together with joint working protocols with the local housing authority and local drug and alcohol services. The service has also recently agreed to accept Camden referrals (from NHS Camden and Islington acute services).

Sara Kelly, Team Manager [email protected]

24. Camden crisis houses Aims

»» Camden crisis houses were established to provide an alternative to acute inpatient hospital admissions based on a person-centred recovery model. Both houses offer a range of treatment and support to enable people to manage their own crisis in a community setting where possible.

Rationale

Camden service users had campaigned for over 10 years for a local crisis house. The growing evidence base shows that people tend to prefer staying in crisis houses than on inpatient wards because they can leave voluntarily, there is a higher staff to guest ratio and they feel safer as there is less likelihood that fellow guests will be disturbed, more peer support and the environment is calm and homely1. The north Camden crisis house is a six bedded facility that was opened in 2008. The Rivers, a six bedded crisis house located in south Camden on the St Pancras Hospital site, was opened in December 2013. The overall spend was £1 million.

Development

The Camden crisis house model includes a crisis team who support people in their homes and act as gate-keeper for admissions and a structured acute day treatment programme, where guests are encouraged to participate in therapeutic groups. The houses are accessible for people and their carers to get support. Service delivery is informed by an understanding of the experience of service users and their carers. People are admitted to the houses at the height of acute crises for brief stays of on average two to 10 days. Most people (74-78 per cent) are discharged to their homes. The north Camden crisis house was a joint partnership between Camden Council and Camden and Islington Foundation Trust.

Benefits and outcomes

People report that they are managing better with everyday life, and experiencing fewer symptoms, when they return home from the crisis houses. An evaluation of the service revealed that it was a cost-effective alternative to inpatient hospital stay: client rated outcome measures are high with a mean of 26 – 28 out of a maximum rating score of 32 when compared to 21 for inpatient wards (2010 evaluation).

Tips for commissioners

Establish more crisis houses in more residential locations. Stay involved in the project. Service user involvement is paramount to the success of both houses. Evaluation is also crucial as it proves effectiveness, dissipates any myths about the houses, helps to motivate staff and maintain high standards of care. Having a diverse and multidisciplinary staff group to match the service users also fosters better therapeutic alliances.

Contact

Kate Clayton, Operational Manager [email protected]

Challenges

Financing the Rivers was challenging from the outset as building work coincided with a Trust reorganisation and the world economic downturn. There were challenges during the building of both Houses with maintaining a balance between a design which was homely and welcoming, yet safe with minimal ligature risk.

1 Gilburt et al 2010; Osborn et al 2010; Sweeney et al 2014

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25. West of Dorset recovery house Aims

»» To provide an alternative to acute psychiatric inpatient admission, which allows care and support to be delivered in a safe environment that promotes recovery.

Rationale

The service was opened in April 2013, as part of a reconfiguration of mental health acute care services, in which hospital bed numbers were reduced and home treatment provision increased.

Benefits and outcomes

»» Increased choice »» Avoidance of hospital admission »» Positive experience of mental health services, “treated as a person, not like a patient.” »» Recovery aided by the calm, homely environment »» More opportunities to maintain daily living skills, Development community involvement and employment The service was commissioned by Dorset CCG, who »» Partnership between health and third sector developed the service specification in collaboration providers generates different perspectives on with Rethink Mental Illness and the Crisis and Home delivery of care and service development Treatment Team (CHTT) provided by Dorset Health»» Reduced stigma/institutionalization Care NHS Foundation Trust. CHTT offer a stay at »» Improved access to acute mental health care for the recovery house to people whose needs can be people living in remote rural areas safely and effectively met there and who would otherwise require hospital admission. Care plans are developed and delivered in partnership by the recovery house team and CHTT. The staff establishment consists of a Services Manager (half-time), Shift Lead and 5.7 Mental Health Recovery Workers. Daytime shifts comprise at least two staff and two sleep-in overnight. The annual cost is £327,777, including building costs. Existing resources were aligned to support the service e.g. the Services Manager also leads Rethink community services; a Rethink Carers’ worker is linked to the house.

Challenges

»» Convincing stakeholders that the house provided a viable alternative to hospital admission »» Developing effective shared protocols with a recently expanded CHTT »» Maintaining sufficient referrals to achieve target occupancy level of 95 per cent »» Building positive relationships with local residents

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Tips for commissioners

A good relationship between operational managers of the recovery house and CHTT is key. Specifying a maximum stay of two weeks maintains access and promotes good care planning. Allowing service-users to transfer from hospital widens access; specifying that this can only occur within 72 hours of hospital admission helps maintain the recovery house as an alternative to hospital stays, rather than a continuation.

