www.england.nhs.uk • Andy Bell, Deputy Chief Executive, Rebecca Campbell, Quality Improvement Manager and Sarah Boul, Quality Improvement Lead • Twitter: @YHSCN_MHDN #yhmentalhealth • July 2017 Mental Health Commissioning Workshop: Using economic evidence to improve services for adults Cloth Hall Court, Leeds 11 July 2017
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www.england.nhs.uk
• Andy Bell, Deputy Chief Executive, Rebecca Campbell, Quality Improvement Manager and
Sarah Boul, Quality Improvement Lead
• Twitter: @YHSCN_MHDN #yhmentalhealth
• July 2017
Mental Health Commissioning Workshop:
Using economic evidence to
improve services for adults
Cloth Hall Court, Leeds
11 July 2017
www.england.nhs.uk
@YHSCN_MHDN
#yhmentalhealth
Housekeeping:
www.england.nhs.uk
Welcome, Introductions and Apologies
Andy Bell, Deputy Chief Executive, Centre for Mental Health
www.england.nhs.uk
Keynote Address
Debbie Taylor, Creative Minds Peer Project
Physical and mental health: the economic evidence (so far) Andy Bell, 27 June 2017
Mental health care funding
NHS currently spends about £14bn on mental health care (13% of the total budget)
Not treating mental ill health costs a further £14bn:
People with long-term conditions
Medically unexplained symptoms
Other complex needs
Mental and physical health overlap
Mental health and long-term conditions
20-50% of people with cardiovascular diseases have depression
People with diabetes twice as likely to have depression
Anxiety ten times as prevalent among people with COPD
One third of women with arthritis also have depression
The impact of co-morbidity
Mortality from asthma is doubled if you also have depression
People with chronic heart failure and depression eight times more likely to die within 30 months
Higher mortality and more complications from diabetes
Impact on NHS costs
Costs of healthcare rise by at least 45% regardless of severity of physical illness
The more comorbidities, the higher the costs
The costs of co-morbidity in hospitals
Half of hospital inpatients have a co-morbid mental health problem
Less than half of those are identified
15% A&E cases relate to mental illness or alcohol misuse
Mental ill health costs £25m for a 500-bed hospital (15% of all expenditure)
Benefits of liaison psychiatry
Liaison psychiatry services can:
Reduce admissions from A&E
Reduce lengths of stay (2-5 days per elderly patient)
Reduce readmissions and enhance independent living after discharge
Build skills and confidence of hospital staff
Savings estimated at £5m per hospital
Integrated care and support
Structured approach to care outside hospital involving:
Care coordination by a case manager
Systematic management and outcome tracking
Multi-disciplinary team
Collaboration between primary and specialist care
Key role for voluntary sector
Economic evidence for integrated care
US evidence shows every $1 invested generates social benefits of $5
Cost per QALY estimated by NICE at £4,000
Strongest evidence base for patients with diabetes and depression
Some small-scale studies show benefits for coronary heart disease and COPD
Scale and cost of medically unexplained symptoms
Estimated 25% of people in GP surgeries and up to 60% in some outpatient departments
2-3 times higher use of health services
Costs £3bn a year to NHS (for adults of working age)
Cost per case £700 a year (and £3,500 for most costly 5%)
Supporting people with medically unexplained symptoms
Limited evidence for benefits of GP training
Strong evidence for CBT and other structured psychological interventions
Some evidence that these lead to reduced use of other health services
Primary care outreach for complex needs
City & Hackney Primary Care Psychotherapy and Consultation Service
Supports people with ‘complex needs’ including medically unexplained symptoms
Offers advice and support to GPs in managing patients
Provides direct service to patients with a range of psychological therapies
Evaluation results
High recovery rates (55% recovery; 75% reliable improvement)
Cost per QALY of £11,000
Saves NHS one-third of its cost within 12 months
Very high GP satisfaction
Physical health for people with psychosis
15-20 year shorter life expectancy
Excess mortality related to physical ill health
Smoking cessation based on NICE guidelines:
Average gain of seven years of life per person who quits smoking
Likely savings from reduced healthcare costs
Meeting physical health needs
Annual physical health checks (Bradford)
Medical liaison in inpatient services (West London)
What hinders integration?
