Prior to this service there was no capacity to see mental health patients out of hours except via A&E, and no self-referral route, meaning many patients came direct to A&Es to seek help. Service users told us that it was very difficult and stressful trying to get help for mental health crisis and they found ED a stressful environment.
We have developed an all age community-based 24/7 mental health crisis care pathway, directly accessible to all professionals, service users and carers, thereby ensuring timely access to safe, effective, high quality care for people in mental health crisis.
What We Did
Prior to this service there was no capacity to see mental health patients out of hours accept via A&E, and no self-referral route, meaning many patients came direct to A&Es to seek help.
- Service users told us that it was very difficult and stressful trying to get help for mental health crisis and they found ED a stressful environment.
- We have developed an all age community-based 24/7 mental health crisis care pathway, directly accessible to all professionals, service users and carers, thereby ensuring timely access to safe, effective, high quality care for people in mental health crisis.
New community based crisis mental health service- “ First Response” :
- Provides assertive and responsive support and triage for anyone experiencing mental health crisis, including providing face to face assessment if needed.
- Open 24/7 for people of all ages from throughout Cambridgeshire and Peterborough.
- Welcomes self referral as well as urgent referrals from carers, GPs, ambulance crews, police (anyone!) and from the Emergency Departments
Calls are taken by telephone triage staff who have been trained to use a validated mental health triage scale, supervised and supported at all times by a band 7 mental health practitioner.
Patients who require an urgent psychiatric assessment will be offered this at home or close to home. They can then be referred directly into CPFT services if needed.
Many people contacting the service do not need assessment but rather can be supported with phone support and advice and referral to voluntary sector organisations.
A vital part of the FRS model is the availability of a Sanctuary, run by Mind in partnership with FRS. The Sanctuary provides a safe space to provide support and de-escalation. Every evening FRS staff are able to refer suitable patients, after triage, to use the Sanctuary, with once centre open in Cambridge and one in Peterborough
Visitors to the Sanctuaries have also been referred to numerous other voluntary sector organisations for further work, helping to reduce their need for crisis support in the longer term.
Impact so Far (until February 2017)
The service opened 19th September 2016:
We are now managing 300 referrals a week:
- 72% are managed by phone (support / advice and signposting)
- 17% are seen for urgent face to face assessment by the team
- 8% are referred into mental health services for longer term follow up
- 3% require emergency services input
- 61% calls are self referral but a significant number also from GPs, police and ambulance services.
- There have been over 800 visits to the Sanctuaries
Impact on Wider System:
- ED attendance for any “Mental health” need down 19%
- Admissions to Acute Trusts for MH patients from ED down 20%
- Ambulance conveyances down at least 11%
- 111 calls and OOH GP appointments down 45% and 39%
- Number of overdoses reported by EDs down 16%
Impact on ED is continuing to improve and we expect this to become even more significant.
Some Service User Feedback
“I thought the service was very effective at providing the needed help”
“I was very impressed by the service responding immediately, plus the therapeutic environment”
“Sanctuary is a very good place to go instead of A&E, no waiting times, get an appointment allocated quickly”
“Quick to answer, ask appropriate questions etc”
“I feel the support I get is excellent”
“The lady I saw was kind and professional, and handled my admission to hospital sensitively”
“Thank you for your lifesaving service”
“Just wanted to share some positive feedback from a client who is currently with CRHTT. ..This lady has episodes of transient psychosis and usually requires detention under the MHA. I first detained her under section 2 a few years ago and she found the whole process of becoming unwell and then being detained, understandably very distressing. During this most recent episode, however, she was able to access timely support from FRS who advised an increase in her medication and a dose of diazepam and home treatment rather than admission. This was her preferred choice and did not cause any disruption to her home/ family life…I am happy to let you know that she is continuing to make a recovery without need for either admission or to go through the process of a MHAA and possible detention. This has really helped her reframe her ability to cope with acute distress and strengthened her skills in self management of her illness. Thankyou so much as the service has really made a difference. She returned to work today!” AMHP – home treatment team
“I thought you would appreciate knowing that we have received fantastic support from FRS today…I have had two separate high risk missing person incidents, …On both occasions we have been supported by FRS without reservation, which is something that I will encourage all other Force Duty Manager’s to keep in mind for future similar incidents. – Force Duty Manager, Cambridgeshire constabulary