Contact

Deborah Rodin, Services Manager [email protected]

26. HPFT: Host families scheme Aims

»» The Host Families scheme from Hertfordshire Partnership NHS University Foundation Trust (HPFT) is an alternative to hospital admission or follows on from inpatient care and aims to offer intensive intervention and support to service users in a crisis, building on strengths and assisting the service user to manage the crisis at home whenever possible.

Rationale

The scheme is an integral part of the Crisis Assessment and Treatment Team (CATT) providing a supportive, therapeutic alternative to inpatient care. Host families are recruited to offer a supportive family environment to mental health service users.

Development

As part of the development of the scheme the HPFT staff visited a Host Family Scheme in Lille, France and gained their support in developing the Hertfordshire model. A particularly important aspect of the Lille scheme involves closely ‘matching’ the service user with a host family. HPFT adopted a similar process which means the CATT, informed by a recovery-oriented approach, looks at the service user’s strengths and interests as well as needs and issues. For example, if the service user enjoys gardening it may be beneficial to place them with a host interested in gardening. A key part of developing the model included establishing a steering group with service users and carer representation and voluntary sector involvement. The scheme is managed and supported by CATTs throughout Hertfordshire. It offers 24 hours, 7 days a week individualised support to people aged 18 and over and aims to assist the service user and relevant carers to learn from the crisis and endeavour to reduce the service users vulnerability to crisis and maximise their resilience and recovery. The host family are expected to support a recovery model of work and receive ongoing appropriate training and support to do this. CATT actively involve service users who have stayed with host families in planning service development and providing feedback about their experiences of the service to ensure continuous improvement. There are currently 11 host families and 61 people have been placed with a host family; placements that have prevented hospital admission or supported early discharge.

Challenges

The concept of supporting people who are acutely unwell in a family home raised some concerns therefore the team have worked with Hertfordshire County Council to put in place a robust safeguarding process. Collect measurable qualitative and quantitative data from the start to demonstrate quality and impact of Host Families scheme as a true alternative to inpatient care.

Benefits and outcomes

»» Raise awareness and understanding of mental health issues in local communities; promote social inclusion and reduce stigma »» Reduce pressure on acute inpatient care services »» Offers people an alternative environment in which to receive treatment in; less medical, more social »» HSJ award – Innovation in mental health 2012 »» Evidence of good clinical outcomes

Tips for commissioners

Offer host family as a choice at point of assessment when an individual’s needs are increasing and they enter the acute pathway.

Contact

Sarah Biggs, Hertfordshire Partnership University Foundation Trust [email protected]

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27. Redbridge home treatment team Aims

»» To provide a genuine focus on the provision of multi-disciplinary acute home treatment as an alternative to admission through the introduction of an integrated care pathway model »» To allow inpatient wards to better focus care on clients whose risk profile requires admission

Rationale

In 2008 in response to the social inclusion agenda and the desire to improve acute care, North East London Foundation Trust embarked on the redesign of trust wide mental health acute services for working age and older people. This involved the progressive introduction of a new model of integrated care pathway working to the four London boroughs served by the trust, adapted to the needs and resources in each area. This way of working has led to less demand for acute inpatient treatment; it has therefore been possible to divert resources to home treatment teams and towards improving the quality of care.

Development

Redbridge home treatment team is a 24-hour acute service working with people experiencing acute episodes of mental illness including people with learning difficulties, personality disorders where the risk profile indicates this is required and substance misuse problems (where this is not the primary presenting problem). The team is multi-disciplinary, including social care staff, psychologists and occupational therapists. All referrals to acute services are initially assessed by a mental health practitioner - referring teams are guaranteed an immediate telephone response and physical assessment when needed within two hours. The home treatment team have a 100 per cent gate-keeping role to their wards and are also 100 per cent involved in inpatients discharge: arranging same-day home visits for service users discharged from hospital and daily follow-up until the end of the acute phase. The team work with acute wards on a daily basis to progress discharges and identify outstanding practical issues: the co-location of the team with the wards at one central base facilitates this integrated way of working. Redbridge actively involve service users and their families in their treatment and seek feedback.

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Challenges

It is important to ensure all care pathway teams, including access and liaison psychiatry at A&E are working to the same model and with sufficient resources.

