NELFT Integrated Adult Care Pathway - Acute and Crisis Care

1. NELFT Integrated Adult Care Pathway- Acute and Crisis Care Wellington Makala

2. Introductions Wellington Makala Deputy Director - Mental Health Inpatient Acute Directorate BME Ambassador

3. RCPsych Acute Commission Report NELFT • Highest ratio of HTT : inpatient care in London • Adult beds: 10 per 100k • OPMH beds: 5 per 100k • No OOA bed since 2008 • SPA - Access Assessment and Brief Intervention Teams

4. Standard Adult Care Pathway HTT Gatekeeper ward Crisis

5. NELFT Integrated Adult Care Pathway SPA– Crisis/Gatekeep Crisis HTT – Alternative to inpt bed

6. Managing Patient in Crisis

7. Mental Health Direct 0300 555 1000 Mild Moderate To Severe Community Recovery Teams Home Treatment Teams Acute Inpatient Teams Patient in Crisis (OOH) Talking Therapies Access and Assessment including MHS Liaison Brief Intervention Medical Interventions Psychological/CBT Groups Psycho-social interventions Education & Employment Integrated Adult Care Pathway Primary Care Psychological Services GP – refers Patient Referral to Secondary care Stable MH Recurrent/ Chronic MH SMI Cases

8. Crisis Care Concordat In 2014 NHS England welcomed the mental health crisis care concordat as an important step forward in improving care and standards for people in a mental health crisis. The Concordat, launched by the Department of Health, is a joint agreement which describes how police, mental health services, social work services and ambulance professionals should work. The Crisis Care Concordat published ‘Guidelines for Commissioning’ in 2015 which recommended the consideration of 24-hour telephone crisis lines and ‘St Triage’ police/mental health partnership working as part of a care pathway portfolio of Crisis response services. In these schemes, mental health professionals provide on the spot advice to police officers who are dealing with people with possible mental health problems.

9. Why Is it necessary? Policing Mental Health relates to about 20% of police time. Home office, Department of Health and ministry of justice have identified a need to work more collaboratively. Supports the drive described within the new MH concordat. Police Federation raising concerns over the use of S136 MHA powers. Reports outlining that custody is not a place of safety, we should not be criminalising persons suffering from mental ill health. Prevent presentations to accident and emergency departments when a person has no physical health concerns.

10. NELFT MHS ACUTE CARE PATHWAY Over the past few years NELFT Acute and Rehabilitation Directorate (ARD) have introduced a real focus on offering acute crisis care in the patients own home as an alternative to acute admission. This has been achieved through Home Treatment Teams who offer an alternative to acute admission. As an extension of that service NELFT have introduced Street Triage Pilot. Street Triage Pilot was launched  on 7 April 2015. NELFT joined forces with MET Police to pilot a new project to ensure people with mental issues are prevented from detention under S136 of the Mental Health Act  ’83. In April 2016 BHRW CCGs agreed to continued funding with the addition of LAS joining this collaboration. he Team covers all 4 NELFT boroughs. Mental Health Direct was launched in January 2015. It has been funded from via a successful joint bid against monies that became available for Crisis services nationally over the winter period.

11. Street Triage Team Dedicated phone line for MET/LAS officers 07872 050 047. Three full time band 6 MH nurses. Part time manager band 8a senior social worker. 17.00-01.00am. Mental Health Direct Dedicated phone line 03005551000. Band 6 mental health professionals Clinical Cover . Hours 24/7. Fulltime Band 8a Manager.

12. Mental Health Direct Mental Health Direct is a dedicated out of hours crisis service staffed by qualified Mental Health professionals-CPNS/Social Workers. MHD is a 24 hour Telephone crisis line and is an integral part of NELFT’s Crisis Care Pathway that includes Extended Hours Access Teams, Home Treatment Teams and the Emergency Duty Team. This service has historically not had dedicated clinical or administrative staff, but rather has been run as a sub service of the Trusts switchboard.  Available for people who are in crisis or wish to discuss issues regarding their mental health and their carers. Signposting / referrals to appropriate health, social care or support services. Line management support.

13. Benefits Of MHD to date • Access to support before crisis point • Urgent and emergency access to crisis care. • Quality of treatment and care when in crisis   • A reduction in the demand on A+ E departments. •  A reduction in calls to the NHS 111 service by people experiencing mental health crisis. •  Signposting to NHS 111 or General Hospital if the calls relate to physical health problems. • Less pressure on Home Treatment Teams to provide telephone support whilst out on visits or carrying out assessments.