The Health Visitor stated that the 2 practitioners (from FRS) that she had met on the home visit were friendly and keen to work with the HV team. …Assessments were able to be integrated seamlessly and the adult mental health team clearly valued the HV team input and vice versa. In addition to this, the HV was impressed with how quickly the mental health team arranged medication for this lady and reassured her regarding her care and follow up…The effect of parental mental health on the baby was clearly recognised and it appears that services within the Trust all worked together in a joined up and responsive way to get a good outcome for the whole family. – Health Visitors
“I used this service last night and it was brilliant. Was a bit time consuming but ended up with us having a member of their team on scene 40 minutes after our call and they booked the pt straight into oak ward. Hopefully this is going to be the way forward. From first experience it is a referral pathway that works.”- East of England Ambulance Service
Wider Active Support
We have worked hard throughout the development and implementation of FRS to ensure that there are strong links with all local services that provide for our patients with mental health problems:
Our Sanctuaries also provide care and support for individuals experiencing a mental health crisis and are provided by the third sector (MIND). Sanctuary staff have established strong networks and links across the Cambridgeshire & Peterborough crisis care pathway and are continuously seeking professional support from the 24/7 First Response and other health and social care staff. Social issues such as housing problems are common in patients attending the Sanctuaries which has meant that Sanctuary staff have needed to develop a rapid access pathway to social care services. Similarly drug and alcohol issues are common and Sanctuary staff have been trained by substance misuse staff in the management of these and how to access further help if required.
FRS has also developed strong working relationships with the mental health practitioners in the Integrated Police Control Room that provide advice and support to the police. We are currently working towards a more integrated service that spans all emergency services, and the development of a “blue light” response capability (pilot will be starting in June 2017).
At a strategic level we have a strong local Crisis Care Concordat with sign up from all key stakeholders and supported by a senior manager (joint funding). A Crisis Concordat Delivery Board meets bimonthly and holds to account those responsible for delivering the components of our Crisis Concordat action plan. Partners are working together to shift the emphasis from acute crisis care to more preventative models and work is ongoing to further develop FRS adult & CYP pathways, currently focusing on our BME population, links with emerging models of primary care, improving patient flow and ensuring robust links to the wider local MH system.
Real patient, carer and public involvement throughout the FRS ongoing development and implementation helps us to ensure openness and transparency, and also ensures that patients are put at the centre of all service developments. This is a fundamental principle that Cambridgeshire and Peterborough have signed up to and work hard to achieve, hence we have employed engagement workers who provide our Service User Network (SUN) with the support that they need.
The people using services and their carers are the experts in terms of what works well and what doesn’t, therefore involving them and listening to their experiences and ideas is key to improving and developing services.
To date patient and carer involvement has comprised of face-to-face briefings as well as written updates through local carer and patient representative groups. Our local service user network (SUN) has played a key role in developing a values framework, supporting patient and carer engagement and ensuring service user representation on the delivery board. Our Sanctuary model was fully co-designed with patients as illustrated in the slides attached.
Wider public engagement on the Vanguard programme has been managed by the CCG as part of the System Transformation Programme. A number of engagement activities have taken place over the last eighteen months including: Saturday public cafés, public involvement assembly, presentations to community groups and road shows at community healthcare bases, hospitals and GP practices.
Cambridgeshire and Peterborough have a very diverse population with areas of deprivation and rural isolation. The greatest concentration of ethnic groups is based in Peterborough, where the population is approximately 35% black and ethnic minority. It is important that any engagement activity therefore takes into account the diversity of our local communities and this is robustly monitored via the Operational Implementation group as well as local Crisis Care Concordat. We are currently developing a BME Crisis Mental Health engagement strategy focused on improving access to FRS and have employed an experienced BME engagement worker to help us with this work.