Benefits and outcomes

»» Increased treatment at home - promotion of social inclusion, reduction in social isolation »» Enhanced patient involvement in the delivery of care and service user and carer engagement »» Reduced risk of long-term adverse effects caused by multiple or long admissions »» Progressive reduction in acute bed usage and bed base »» Improved financial efficiency of ongoing service delivery

Tips for commissioners

Ensure sufficient investment in home treatment teams in order to allow them to safely deliver home treatment as an alternative to admission, alongside increased investment in remaining wards to allow them to work with the more efficient model.

Contact

Pete Williams, Assistant Director NELFT MHS Acute Services Lead [email protected]

28. South Tyneside crisis resolution and home treatment team Aims

»» To provide intensive home based treatment to people in mental health crisis as an alternative to hospital admission.

Development

Northumberland Tyne and Wear NHS Foundation Trust provides a crisis resolution and home treatment team (CRHT) with the capacity to visit service users up to three times daily, providing a range of psychological and physical interventions including support and psycho-education for carers and families. The team works extensively with the inpatient units; gatekeeping 100 per cent of admissions and also providing early discharge planning. The team provide a 24 hour mobile workforce inclusive of nurses, doctors and support workers; access to specialist clinical advice is available by accessing scaffolding and augmenting services to ensure that all the clinical needs of the patients referred to the service are met. The introduction of the use of mobile solutions has improved performance in record keeping and also reduced time spent completing documentation. The team have access to laptops and also digital dictation services with the ability to dictate, using an app on their mobile phone, and send to a transcription service, which inputs into the patient record. Access to the Team is via the South of Tyne initial response service which provides 24 hour telephone access for all referrers who require urgent support from mental health services.

Benefits and outcomes

»» Frequent hospital admissions for some service users are neither helpful nor provide any therapeutic benefit. Through the use of MDT meetings and working collaboratively with service users we have been able to provide robust packages of care working within a recovery based model »» The introduction of “mobile solutions” has reduced clinicians administrative workload; providing a more timely response to referrals and allowing the clinical staff to focus more on clinical interventions »» The use of the initial response service to manage telephone referrals provides a central point of access; this means the team are only contacted if a face to face response is required and avoids disruption to clinical care »» Maintaining an individual’s care in the community, reducing the adverse effects of hospital admission »» A significant reduction in hospital admissions and bed usage and improved financial efficiency

Contact

Emma Bailey, Team Manager, CRHT Sunderland and South Tyneside [email protected]

A nurse initially completes a telephone triage, the outcome of which may require a face to face triage or a crisis assessment provided by the CRHT. This triage model supports clinical staff to work in the community and provides a central hub for all referrals.

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29. What makes a good crisis plan? Aims

»» To co-produce what is considered to be an exemplar crisis plan and good practice standards for the crisis planning process

Rationale

Quality statement nine of the NICE guidance on service user experience in adult mental health service (2011) states that people using mental health services who may be at risk of crisis are offered a crisis plan. NICE (2011) define a crisis plan as a future statement of preferences and practical arrangements. It may therefore be considered as an advance statement. In summary, there are three main types of advance statements developed by people with mental health conditions and these are generally known as psychiatric advance directives. In 2013/14, one of the Trust’s CQUIN targets is to review the crisis plans of people on Care Plan Approach and implement a programme to improve the quality of crisis planning. The first outcome for this CQUIN has been to co-produce what is considered to be an exemplar crisis plan and good practice standards for the crisis planning process.

Development

A three-stage process was used: »» Stage one reviewed the research literature. »» Stage two a workshop took place bringing together the expertise of service users, carers, friends, families and professionals to identify what makes a good crisis plan. »» Stage three involved the undertaking of a Delphi exercise to identify areas of consensus.

Challenges

The challenge is to move from this process into the day-to-day reality of collaboratively developing crisis plans in our routine practice but more importantly, the accessing and honouring of the plans when a person is in crisis.

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Benefits and outcomes

Through the literature review and the workshop a total of 94 statements were generated for what makes a good crisis plan. 78/94 statements reached positive consensus within the Delphi exercise. The 16 statements which reached ‘no positive or negative consensus’ were analysed further to understand if there were differences between service users, carers, friends, families and mental health professionals. There were no differences for 10 statements with all respondents being clustered in the centre of the scale. However, for 6 statements, respondents did differ in their responses. In particular, 10 per cent of service users and 25 per cent of carers and families in comparison with 49 per cent of mental health professionals disagreed or strongly disagreed with the statement that crisis plans will not work because services will not honour them. The 3 stage process for co-producing an exemplar crisis plan and good practice standards appears to have worked well. Anecdotal feedback from participants has been very encouraging about the trust working in this way and involving a wide range of people to coproduce this work on crisis plans. The Delphi exercise has enabled service users, carers, friends, families and mental health professionals to freely express their opinions without undue social pressures to conform from others in the group but also enabled a greater number of people to be part of the process of coproducing a solution to crisis plans. The issue of trust came up strongly in the workshop and continued throughout the Delphi exercise.