Cultural divides between mental and physical health care
Separate training for professionals
Different funding streams and accountability systems
Benefits don’t always accrue to same organisations that carry costs
Stigma
Tackling unmet mental health needs
Collaborative care for people with long-term conditions and mental health problems
Psychological therapies for people with medically unexplained symptoms and complex needs
Liaison psychiatry in every hospital for all patients
www.england.nhs.uk
Bridging the Gap
Dr Christian Hosker, Leeds and York
Partnership Trust
The Leeds Liaison Psychiatry Service
Bridging the Gap
ME
Consultant Liaison Psychiatrist Lead Clinician - Ward based service for general hospital
inpatients - ED and Self harm presentations A general liaison psychiatry clinic - Specialist outpatient clinics - Transplant psychiatry clinic
Special interest in palliative care psychiatry & psycho-oncology -hospice based palliative care clinics -A psycho-oncology clinic at the Leeds Oncology Institute
The service in Leeds
HMHT
HMHT
HMHT
HMHT
WA HMHT
OP
OP HMHT
OP NICPM ALPS PSM CFS
OP YCPM ALPS PSM CFS
OP YCPM
1970s
1980s
1990s
2000s
2010s
Current service provision
4000 assessments PA 18 band 6-7 staff
3 WTE 500 Assessments PA
8 beds 25 admission PA
471 Assessments PA
669 Assessment PA
2770 assessments PA
8465
LIAISON PSYCHIATRY OUTPATIENT SERVICE
Bridging the Gap
Mission
• Improve the health outcomes for patients with co-morbid physical and mental health disorder
• 30% of population have LTC – 2-3 times more likely to develop mental health
problems
– General population : 5-10% depression prevalence
– Diabetes : 18%
– Coronary heart disease : 23%
• Multiple LTC – 7 times more likely to be depressed
• Mental illness predicts:
– Poor health outcomes
• Increased mortality
• More presentation
• Reduced independence
• Low QoL
• Poor treatment engagement and self management
Costs
12-18% of all NHS expenditure on LTC linked to mental health Increased service use
More admissions More acute episodes Greater length of stay
Wider economy
Greater unemployment Cost sits within the most complex patients (Kings Fund 2012)
Interventions will pay for themselves (King’s fund)
Interventions: LTC pathway Function
Time
Intervention
Medically Unexplained Symptoms
Terminology…
…cases that present with physical symptoms that are a problem and which may have a psycho-social origin but are also possibly
mediated by organic brain processes (PSPWPOPMOB)…
MUS: What are we talking about?
• Illness versus disease – 5-7% of population (SSD)
• MUS
• Functional somatic symptoms
• Somatisation
• Somatic symptom disorder
• Confusing for patients/staff…!!!!
Typical case:
• JD has been troubled by medically unexplained symptoms within the context of a long history of anxiety, depression, dyslexia and dyspraxia. He has been assessed by a private neurologist and had a normal MRI scan, nerve conduction and EMG and there were no abnormalities on a range of blood tests (autoantibodies, B12, Folate etc). His function is poor and he was described as spending most of his time in bed and not washing.
School difficulties
Work difficulties
Tinnitus
10 year work absence Employment support Near employment
CBT Back pain Move less frequently Exacerbates stiffness Creates stress Reattribution 1. Making patient feel understood 2. Change the agenda 3. Make links to psycho-social stress
Enhanced care Looser, integrated approach
MUS PATHWAY
The Leeds Liaison Psychiatry Service
Development
• Within existing commissioning arrangements
• Clinician led
• Aim: Improvement in quality, efficiency, consistency, outcome
• T & F group
• Evidence led
• R & D support
The pathway
• Medical triage
• CBT default position – Woolfolk & Allen
• Alternative, less manualised arm
• Launched Oct 2015
Pathway - detail
• Referral – correct pathway identification
• Assessment booklet sent out
– EQ-5D-5L
– SF36
– PHQ-9
– CORE 10
– TOMS (CROM)
Medical assessment
Referred patients
• N = 40
• Referral source – 1/3 GP
– 1/3 General Hospital
– 1/5 Mental Health Trust
• PHQ-9 14 Mod depression
• GAD-7 12 Mod anxiety
• WSAS 20 Significant functional impairment
Referred patients
EQ-5D-5L Mobility 3
EQ-5D-5L Self-care 2
EQ-5D-5L Usual activities 3
EQ-5D-5L Pain 3
EQ-5D-5L Anx/dep 3
EQ-5D-5L Your health today 45
fibromyalgia, migraine,
depression, non
epileptic attacks
non cardiac chest pain,
anxiety, PTSD, pre-
existing cardiac
disease
face and head tingling
Giloma and secondary
epilepsy. Dissociative
attacks
depression, anxiety,
non epileptic attack
disorder, self injury,
bulimic symptoms
post concussional
syndrome, PTSD,
generalised anxiety
throat burning, urgency
NEAD
Non epileptic seizures,
Lupus with possible
cerebral involvement.
