The mental health liaison service is a key part of Sheffield Health & Social Care NHS Foundation Trust. It provides 24/7 mental health care for people aged over 16 who are being treated for physical health conditions at Sheffield Teaching Hospitals NHS Foundation Trust. The service provides psychiatric assessment and treatment to service users experiencing a wide range of mental health problems which may include self harm, depression, anxiety, psychosis, dementia or medically unexplained symptoms. This also includes assessment and management of their mental health needs and risk of harm to self or others. The team is made up of mental health nurses, support workers, psychiatrists and administrative staff
Highly Commended in the Integration of Physical & MH Care Category - #MHAwards18
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
The mental health liaison service is a key part of Sheffield Health & Social Care NHS Foundation Trust. It provides 24/7 mental health care for people aged over 16 who are being treated for physical health conditions at Sheffield Teaching Hospitals NHS Foundation Trust. The service provides psychiatric assessment and treatment to service users experiencing a wide range of mental health problems which may include self harm, depression, anxiety, psychosis, dementia or medically unexplained symptoms. This also includes assessment and management of their mental health needs and risk of harm to self or others. The team is made up of mental health nurses, support workers, psychiatrists and administrative staff. The service works with hospital staff to increase the detection, recognition and early treatment of people with mental health needs while also reducing the time that some people need to stay in hospital, preventing unnecessary re-admission and encouraging faster recovery from mental and physical illness. The service receives just short of 6,000 referrals a year from the Sheffield Teaching Hospital’s A&E department and acute wards ensuring that the mental health needs of people in Sheffield are also addressed when they are in hospital for treatment for their physical health needs.
The service works with A&E and the Medical Admission Units to proactively assess patients in a timely way to avoid admission and/or facilitate timely discharge from hospital. As well as assessment the service provides a range of additional support to patients and healthcare professionals including: * Supported discharge follow-up for those patients who are thought to be at risk in the community due to their mental health difficulties and who do not already have other secondary mental health service support in place; * An outpatient service to working age adults with medically unexplained symptoms and long term conditions; * Second opinions on complex mental capacity issues and psychiatric care of patients under the Mental Health Act 1983; * Teaching and training on mental health issues to a range of healthcare professionals working in general hospital settings as well as more general advice and support.
The service is totally committed to providing a high quality service to patients and staff at Sheffield Teaching Hospitals NHS Foundation Trust, ensuring that specialist mental health assessment is offered to people who may not have otherwise had this opportunity and may have found themselves either discharged to the community without support or enduring a lengthy hospital admission. The 24 hour service provided to the A&E Department also helps to ensure that patients presenting at A&E do not have a long wait for mental health assessment, thus improving the patient experience as well as health outcomes for these patients. The specialist skills and knowledge of the service provides support to all manner of mental health conditions and crisis that affect all age ranges, therefore, ensuring parity of esteem and the flexibility to give the best and quickest response to the individual patient and aid the flow through the acute hospital. The service sets high standards for itself and applies the latest research and evidence based practice, are active in clinical development and have a successful CPD forum which is well attended and which other teams are encouraged to attend. After only two years and following much hard work using the microsystems quality improvement approach, the service gained the highly prized Accreditation status from the Royal College of Psychiatrists.
What makes your service stand out from others? Please provide an example of this.
The service is a cohesive, well led team delivering high quality care for the patients of Sheffield Teaching Hospitals NHS Foundation Trust. All team members are deeply passionate about providing the level of service that they would want for their own loved ones, should they ever need it. Team members at all levels and of all professions are constantly looking for ways to improve the delivery of care, service pathways and the way they interface with other services. All of which means that the service’s patients receive an excellent service which is well regarded by patients, healthcare professionals within the Sheffield Teaching Hospitals NHS Foundation Trust and within Sheffield Health & Social Care NHS Foundation Trust itself. An example of the service’s innovative work: The service provides a supported discharge service to patients over the age of 65 to support timely discharge from hospital, ensuring that discharge is not negatively affected by the patient’s mental health needs not being met. Once at home, the service reviews the patient’s needs for ongoing support, including consideration of their wider needs, for example, referral to the Memory Service, a Carers Assessment, social support or engagement with voluntary sector or charitable services. Issues such as social isolation and loneliness are also considered and addressed.
