The hub was originally established when The Harbour opened in March 2015 to centralise the management of bed capacity across the Trust's bed stock on a pan Lancashire basis. In January 2016 the Trust declared a major incident due to demand for mental health beds which was seen across the country. At this time we had 97 people being treated outside of the Lancashire are and we had 27 unallocated bed requests with no capacity in the Trust. It was recognised at this time that clinical input was needed in the bed management team to risk assess and prioritise patients waiting for beds and also to review and have clinical conversations about the appropriate use of enhanced community services to support people in the least restrictive way.
What We Did
The hub was originally established when The Harbour opened in March 2015 to centralise the management of bed capacity across the Trust’s bed stock on a pan Lancashire basis.
In January 2016 the Trust declared a major incident due to demand for mental health beds which was seen across the country. At this time we had 97 people being treated outside of the Lancashire are and we had 27 unallocated bed requests with no capacity in the Trust. It was recognised at this time that clinical input was needed in the bed management team to risk assess and prioritise patients waiting for beds and also to review and have clinical conversations about the appropriate use of enhanced community services to support people in the least restrictive way.
How this has made a difference to people working in the service – community staff have direct access to a centralised point of contact to make bed requests and to explore appropriate enhanced community services. It has reduced the burden on crisis teams, they no longer have to make repeated phone calls to locate a bed. For the patient, this means that they are supported in the most appropriate way. For example, a crisis practitioner may feel that an admission is needed, however The Hub may advise that the crisis support unit may be able to provide a high quality assessment and formulation to support the patient in a way that meets their clinical needs that the crisis practitioner had not considered as part of their assessment for admission. If they do need access to a bed, they are more readily available. There has a been a massive reduction in OATS from January 2016 (97), at this time May 2017, OATS fluctuate between 15 and 24. Patients are getting faster and more appropriate access to help in times of crisis, therefore quality is increased and keeping patients closer to home or in the community also represents increased quality. Because patients are getting more timely access to hospital admission, the length of stay in hospital is also reduced which is another quality outcome.
Wider Active Support
In establishing the clinical model in The Hub, the police are able to call the centralised number to find the nearest 136 suite to bring patients too. This means that patients are taken to a place of safety as soon as possible to be supported and assessed as near to their home as possible.
I work very closely with the CCG commissioning support unit to review funding requests outside of panel so that we reduce the amount of delayed transfers of care in the trust. We have developed a PICU clinical advisory group that we co-chair to ensure that patients (within reason) aren’t nursed in a restrictive environment for longer than they should be and we have a weekly telecom to address any issues that have been identified in finding appropriate on-going placements to meet patient’s needs.
I have worked in partnership with The Priory in Preston to block book beds in the area so if there is no bed availability in Lancashire Care, the patient is still cared for locally. The Priory have agreed to take on our CPA standards and we have weekly reviews of the patients that we have in those beds. We have built a positive relationship with this provider and the consultants within the service to ensure that the patient’s needs are met at all times.
The most recent development is a pilot involving a partnership with the charity, Birchwood Centre in West Lancs, we have 2 beds there that opened in spring 2017. These are for people in crisis or step down from inpatient wards when appropriate (patient is ready for home treatment) and they receive the same level of care as if they were at home. If the pilot is successful the plan is to increase the number of available beds.
When I came into post I did a survey of staff to ask for suggestions and ideas of how we can improve flow through the mental health networks. From that, I was able to map and pick out key themes and improving communication was a big factor.
We have listened to feedback/complaints from patients that have been sent out of area to develop the service. As part of the new process, I always ask the referrer to liaise with the patient and their family about the suggested intervention/placement if the clinical need suggests that an out of area treatment is required and there are no beds in LCFT. A recent example, I received a thank you from a lady who’s son was in a PICU bed outside of Lancashire and she wanted him to be brought back to the area. So I worked with her and the local PICU team to identify the next available bed and kept in regular contact with the mum until he was brought back to Lancashire (within a few days.) I met with the ward and family afterwards; they were happy that their son was back in the local area and he went on to recover.
Looking Back/Challenges Faced
Looking back with hindsight, I would have based The Hub in a central locality to denote that it is a pan Lancashire service model, as some perceive it to be solely attached to The Harbour and it isn’t. This is something that I am working to address. I would have digitalised The Hub earlier and involved teams from other networks in the development of the clinical model because we are seeing an increase in the number of people with learning disabilities coming into the service now, so there is a need to upskill the team in The Hub about their clinical needs and legal requirements. We are learning and developing as we go along. I would have invited people into The Hub at a much earlier stage for them to see and understand the work that takes place in there to reduce barriers/silo working.
I have developed escalation plans for community and inpatient services that are used routinely now. I have also developed a planning document that is updated during holiday periods and winter that can be readily updated to reflect current pressures at that time. I have supported the Team Manager so that his skills can be developed in the new role so that he is able to deal with and face the challenges that we encounter each day. In terms of the wider team, when they came together I held an away day to set out clear expectations of the new service, our vision for The Hub and identified their ideas to do things differently. I did some work around personality testing to ensure that they understood each other and could work well together, and they are now a really strong team with their own team brand.
The links and relationships that I have established with partners are really important to the sustainability of the service. For example, working with the CCG to secure funding and the development of new enhanced community services. There is a multi-disciplinary approach to how we run The Hub which is essential to its sustainability; the development of a weekly out of area treatment meeting that the clinical director, hub team manager and OATS practitioners attend and there is a daily telecom involving the matrons across the Trust to identify any potential discharges for the day and any acuity/staffing difficulties that need to be addressed. Skype is used for a mid-day catch up so that the senior leadership team are aware of any outstanding issues/barriers to discharge.
Evaluation (Peer or Academic)
Our position with regards to OATS is constantly under review and evaluation by commissioners, and we have been able to reduce and sustain from a position of 97 down to less than 25 on average over the last 12 months. There is a monthly meeting with commissioners and the position is reported as part of the overall report.
We can demonstrate from our network performance reports a reduction in delayed transfers of care and length of stay (we are below the average in national benchmarking.) These are good quality indicators.
I see less complaints now from people/their families about being sent out of area, which suggests an increase in patient satisfaction
For people using our service the positive outcomes are; increased access to the most appropriate service required in a more timely way, an increase in options available to them when in crisis, care closer to home (less likelihood of being placed outside of Lancashire), reduced length of stay on average.
For people working in the service, better co-ordination between inpatient and community services, pressure on crisis teams reduced and time saved (more time with patients!), increased choice of treatment/interventions are communicated outwardly.
I have an open invite to commissioners, 3rd sector providers and other mental health trusts to come and see what we do. Bradford NHS mental health trust have visited and taken the escalation documents so that they can develop their own and they also took away our concept of having Skype meetings.
Is there any other information you would like to add?
Now that The Hub is well established in adult and older adult mental health services we are now doing a pilot with CAMHS to explore if it would improve their capacity and flow and patient experience by co-ordinating bed requests for young people.