REM Sleep disorder.
Adrenal insufficiency,
Fibromyalgia, Chronic
constipation.
None epileptic attack
disorder, ? Epilepsy
MUS, CFS, epilepsy
1Emotionally unstable
2Cyclical vomitting
3Headaches
Other
1Dissociative Motor
Disorder
2
3
Other
1Somatoform
autonomic dysfunction
(IBS)
2
3
Other
1 psychologic non
epileptic attacks.
2 Psychogenic
movement disorder
3
Other
Our experience…
• Hard work!
• Solid process
• Pathway leaders
• Feedback to clinicians
• Improved focus
• Improved training
• Improved patient experience
• Live process - adaptable
Our experience
• Integrated across health setting???
• Capacity issues
• Cant help everyone
• Lacking a forum for shared experience…
Future ambitions
Questions…
www.england.nhs.uk
Group discussion 1:
How can we bridge the gap?
What provision do you have now?
What are the main gaps and concerns you
have about this area?
How might you go about addressing these?
What support do you need to do this?
The acute care pathway: crisis services and out of area placements Andy Bell, 27 June 2017
Economic evidence on the acute care pathway
Limited evidence about cost-effective interventions
Major cost pressures:
Inpatient admissions: account for 51% of mental health care spending but 11% of activity
Out of area placements
Delayed discharges and transfers of care
Economic evidence for crisis services
Strong evidence of economic benefits of faithfully implemented Crisis Resolution and Home Treatment (CRHT) teams
Net savings estimated at £2,300 per person
Limited economic evidence for crisis houses and other alternatives to admission
The many costs of out of area placements
Hard to quantify but will include:
Time taken finding a bed: key role of AMHPs
Trauma for the individual and family members
Transport (ambulance and police)
Ongoing contact with local authority & CCG
Opportunity cost of spending on services outside local area (and NHS)
Poorer outcomes, including higher suicide risk
What causes delayed discharges?
Housing difficulties (which escalate the longer a person is in hospital)
Lack of contact with local areas (for people in long-stay out of area placements)
Possible solutions: learning from Bradford
Close working with the police to respond quickly to crises
Embedding AMHPs in community teams
Alternatives to admission
Housing rights help and advice
Joint health & care commissioning
Shared discharge planning
Rehabilitation services
10-20% people with psychosis require longer term support
80% rehabilitation referrals are from acute inpatient wards
Two-thirds recover well with effective rehabilitation (c. 12 month inpatient admission followed by community support)
Many of these services have been cut or reduced…
Long-stay inpatient admissions
Growth in out-of-area placements and private sector provision
Emergence of ‘locked rehab’ wards
Evidence of individuals spending many years in wards: dislocated from family, community and local services
Need for recognition of this group & locally based support
www.england.nhs.uk
Time for some lunch?
www.england.nhs.uk
Improving Rehabilitation
Pathways
Dr Mike Hunter, Sheffield Health and
Social Care Trust
The “Other” Out-of-Area Story
Mike Hunter, Medical Director @SHSCFT
Associate NCD @NHSImprovement
@DrMikePsych
Do Something Novel to Liberate Resources
Our Out-of-Area Experience
Our Local Service Experience
Are the Service Users Different?