In addition, the service supports families and seeks to fully engage them in care planning and discharge arrangements. The service identified a gap in services for supported discharge for working age adults. Team members were concerned that those patients who were assessed as not meeting the criteria for support from secondary mental health services but had clear needs to manage their current presentation or crisis were being left without support. The needs usually centred around social needs, enablement support or behavioural needs. In order to address this gap the service identified a development role for its support workers.
A proposal for support workers already working with older adults (over 65) on supported discharge to extend their remit to working age adults was made to the Multi-Disciplinary Team where it was fully discussed. The feedback from support workers to the initial proposal was wariness, they described a lack of confidence in supporting working age adults. The service used the proposal as a positive opportunity to develop the skills, knowledge and confidence of its support workers in working with adults. Clear guidelines for referral were set including the expectation that the referrer must provide support to the support worker throughout supported discharge. Extensive preparation took place prior to the change which involved the support workers at every step. The change also offered the opportunity to use the Recovery Quality of Life (ReQoL) Patient Reported Outcome Measure (PROM) to support the intervention. Weekly meetings were held with the support workers in order for them to have time to discuss the patients, ensure that interventions were being delivered appropriately and that any difficulties can be discussed and resolved. This has proved to be a successful ongoing venture which meets the needs of patients and has provided positive outcomes for them as well as an improvement in their health and functioning. It has also supported the development of the support worker roles within the service.
A further example of their solution focused approach is evidenced by the following. The Trust undertakes standard audit on record keeping and assessments. One of the audits focuses on the use of abbreviations and jargon, however, the staff within the service felt that there were no clear guidelines or standards for what is best practice. They took the initiative to develop their own standards in order to reduce variation and improve accessibility and understanding of records. Staff within the service are clear that the service user record is the property of the service user and any information within the record should be easily understandable by the service user. The service’s standards for service user friendly records are now being adopted by the Trust as the model for all services and all record keeping. In addition, the Trust has struggled to embed the use of the Friends and Family Test for service user feedback in all clinical teams. However, the Liaison Service stand out as managing to do this effectively and now the Trust is using the service as an example to promote to other services to improve their use of the Friends and Family Test. Yet again this is an example of the service using a solution focused approach to addressing issues.
How do you ensure an effective, safe, compassionate and sustainable workforce?
The service offers a comprehensive in house Continuing Professional Development (CPD) programme in order to offer staff the time to learn, develop and reflect in a supportive environment. Staff are also fully supported to engage in other opportunities to learn such as National Conferences, University based courses and any other ad-hoc opportunities which may arise. The service is highly compliant with supervision requirements, both in terms of formal opportunities for 1-1 supervision and more informal “live” supervision within the team. The service as a whole is a very supportive environment where staff are encouraged to discuss patients they have assessed and reflect upon their practice, share learning and gain support from their colleagues and team senior practitioners/manager.
As the service assesses many complex patients with very challenging issues to overcome, the Multi-Disciplinary Team (MDT) is used to discuss these patients as a team so that a consistent, positive approach is offered to the patient and staff feel supported to facilitate the agreed format of the assessment/intervention. Any opportunity for learning from serious incidents is discussed within the service within a supportive blame free culture. The service’s workforce has expanded rapidly from two small discrete liaison teams (older adult and working age) with 15 staff to over double that number today. Previously the Liaison Service consisted of two separate very small teams who worked independently of each other, staff didn’t know each other and were based in different parts of Sheffield Teaching Hospitals NHS Foundation Trust. This transition began in October 2016 and the service moved to a 24/7 model on 24 November 2018 (formerly it operated Monday to Friday 9am-5pm so this was a significant change in of itself). Merging discrete teams who have very different specialist knowledge bases is a great challenge due to the staff preferences for their own area of work, their lack of confidence and desire to work within another area, and their fears around the challenges that it will present to them personally.
Furthermore, changes to the existing shift patters for the staff, (many of whom did not elect to work 24 hour rota) provided further barriers to overcome. The transition has been achieved by the effort and determination of the whole service: there was a willingness (despite the reservations/lack of confidence of staff) to learn the skills required to become skilled in both adult and older adult assessments. This has been in the spirit of enabling staff to feel valued in their speciality and to use their individual skills appropriately within the 24 hour period. For example, the evidence shows that older people rarely attend the emergency department out of hours for mental health problems, therefore, the nurses who were originally within the older adult team predominantly work from 8am to 6pm. They are willing however within these hours to see adults of working age if that is what is required and equally they do work nights and late evenings in order to meet the needs of the team rota and manage the resource effectively.