Contact

Miles Rinaldi, Head of Recovery and Social Inclusion, South West London and St George’s Mental Health Trust [email protected]

30. Ways to wellness: social prescribing for people with LTCs Aims

»» To improve the quality of life of people with long term conditions (LTCs) through access to social prescribing and reducing costs to commissioners. The objective is to develop a sustainable and economically viable model of social prescribing for people with LTCs in order to bring about long term behaviour change, increased social wellbeing and social networks. Ways to Wellness will offer social prescribing to 5,000 patients per year.

Rationale

GPs in West Newcastle have had a longstanding interest in using social prescribing as a way of responding meaningfully to people with long term conditions and mental ill health, especially in terms of recognising the impact of co-morbidity, and addressing the wider determinants of a patient’s wellbeing such as social isolation.

Development

The Ways to Wellness model incorporates learning from a series of social prescribing commissioning initiatives that have been tested locally over the years1. This includes early pilots in practice based commissioning, and a People Powered Health project2. This work tested the role of ‘link workers’ which formed a key part of the model. Link workers provide focused support to help patients identify and access community activities and where necessary specialist advice to help improve their wellbeing. A recent project has looked closely at maximising the effectiveness of the social prescribing offer and the link worker role for people whose needs include mental health problems3. Ways to Wellness Ltd will hold a contract with Newcastle West CCG, whereby the CCG agrees to pay for the provision of social prescribing services to their patients if Ways to Wellness can evidence achievement of performance measures that demonstrate value to patients and a reduction in the use of NHS resources. This will be a Social Impact Bond type model. The main funding has been £130,000 of development funding which came from the Social Enterprise and Investment Fund and the CCG have just submitted their Stage 2 application to the Big Lottery Commissioning Better Outcomes and the Social Outcomes Fund to secure funding to help CCG to pay for financial benefits (such as reduced GP visits) that fall outside of the CCG’s budget. Preliminary projections estimate that £2.75 million to £3 million of social investment.

Challenges

»» Practice engagement - ways of informing and changing GP behaviour »» Public and patient engagement - ways of informing and changing patient expectations »» Having access to good quality information about what resources, services and groups are available »» Reduced capacity in community, health and social care resources due to public spending cuts »» Finding a set of comprehensive metrics simple enough to base contracts on and trigger payments.

Benefits and outcomes

»» Improvements in patient self-management and in patient’s health compared with predictions »» Reduction in secondary care usage leading to net savings because of reduced NHS usage »» Reduced visits to GPs »» Reduced reliance on prescription drugs for some conditions (such as those for depression)

Tips for commissioners

As an evolving project, there has been a culmination of several years of experimentation and investment in social prescribing - there isn’t a quick commissioning fix. Building trust and relationships to establish confidence to do things differently is key. The recent Ways to Wellness procurement prospectus for link worker provider host organisations and the open and consultative way in which it was put together and the fact that it has a values base are very good learning point for commissioners.

Contact

Sandra King, Project Director, Ways to Wellness [email protected]

1 Thanks for the Petunias, A guide to developing and commissioning non traditional providers to support the self management of people with long term conditions, NHS, 2011, www.diabetes.org.uk/upload/Professionals/Yearper cent20ofper cent20Care/thanksfor-the-petunias.pdf 2 www.nesta.org.uk/project/people-powered-health 113 3 Social Prescribing for Mental Health - and Integrated Approach (Draft report) http://movingforwardnewcastle.co.uk/

31. The Sandwell Esteem Team Aims

»» The aim of the Esteem Team is to support people with mild- moderate mental health conditions and complex social needs at an early stage to prevent deterioration and admission to secondary care services. It aims to empower patients to take control of their own lives by offering guided therapies and tools for self-help.

Rationale

Benefits and outcomes

Development

»» Review processes and interventions on an ongoing basis. Early intervention and reaction to problems ensured continuity of service for patients during the restructure of the team »» Co-production and involving patients and service users in service design. »» Skill mix and staff roles »» Staff have experience of mental health conditions; therefore understand the patient’s issues. »» Awareness-raising and relationship-building »» The team relies strongly on relationships with other services, particularly those in the voluntary sector, to offer patients access to a range of services and support groups. »» Holistic care tailored to patients needs using a stepped care approach »» The team tailors care packages to the specific need of patients.