Getting a Grip
Cumulative admissions Cumulative total
Looking to the Community
See the Person in the System
Socially Based Care
‘Bricks and Mortar’ tenancies
For example:
Sheffield City Council
South Yorkshire Housing
Care for J
Social Care via SDS /
Supporting People
For example:
Tenancy support
Vocational support
Befriending
Domestic services
Healthcare
For example:
SHSC– SORT/CERT
CPA
Manage/contain risk
GP
Housing Benefit
Crisis Provision
For example:
Overnight support
Crisis House
Short-term care beds
A Credible Social Housing Partner
Staffing Establishment
Team Manager and Deputy Team Manager
Senior Psychologist
Psychologist and Assistant Psychologist
Consultant Psychiatrist
Occupational Therapist
Administrative Support
Mini Teams
Mini Teams for 8 Service Users
Two Band 6 CPNs
One Band 4 Development Role
Eight Band 3 Recovery Workers
+/- Apprentice
[2 3 1]
[6 9 3]
Planning Every Day
Reflective Practice
• “You can see it can’t you the fluctuations in the team alongside the service users, that we go up and down as well and kind of mirroring their experiences.”
• “It helps us notice breaks we need, it allows us to come away from and think about what we’re doing.”
“I don’t think that anybody feels like they can’t bring an issue, like it doesn’t matter who you are or what the issue is if its there and we talk about it … and if things have gone ‘wrong’ there hasn’t been finger pointing or blame its been more of a ‘well, ok what can we do from this point’ ... it’s never been like ‘oh well, that failed’ or ‘that was rubbish’ its been ‘ok lets try something different’ which from my experience as working as nurse is very very rare”
Sad, fear, guilt, shame, worthless hopeless
I can’t talk to
my parents/ hide
behind a smile
Triggers
Mum diagnosed with breast cancer Family experiencing physical health
problems. Finding collage challenging
Historical Factors
Trauma
I hide it
because I
don’t want
people to feel
sorry for me.
embarrassed
I’m not
important/burden
Try to avoid
feelings &
thoughts
Short term:
sleep/
Self-harm/isolate
myself at home
Works for 5 mins
I’m useless, I’m a
failure, I’m not good
enough, I can’t do
anything right, My thoughts go
round and round
in my head.
Short term: self
harm
People try to stop
me self-harming
Critical
Controlling
I
Criticises
Controlled
I want to
kill myself
Team becomes
anxious
Rescuing
Perfect care
I
Rescued
perfectly cared
for
Splits team
Lack of shared
understanding
between teams
Lack of
consistent
working with
the service user
Team feel
stressed worn
out
Developing Understanding
• “Because your clients are behaving in ways that elicits a response from you but when you have got that diagram you can see other avenues and you can see why.”
• “Having the team formulation and having like a diagram that explains your own responses so you know that sometimes the feelings that you are feeling are natural … you know where it’s coming from.”
• “It helps because you feel like you have understood the problem a bit more ... that gives us confidence in what we are doing .. .its easier to give our service users confidence.”
The Main Risks
• It doesn’t work and people are readmitted to the acute care system.
• It doesn’t work and there are many SUIs.
• It doesn’t work because people become institutionalised in the community and can’t move on.
Reducing Bed Nights
• Twenty-seven people had been using 9855 bed nights per year.
• In the last 27 months, a 99% reduction.
Incidents
• Approximately 70% related to self harm.
• Approximately 30% related to threatening behaviour.
Next Steps
• Some people are now moving on.
• We want to link this with our development of personality disorder / trauma-focussed / formulation-led services more widely in the City.
From the Q4 data (Jan-Mar 16/17), people from the North region spent 13,476 bed days out of area at a
cost of £2,466,090 (lowest cost across all regions, despite large geography).
Possible priority areas for improvement:
Greater Manchester STP, has the highest no. of OAP bed days of all STP areas.
Tees, Esk and Wear Valleys FT, Greater Manchester Mental Health FT and South West Yorkshire
Partnership FT reported the highest OAP bed days over the period across the North region. In these
cases, most people were remaining within the organisation, but the distance travelled to inpatient unit
disrupted their continuity of care.
A number of CRHTTs in Greater Manchester appear to be poorly resourced. This is also the case
for Lancashire Care NHS Foundation Trust, where CRHTTs aren’t able to visit people 24/7 and
reportedly spent more than £750K on OAPs during the quarter.