There are extensive in house learning opportunities and medical staff also supported the transition by reflecting a similar willingness to work across the age range and to support staff who need to discuss a patient they have seen and needed some medical advice. For example, the staff who are more confident with adult patients have gone to assess someone with a cognitive problem/complex physical health issues and have been able to come and discuss the patient with the medics in order to formulate an appropriate plan of care. This has enabled staff to have the confidence and to learn and develop skills while maintaining a safe, effective service for patients. As a result of the above, the service receives an extremely low number of complaints and many, many examples of positive feedback from patients and their families: Examples include: • “Expert advice, and genuine caring approach – #### was asked relevant caring questions and given time he needs” • “They were exceptionally helpful and #### / ######### were very friendly. A true credit! Absolutely incredible duo very talented and wish them the best for the future” • “I believe my life has been saved today. Thank you.” • “Very happy with the support which you are giving to my mother. It is very reassuring that I know that you are trying to support my mother in this period in her life. You are all doing a fantastic service in helping my mother and I am very grateful with all your teams support”
Who is in your team?
1 Team Manager – Band 8a – 1.0 WTE • 3 Senior practitioners – Band 7 – 2.6 WTE • 19 RMN – Band 6 – 18.4 WTE • 3 RMN – Band 5 – 2.4 WTE • 2 Admin – Band 4 – 2.0 WTE • 2 Admin – Band 3 – 2.0 WTE • 3 Support Workers – Band 3 – 2.6 WTE • 3 Consultant psychiatrists – 2.0 WTE • 2 Specialty Doctors 1.0 WTE • 1 Specialist Registrar (ST5) Doctor WTE • 2 Core Trainee (CT3) Doctors WTE
How do you work with the wider system?
As a team, the service works hard to support not only colleagues within the Sheffield Teaching Hospitals NHS Foundation Trust but also with colleagues within their employing Trust, Sheffield Health and Social Care NHS Foundation Trust. They do what it says on the tin – liaison – liaison at all levels and across multiple organisations and agencies. Liaison with the community teams and in-patient services is critical for the experience of the patient. Where necessary the service takes the initiative and lead on multi-disciplinary /multi-agency approaches to care delivery. The service work with Sheffield Teaching Hospitals NHS Foundation Trust to formulate plans of care for people who attend frequently or who have special needs for support while in the emergency department or general hospital wards.
The service attends meetings which feed into the governance structures for the Sheffield Teaching Hospitals NHS Foundation Trust as well as having joint meetings at senior practitioner level with the Accident & Emergency Department to review any difficulties, improve care pathways and patient experience. This includes reflection upon and joint learning where a patient may have had an adverse experience of using the Accident & Emergency Department. The service also works closely with the Alcohol Liaison Service in order to meet the mental health needs of patients who also have substance misuse issues. The service also works closely with the Child and Adolescent Mental Health Services provided by Sheffield Childrens Hospital NHS Foundation Trust to address the challenges of assessing 16/17 year olds who either present in the Accident & Emergency Department or are admitted to a ward at Sheffield Teaching Hospitals NHS Foundation Trust. There is a lot of positive work ongoing in this area and the Liaison Service are a key part of this.
Do you use co-production approaches?
Improvements in service delivery have been largely driven by national targets and increased resource to the teams. The service uses feedback from patients and family members (both positive and negative) to evaluate the service and address any concerns. All complaints or compliments are shared across the service and discussed at team level. Sheffield Health & Social Care NHS Foundation Trust (the service provider) puts service user and carer engagement at the heart of everything it does, therefore, the service is aspiring to develop co-production approaches with current and former patients and their families. The service has recently begun an initiative using the survey model from the Five Year Forward View on people’s experience of using A&E to access mental health support, to gather ‘live’ data on a weekly basis from people who have used the service and use this feedback to drive further service improvements and enhancements.
Do you share your work with others?