The implementation of our service has been clinically-led from the start, with membership on the delivery board from primary care, acute hospitals and mental health specialists. There have been a number of briefings with GPs to develop the model including with our local GP Mental Health Leads. The Crisis Care Concordat also provided the opportunity to discuss the proposals with clinical colleagues across the county. Wider clinical engagement includes colleagues from acute hospitals, third sector, local authorities, ambulance services and the independent sector.
Looking Back/Challenges Faced
Key lessons to be learnt:
- Multiple stakeholders involved – need a clear governance structure with wide representation and engagement.
- Patient and third sector representation – how do you democratically select the representatives? We used our existing SUN Network.
- Need for clarity around the requirements of a business case to support long term funding to sustain the service and how to obtain the necessary information – this includes financial information e.g. acute hospital tariffs for MH admissions.
- Commissioning & Contracts: the new First Response Service was initially launched only in the Cambridge locality and later rolled-out wider across the whole Cambridgeshire & Peterborough area. Due to the speed of the project had it was difficult to have all necessary contractual arrangements in place which created a number of issues with regard to access, out-of-area payments and subcontracts.
- Variability in population demographics: the FRS/Sanctuary model was implemented in Peterborough in phase 2 of the project, having proved successful in Cambridge. However there has been less patient engagement with the service in Peterborough and therefore more work is being done to explore the best models of crisis mental health support for BME communities. This is now being addressed via the Crisis Care Concordat and reviewed based on the JSNA results.
- DOS: there is a need for an up to date and comprehensive directory of services to include all mental health, local authority, and third sector services. This enables effective supported signposting and needs to be easily accessible e.g. via a mobile app (MiDOS, MyHealth) and a “one stop” mental health website.
Prior to the First Response Service starting service users with mental health crisis were attending A&E in large numbers, often by ambulance. These patients were frequently admitted while waiting for psychiatric assessment. Once they had received a psychiatric assessment the majority were not offered any new intervention, as they often did not meet threshold for mental health services, or were already within services.
The first response service has allowed us to provide much more cost effective model of providing crisis care. The telephone triage allows us to introduce a stepped care element into crisis provision, with face-to-face assessments for those who are triaged as urgent or high risk, and telephone support with referral to the sanctuary for others. Use of a standardised mental health triage scale (The UK Mental health Triage Scale) has helped to ensure all service is safe and effective. The telephone triage element also allows us to have one team which covers the whole area.
Joint working with the voluntary sector in providing the sanctuary has allowed us to provide cost-effective high quality supportive safe spaces for patients, at a fraction of the cost of an emergency department attendance, and with greater therapeutic impact.
Even though all of the above examples illustrate the value of the FRS to the wider system; we have taken the following steps to ensure the newly established crisis care service could be sustained going forward:
- The service was part of the Vanguard Programme through partnership working between the CCG, the mental health trust, Cambridge Constabulary and the Voluntary Sector: working together to provide better, safer care that can reduce A&E attendance and therefore also provide cost savings. All the work has been documented using AGILE project management methodologies; Logic Models and Value prepositions have been shared with the NHS England and are being updated on the on-going basis to reflect learning to date. This allowed robust implementation, and minimized delivery gaps.
- Service users were at the heart of the project from the outset, and had a major role in the service development. We had service user representation at the design stage and at the service development “Delivery Boards”. We continue to receive and use service user and carer feedback as the service develops. Service users and carers have told us that provision of a 24/7 service which they can choose to access themselves (without having to seek referral) when they need it, where they need it, provides an essential safety net, empowering them to manage their illness themselves, knowing the help will be there when they need it. The service is very much built around needs of service users and carers which therefore provide commissioners and providers with assurance that there is a need to continue and sustain the service going forward. The service users’ voice champions the service.
- Commitment via the Crisis Care Concordat partnership working to establish a seamless health & care pathway for those experiencing mental health crisis as part of the recently updated action plan with specific emphasis on securing delivery of improved outcomes.
- Financial sustainability – data analytics is in place to showcase that services is reducing activity as per impact outlined in the section below and therefore service is able to pay for itself without creating adverse effects to the system. The service is part of the STP assurance checks and financed accordingly.
- Contractual Framework – the service is underpinned by the robust contractual framework bringing together all the partners.