Patients can feel left unsupported if a care intervention is not successful. Complex referral pathways can mean that patients get ‘lost’. In standard practice patients can access a certain number of therapy sessions and have to seek a new referral from their GP once these end or if their condition has not improved.

The hub is mainly funded by the Sandwell and West Birmingham CCG. The cost for the Esteem Team in 2012/13 was £490,349. In 2013/14, the budget was £569,674. The team is part of the Sandwell Integrated Primary Care Mental Health and Wellbeing Service (the Sandwell Wellbeing Hub). It is a holistic primary and community care-based approach to improving social, mental and physical health and wellbeing. The team receives referrals from secondary, primary and community care organisations as well as social care and probation services. Patients can also selfrefer. Link workers are navigators, typically having a social worker background and/or experience with mental health conditions. Link workers form close relationships with patients, visiting patients at home and accompanying them to appointments.

Challenges

In the absence of formal referral criteria, many services would refer inappropriate cases to the team, which led to duplication and increased the team’s workload. The team would also receive referrals of people with acute suicide risks. The team helps in these cases by alerting the appropriate services, but at the expense of prolonging distress for the patients and creating additional work.

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A statistical analysis carried out showed significant levels of improvement on a clinical and a wellbeing scoring tool (the Core 10 and Warwick-Edinburgh Mental Wellbeing Scale -WEMWBS). There was also a reduction in the percentage of patients with a diagnosis of clinical depression.

Tips for commissioners

Contact

Ian Walton, IAPT lead, Sandwell and Birmingham CCG [email protected]

32. Manashanthy: CBT for Tamil people in south west London Aims

»» The aims of this project were to identify needs in the Tamil community, raise awareness of existing IAPT services and offer interventions to meet their needs.

Rationale

The group was developed as part of the Improving Access to Psychological Therapies (IAPT) initiative in Wandsworth and Merton. A mission statement of IAPT is to improve access to psychological therapies for ‘hard to reach’ communities: actively working with a potentially excluded group to minimise this and offer better service. The Tamil community was identified as one such marginalised community in south west London, and the Manashanthy group (mindpeace) has been developed.

Development

Tamil speaking cognitive behaviourial therapy (CBT) therapists were employed and trained to provide workshops at the Wimbledon Shree Ganapathy temple to the Tamil community, as well as via other local temples and churches. Additional support came from a community development worker increasing awareness of the work with local GPs. The workshops covered IAPT services in general, stepped care approach, how to access IAPT services, basics of CBT, mindfulness, basics of PTSD and available support. The temple offered rooms for clinical work this was an ideal setting as the Tamil people were comfortable and familiar with the Temple as a place of safety. The first group ran in October 2010. Since then there has been a process of learning and adapting for example changing the number of sessions offered and tailoring the treatment model used to incorporate eastern healing methods and mindfulness.

Benefits and outcomes

»» A culturally adapted CBT model has been established »» Good clinical outcomes »» The service is working with a number of partner organisations, including Asylum Welcome, Freedom from torture, Food Bank Project, Tamil Welfare Organisation and Tamil English Teachers »» Promoting the service with GPs, CMHTs and traumatic stress services

Tips for commissioners

»» Community engagement is strengthened by training staff from local communities to deliver interventions »» Co-production with communities ensures interventions that are tailored to the local needs »» Key performance indicators need to be flexible to enable innovative working

Contact

Meera Bahu, Psychological Therapies and Wellbeing Service, Wandsworth [email protected]

Challenges

There were number of challenges in developing the Manashanthy Group: developing partnerships with community organisations and developing culturally appropriate services took time and required flexibility; overcoming stigma; equipping therapists to work with people who have been tortured to manage their own distress and reactions; clients would “drop out” or “disappear” because they had been sent back home or moved to a different place, this disturbed the group dynamics; a community setting means working in a non-clinical environment which increases the risk and health and safety issues.

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About the Strategic Clinical Networks The London Strategic Clinical Networks bring stakeholders -- providers, commissioners and patients -- together to create alignment around programmes of transformational work that will improve care. The networks play a key role in the new commissioning system by providing clinical advice and leadership to support local decision making. Working across the boundaries of commissioning and provision, they provide a vehicle for improvement where a single organisation, team or solution could not. Established in 2013, the networks serve in key areas of major healthcare challenge where a whole system, integrated approach is required: Cardiovascular (including cardiac, stroke, renal and diabetes); Maternity and Children’s Services; and Mental Health, Dementia and Neuroscience.

Strategic Clinical Networks | NHS England (London Region) 020 7932 3700 | [email protected]

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