14. Key outcomes Reduced inappropriate or unnecessary use of Section 136 of the MHA. Reduced time spent by MET/LAS officers dealing with those with mental health problems. An improved experience for people who come into contact with the police through either detention under Section 136 or for other reasons related to their mental health. Reduced inappropriate use of A&E as a place of safety. Reviewed and Improved crisis, care and contingency plans for service users. Reduced number of attendances in custody. Improved multi-agency team work. Reduced costs to health, criminal justice system, Ambulance service and Acute Trusts.

15. Key elements of the scheme Dedicated phone line and telephone support available to service users experiencing crisis. Dedicated phone line and telephone support available to the MET and LAS from 5pm to 12 midnight. Sharing of information to enable informed decisions to be made by officers on the street/homes about the options available to them. Face to face assessments where appropriate (on the street / people’s homes etc.) Onward referrals to appropriate health, social care or support services of individuals who have come to the attention of the police. 7 day follow up those individuals referred on to other agencies.

16. Street Triage Service User Feedback

17. Street Triage Service User Feedback

18. Street Triage Service User Feedback

19. UNIQUE SOLUTIONS Better engagement and improved crisis experience with our service users. Less stigmatizing for our service user. Stronger partnership and collaboration with key stakeholders : Developing wider intelligence and information sharing Inc. A&E, GP’s. Increasing trust between the MET and LAS to deliver a better service to the public. Sharing information to inform MET decision making at the start of the process (“The more we know, the earlier, the better the decision!”) Still retain the ability to provide a face to face assessment across the NELFT Boroughs. Softer option in that police do not need to exercise power and control, this is in turn less stigmatising / intimidating/threatening to our service user. The desired mode of conveyance being via LAS.

20. Moving Forward An integrated team model i.e. combined and dedicated team of Street Triage and Mental Health Direct Nurses working under the same management with one identity. Single point of referral which would be less distressing to our service users. Permanency - we believe this would have a direct impact in reducing s136 incidences. Staff development and supervision to ensure good clinical governance and quality assurance.

21. Current Mental Health Crisis Service We currently have a number of services providing the crisis and acute response for NELFT with different levels of funding. Some of the services are currently funded through the crisis concordant funds. Bleep Holding Team Section 136 Switchboard Enhanced Mental Health Liaison Service Emergence Duty Team Access Assessment & Brief Intervention Team Emotional Wellbeing Out of Hours Service Street Triage Mental Health Direct Acute Crisis Assessment Team (ACAT)

22. Street Triage EWB OOH MHD EDT Switchboard EMHLS Home Treatment AABIT Fragmented Crisis Services ACAT Section 136 Bleep holding

23. ACAT MHD Street Triage EDT. EMHLS Section 136 Bleep Holding Home Treatment EWB OOH Switchboard AABIT New Teams NELFT Integrated Acute Crisis Services

24. LAS Acute Inpatients Police Acute Crisis Services AABIT New Teams BHR Integrated Acute Crisis Services Voluntary Sector

25. Why integrated offer? Single point for all the crisis services for NELFT which would mean doing the day first point of contact being Access Assessment and Brief Intervention (AABIT) and out of hours all referrals would go through the MHS Acute response services. This we believe would give a better service user experience for mental health patients during period of crisis. The integrated offer would make it easy to develop a seamless care pathway for the LD cohort as per TCP programme, we are already providing as part of the integrated offer out of hour for Children and Young Persons in Essex which is funded by Essex. This offers brings all crisis services under one management structure

26. NELFT Acute Care Pathway • Redesign led to reduced demand for Mental Health acute working age and older persons inpatient treatment to provide the highest ratio of acute home treatment to inpatient care and the lowest acute bed base across London: • •2008-09 - 170 • •2009-10 - 150 • •2010-11 - 125 • •2011-12 - 125 • •2012-13 - 100 • •2013 – present – 100 SPA Teams / MHD / HTT Recovery Focused Services

27. Overview of Care Pathway More investment in community services Reduction of bed base Putting People First - Patients managed in the lest restrictive environment Improved care pathway with primary care Reduction of CRT caseloads focusing on long-term SMI Integrated MHS pathway Investment in Integrated Crisis Care Pathway 98.5% of all our Mental Health patients in the community & 2.5% inpatient