Evaluation (Peer or Academic)
RAND Europe is conducting evaluation of the FRS & Sanctuaries for which data collection is still underway and therefore the below quote should be read as emerging insights as part of the ongoing evaluation, rather than quality-assured final evaluation findings; full report is due to be completed late summer.
While the evaluation of the First Response Service and wider Mental Health Crisis Care Pathway, as a particular element of our evaluation of the Cambridge and Peterborough UEC vanguard, is ongoing, it is notable that interviews conducted so far with a wide range of stakeholders (representing primary care, secondary care, community care, commissioners, ambulance services, police, local authority and service users) show broad and enthusiastic agreement that the Mental Health Crisis Care Pathway has either met or exceeded their expectations of the model. Stakeholders have also reported a diversity of emerging impacts on timeliness, appropriateness, quality and cost of care.
The independent financial evaluation concludes
“…Therefore it is likely, including these savings above, that the savings profile would meet the cost of the service…”
Impact to date:
- The service has demonstrated an immediate decline in the use of ED for MH with a 20% reduction in attendance despite the local context of many years of rapidly increasing figures.
- There has also been a 26% reduction in numbers of MH patients admitted to Acute Hospitals from ED
- Reduced ambulance call outs, assessments and conveyances to ED for MH patients
- Reduced need for OOHs GPs to see MH emergencies
- Impact on the urgent and emergency system is predicted to increase once the service becomes more established.
- The implementation of FRS and the sanctuary has already forced the system to change. Therefore we have seen system transformation for a relatively small amount of money. How we have done this:
- Greater integration of DAAT, Local Authority and Mental health services
- Pooled budget arrangements with police to further solidify our commitments to ensuring Safer, Faster better services for our communities
- Statutory and third sector services working more cohesively allowing improvements in the wider MH pathways
- The service is now responding to people previously unknown to traditional mental health services meaning we are starting to treat our future mental health populations today. This has created a public expectation on the health system to achieve parity of esteem for mental health.
- The service has changed the way that our patients and professionals are using services. Health visitors, drug and alcohol services, GPs now have a service that they can refer people to which means a reduction in their time.
- Improved quality of care – Consistent with national guidance and local Crisis Concordat plan
- Improved patient and carer experience
- Improved patient safety (reduction in overdoses since FRS started)
- Enhanced early detection of severe mental illness and relapse, allowing early intervention
- Reduced pressures on EDs throughout the region through avoiding attendance and diversion from ED front door
- Reduced pressures on ambulance service
- Reduced pressures on GPs especially OOHs
- Increased flow in EDs due to a reduced admission of MH patients to short stay ED assessment units
- Reduced Health Care Utilisation – LTC and IAPT evidence base shows that fully integrated physical and mental health services can have a profound saving on the healthcare utilisation. FRS becomes a conduit for people to deal with health anxieties.
Covering a challenged health system with diverse health needs, organisations across Cambridgeshire and Peterborough are supporting each other by targeted and proactive communications and engagement activities to ensure stakeholders are consulted, communicated with, and engaged with at the right time, in the right way.
We are committed to sharing as much information as possible with our colleagues at local, national and international levels. This is being done via the following routes:
- ECIP (Emergency Care Improvement Programme) – close collaboration to share best practice and on-going development of the case studies that are being shared with other Clinical Commissioning Groups and Community Mental Health trusts across the country
- Regional Crisis Care Concordat Meetings
- UEC Vanguard Quarterly meetings – New Care Models Team (quarterly reviews)
- Regular updates to NHS England to disseminate information on best practice
- Sustainability & Transformation Programme
- Health+Care National Conference – presentation June 17
- East of England Mental Health Commissioning Network – presentation July 17
Is there any other information you would like to add?
The Sanctuary has received positive service user feedback with over 75% green tokens (these indicate that a visitor is happy with the service), as well as receiving a letter from a GP saying that their patient had been visiting since 1985 and after coming into the Sanctuary agreed to undertake a detox programme. The First Response Service has received very positive feedback from referring agencies including the police and ambulance service. The police control room is making a significant different to officers on the ground as well as dealing with hundreds of mental health related enquiries every week (for service user and professional feedback see section – What we did).