Positive:
Four Trusts in the North (Cheshire And Wirral FT, Rotherham Doncaster And South Humber FT,
Bradford District Care FT and Sheffield Health & Social Care FT) have reported no OAPs YTD.
Many of the CRHTTs across these Trusts deliver the key functions.
Northumberland Tyne and Wear FT has some of the best resourced CRHTTs in the country,
delivering the key functions.
Selected headlines – North Region
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?*
Can the CRHTT assess new referrals at home 24/7?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Sou
ther
n H
ealt
h N
HS
Fou
nd
atio
n T
rust
Southampton Acute Mental Health Team
N Y N N 55 28.50 0.52
3020 £1,778,750 North Hants Acute Mental Health Team
Y Y Y Y 38 24.00 0.63
East Acute Mental Health Team
N N N N 70 25.70 0.37
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?*
Can the CRHTT assess new referrals at home 24/7?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Bra
dfo
rd D
istr
ict
Car
e N
HS
Fou
nd
atio
n T
rust
IHTT Airedale Y Y Y Y 80 16.50 0.21
* *
IHTT Bradford
Y Y Y Y 120 20.50 0.17
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?*
Can the CRHTT assess new referrals at home 24/7?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Do
nca
ster
Ro
ther
ham
an
d
Sou
th H
um
be
r N
hS
Fou
nd
atio
n T
rust
Doncaster Access Team
Y Y N Y 30 20.60 0.69 * *
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?*
Can the CRHTT assess new referrals at home 24/7?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Hu
mb
er N
HS
Fou
nd
atio
n T
rust
CRHTT (HULL?)
Y Y N Y 85 27.00 0.32
600 £240,668
East Riding of Yorkshire CRHTT
Y Y Y Y No data 21.60 No data
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?*
Can the CRHTT assess new referrals at home 24/7?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Leed
s an
d Y
ork
Par
tner
ship
Fo
un
dat
ion
Tru
st
South Intensive Community Service
N N N N 45 25.10 0.56
126 £61,321
West/North West Intensive Community Service (ICS)
N N N N 70 45.80 0.65
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?*
Can the CRHTT assess new referrals at home 24/7?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Lee
ds
and
Yo
rk P
artn
ers
hip
N
HS
Fou
nd
atio
n T
rust
East North East (ENE) Intensive Community Service
N Y N N 55 33.50 0.61 126 £61,321
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?*
Can the CRHTT assess new referrals at home 24/7?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Ro
the
rham
Do
nca
ster
an
d S
ou
th H
um
be
r N
HS
Fou
nd
atio
n T
rust
North Lincs Access Team
N Y N Y No data 26.00 No data
* *
Rotherham Access Team
Y Y Y Y No data 11.50 No data
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?*
Can the CRHTT assess new referrals at home 24/7?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Shef
fiel
d H
ealt
h a
nd
So
cial
Car
e N
HS
Tru
st
West HTT N Y N Y 27 13.20 0.49
* *
South West HTT
N Y N N 25 13.80 0.55
HTT Y N N Y 20 10.50 0.53
North HTT N N N Y 24 10.00 0.42
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?*
Can the CRHTT assess new referrals at home 24/7?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Sou
th W
est
York
shir
e P
artn
ersh
ip N
HS
Fou
nd
atio
n T
rust
Crisis / Home Based Treatment Team
Y N N Y No data 25.00 No data
4383 £351,009
Kirklees Intensive Home Based Treatment Team
Y Y Y Y No data 42.40 No data
Barnsley Intensive Home Based Treatment Team
Y Y Y Y 46 24.70 0.54
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?*
Can the CRHTT assess new referrals at home 24/7?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Tees
Esk
& W
ear
Val
ley
Fou
nd
atio
n T
rust
Harrogate N N Y N 20 18.50 0.93
2204 *
Hambleton & Richmondshire
Y Y Y Y 20 17.20 0.86
The Scarborough, Whitby, Ryedale
N Y Y Y 30 16.00 0.53
Hartlepool Y Y Y Y 18 18.00 1.00
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Is there a 24/7 crisis line in this CRHTT area?
