The Acute Community Services (ACS) at Bradford District Care NHS Foundation Trust has innovatively redesigned the Crisis Care Pathway improving the care and quality of the services they provide. They are a multi-disciplinary team who support services users in urgent need of mental health care in the community.
What We Did
The ACS has successfully moved to an integrated team model from separate teams including the Intensive Home Treatment Team, A&E liaison and First Response Service. Having a more robust approach to urgent mental health care has led to reductions on use of inpatient beds meaning service users have been treated locally for over a year without using an out of area bed, service users are now assessed at home instead of A&E which means there has been a reduction in attendances at A&E and Police have access to urgent assessments meaning they can avoid using section 136 (mental Health Act 1983) detentions.
Take us back a year and we see the new First Response Service being set up as the new urgent mental health assessment service in a separate location to the Intensive Home Treatment who previously worked on both assessment and home treatment. The IHTTs were adjusting to new roles and a new leadership structure preparing them to take on new challenges committing to the redesign of the Crisis Care Pathway.
In the face of this challenge they reviewed their systems, reduced their paperwork and documentation to free up time to care, they took on agile working to ensure they had access to information on the move sacrificing their cumbersome paper diaries and paper systems. They looked at how they could cut down travel time and work locally by postcode to provide continuity of care and almost doubling the time they had to spend with service users.
A&E liaison staff mirrored the efforts of FRS and IHTT in the emergency department increasing efficiency of their assessment time using shared documentation and processes. Through this work they have been able to provide more intensive home treatment to service users needing inpatient care. The results of these improvements speak for themselves having an impact on our ability to support people locally without sending them out of area at a time when they are most in need. We are coming up to a year without needing to use an out of area bed. Having a proactive First Response Service means that people don’t need to wait in A&E to be seen and we have seen attendances reduce by half.
Through partnerships with the Police and having staff in the Police Control Room they have been able to assess people before they are detained by Police which has meant Section 136 detentions under the Mental Health Act have more than halved. Both IHTTs being located separately to the FRS had not been without difficulties having new systems and roles to understand, the Nurses, Advanced Nurse Practitioners, Approved Mental Health Professionals, Therapists, Healthcare Support Workers and Social Workers have become an integrated service in a purpose built suite, developing relationships and respect with a shared vision for improving urgent mental health care that is delivered in a timely manner by the most appropriate professional in the environment that is most helpful to the service user.
Today the hard work and successes of the staff is being recognised nationally, trusts from around the UK have visited the integrated service as an example of a model for urgent and emergency care, FRS won a Nursing Times Award, NHS England have launched their mental health task force and used Bradford as an example https://www.england.nhs.uk/ mentalhealth/case-studies/
We have received visits from Alistair Burt MP, leading figures in Health and Social they have featured in local Bradford Telegraph and Argus newspaper articles and been on the local BCB radio station. These achievements fit with the Five Year Forward View for Mental Health and the trust aims around being recognised as a centre for excellence for urgent mental health care.
Wider Active Support
Having strong partnerships with West Yorkshire Police and Bradford District Metropolitan District Council has been key to our success. Regular senior leadership meetings with a shared vision for redesign and improving the experience of service users in mental health has meant that the organisations have built positive relationships on the front line.
An integrated health and social care model means there is access to housing support and short term placements. Nursing staff have access to social care budget to support short term placements for service users needing short term respite.
Having a close partnership with Police has seen co-location of nurses and social workers with police in the control room. The staff provide advice and support to officers who come into contact with service users in crisis and the Police have committed to using a least restrictive approach to service users by requesting assessments before detaining them.
Bringing in expertise and involvement from service users and carers in service development is a high priority for the trust. Whilst developing the First Response Service, service users and carers were consulted around the recruitment and planning.
The redesign and review of productivity for the Intensive Home Treatment Teams had carer involvement from someone with first-hand experience of urgent mental health care for his two daughters and wife. Co-designing systems and processes with a carer has helped to improve the experience of those using and coming into contact with the service. Having a lead for service user feedback and the Friends and Family Test supports the service to respond to feedback and strengthen systems.
Looking Back/Challenges Overcome
During the implementation of First Response Service Police briefings were carried out to communicate with all frontline Police around how to access the service and to inform them about their dedicated police line.
Changes to the Section 136 suite and the staffing were also relayed which resulted in a spike in section 136 detentions, this was resolved through the partnership meetings and regular updates to frontline officers. Maintaining the reduction on the inpatient beds has been a challenge to maintain, two of the functions around reviewing and ensuring the flow into Intensive Home Treatment are daily reviews and bed meetings.
The daily reviews reporting system was amended to provide an overview for the week rather than a daily snap shot and the bed meetings were increased to daily using the daily review reports to increase the frequency of review and identify issues in the system causing delays such as accommodation and community care packages.
Electronic systems are in place to ensure that all systems, processes and pathways are in a central location for all staff to use. Staff have their own SharePoint site and shared drive, Advanced Nurse Practitioners are senior clinical staff who support the leadership within the service.
The management team have a shared drive which means a new manager could identify the key the systems from one place. The acute services standard operating procedures has also been updated to reflect the redesigned service.
Weekly team leader meetings ensure that all team leaders are working consistently and have a shared vision for the service. These team leaders support the clinical manager and the clinical manager supports the service manager through regular one to ones, operational meetings and the quality and safety meetings, head of service and deputy director meet with the service manager through operational meeting and the quality and safety meetings. There is a weekly dashboard that reports admissions, discharges and lengths of stay for the wards to allow monitoring of progress week by week.
The First Response Service was evaluated by a service evaluation lead and a separate evaluation as commissioned from Mental Health Strategies in the initial 6 months. The reports acknowledge the success of the service and highlighted areas of improvement. One of the recommendations for the service was to engage BME groups this figure is now monitored and a project is being led by an ANP in the service to increase BME engagement with FRS.
A service user experience evaluation has also been commissioned through the Bradford and Airedale Advocacy Group the report is due to be received in the next few months.
Commitment to Dissemination
The First Response Service has been used as a case study for the launch of the Mental Health Taskforce and for the launch of the new nursing strategy.