Does CRHTT have a 4 hour target for all new assessments?*
Can the CRHTT assess new referrals at home 24/7?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Tees
Esk
& W
ear
Val
ley
Fou
nd
atio
n T
rust
Stockton Y N Y Y 25 15.00 0.60
2204 *
Crisis & Access Service
Y Y Y Y 35 38.60 1.10
Middlesbrough Crisis Team
Y N Y Y 30 15.10 0.50
North Durham
Y N Y Y 29 9.00 0.31
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?*
Can the CRHTT assess new referrals at home 24/7?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Tees
Esk
& W
ear
Val
ley
Fou
nd
atio
n T
rust
South Durham and Darlington
Y Y Y Y 40 26.94 0.67 2204 *
146
Case study: Sheffield (1/2) – headlines
In 2011 bed occupancy 120%, 142 beds, almost 3000 bed days out of area
Wards now reduced in size, (69 beds) staffing has stayed the same, so patient-to-
staff ratios have improved, zero out of area .
Because of the reduction of wards, SHSC has been able to significantly reduce the
use of agency staff,
£2 million was invested in community services to ensure its sustainability. This
included investment in IHTTs and new services for people with highly complex
problems often associated with a diagnosis of personality disorder. In addition to
this reinvestment, cost savings of over £1.5 million were made
No increase in incidents, close monitoring of quality markers – which have improved.
147
Case study: Sheffield (2/2) – how did they do this?
Risk-sharing agreement between SHSC and the Sheffield CCG. SHSC took responsibility for the budget for out-of-area placements.
Efficiency programmes reduction in average length of stay from 56 to 31 days. Work focused on improving time spent with patients on the wards, discharge facilitators on every ward, planning for discharge on admission, particularly in relation to social factors and daily bed management meetings with consultants.
Quality initiatives : included: psychology posts on wards; reflective practice supervision for staff; reduction in seclusion and restraint; service user-led, all-staff training programme to improve the management of violence and aggression.
Bed management weekly bed-management meetings chaired by the clinical director, and including all consultants, ward managers, discharge coordinators, partner services (crisis house, respite provision, community teams). Meetings use live data and focus on patient flow.
Investment in intensive home treatment bed-management processes were applied to manage the flow of people. Fewer people accessing home treatment, smaller team caseloads but more intensive treatment for those in HTT.
Whole system approach - vital. Rethink crisis house and helpline, Wainwright Crescent respite and step-down beds; joined-up management/governance between inpatient and community services, live data showing flow across the whole system; and engagement with service users, carers and staff throughout.
148 www.england.nhs.uk
Common themes from other areas that have / are
attempting to reduce out of area placements
Intensive focus on OAPs as a priority – agreement of system priority at all levels
• Agreement at all levels that OAPs are a priority
• Principle that bed / HTT must always be available where that is the right
choice
• Board-level responsibility
• Clinical and/or Service Director who is personally responsible
• Strengthened community services, savings reinvested back into MH
• Financial risk/benefit sharing agreement between providers and
commissioners
• Whole system coming together in partnership to redesign pathways and
agree processes – inpatient staff, CRHTTs , social care, AMHPs, CMHTs,
vol sector, patients, IAPT, primary care
• Intensive focus on flow, bed management
• Community and inpatient teams attend regular MDT discharge meetings
• Use of real time data, including info on bed availability, capacity of HTTs,
community alternatives (e.g. crisis houses)
• Info on patients who have passed discharge dates, reviews / new
discharge dates
149 www.england.nhs.uk
Sheffield – blog from clinical lead, Dr Mike Hunter – now associate national clinical director at NHS
Improvement. Further detail can be found here.
North East London Foundation Trust – highlighted in RCPsych Commission on adult acute psychiatric
care (p27) – NELFT has eliminated out of area placements for many years, with one of the lowest bed
bases in the country - through investment in community services and intensive focus on acute pathway
management.
Leeds and York Partnership NHS FT: Efforts underway in ‘Leeds mental health flow’ project with write
up of the how the whole system is coming together to reduce out of area placements to save £1.5m for
the local health economy.
Bradford: adopted an approach with similar principles to Sheffield. Highlights include:
Vital partnership working with social care and local authority services to reduce delayed transfers of
care, mental health act detentions, admissions and recovery in the community – see next slide!
Whole system approach to eliminating out of area placements in Bradford.
Focus on acute inpatient ward flow, DTOCs, including a 10 point discharge tracker (below):