The service is fully committed to sharing its work with colleagues and other healthcare professionals. The service’s most recent endeavour was to lead the facilitation of a Schwartz Round for Sheffield Health & Social Care NHS Foundation Trust based upon the experiences of staff working with people with personality disorder in the Sheffield Teaching Hospitals NHS Foundation Trust. This was very well received and attended by a wide range of professionals from both organisations. It has been nominated for the national award “Most powerful Schwartz Round” by the Schwartz Round leads for Sheffield Health & Social Care NHS Foundation Trust. The service is a member of the PLAN Accreditation Network and regularly participates within the PLAN chat to contribute and support other liaison teams who have varied enquiries to respond to. The service participates and contributes to a wide variety of local and national conferences and networking events. This includes, for example, conducting a series of workshops for the Suicide Prevention and Self Harm Conference organised by NHS Sheffield Clinical Commissioning Group. The workshops were delivered in the format of role play by Dr Abhi Shetty (Consultant Psychiatrist), Julie Sheldon (Senior Operational Manager) and Catherine Carlick (a service user employed by Sheffield Health & Social Care NHS Foundation Trust).
Some examples of feedback from the event below: I just wanted to say on behalf of the Mental Health Portfolio Team a huge thank you for taking part in developing and delivering the GP & Practice Nurse PLI on 7 June. Your contribution was essential and so very much appreciated. Feedback received included: “I just wanted to contact you and say a massive thank you for yesterday’s PLI. It was truly beneficial to my practice. [It was] thought provoking and made me very reflective of my practice. After yesterday I really took home the sense that this is all our responsibility to be better at helping people with their mental health concerns/needs, not skirting around things, being more open and willing to actively listen, giving people time and being respectful of their story. After all have a physical and mental health” A colleague also got in touch with the service to share how they applied what they had learned from the PLI immediately in a consultation that they had with someone who had self-harmed that very following morning: “I have started today already utilising what I have learnt and putting it into practice. Hopefully I helped [her] in someway by acknowledging what she goes through and offering support, checking she is okay and her concerns are really valid and heard. I just wanted to share this feedback with you all.”
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
The service hold themselves accountable through their governance procedures, regularly measuring performance and data and also active in the governance structures of Sheffield Teaching Hospitals NHS Foundation Trust. They are productive and meet all of their performance criteria and targets. The service uses the ReQoL as an outcome measure (PROM) for people who are referred to and offered an intervention by our supported discharge team. The Recovering Quality of Life (ReQoL) is a Patient Reported Outcome which has been developed to assess the quality of life for people with different mental health conditions. The service were involved in the development of the tool in that staff handed out questionnaires for patients to complete and send back to the University. The answers they gave helped shape the questions asked on the ReQoL. This information is evaluated as part of our continuous quality improvement programme. The service collects service user feedback using Sheffield Health & Social Care NHS Foundation Trust’s Friends and Family Feedback and the service also uses the Plan, Do, Act audit tool which is designed to ensure that the service’s record keeping is aligned to NICE guidelines and evidences NICE guidelines in practice.
The service is paperless and uses its electronic records to collect data including Mental Health Services Data Set. The service collects data to measure its achievements against its Key Performance Indicators and reviews its performance against these on a monthly basis. The service is currently tasked with a CQUIN aimed at reducing overall frequent attendance at the Accident & Emergency Department. The CQUIN has been successful for the financial year and the service has achieved its target of a 20% reduction in the attendance of an identified cohort to the Accident & Emergency Department. This has required a coordinated and enthusiastic approach from the medical and nursing leads within the team. It demonstrates the service’s commitment to supporting the needs of the people it assesses and treats within Sheffield Teaching Hospitals NHS Foundation Trust.
The case study below appears in Sheffield Health & Social Care NHS Foundation Trust’s Annual Report for 2017-18 and illustrates the positive outcome the service has for patients. Jim’s* Story (*not his real name) Jim is in his late 50s and was seen by the Liaison Service for crisis assessment in hospital following an overdose. The assessment identified low mood, social isolation and lack of vocation as the main issues affecting Jim. Supported discharge was put in place to address his social isolation and assist him to engage in voluntary work (something that Jim identified as a goal he was keen to accomplish). He was also assisted to engage in an appointment with his GP to review his medication needs. Jim has had no further attendance at hospital and has reported positive outcomes from his involvement with the team. The supported discharge offered by the Liaison Service reduced Jim’s length of stay in hospital and improved his wellbeing while also reintegrating him into his local community.
Has your service been evaluated (by peer or academic review)?
Our mental health liaison service has been accredited by the Royal College of Psychiatrists until 2020. The Psychiatric Liaison Accreditation Network (PLAN) award provides formal recognition that the service is committed to providing and improving quality of care in psychiatric liaison services. A team of trained reviewers from the Royal College of Psychiatrists visited the service to conduct focus groups with staff, service users, carers and other stakeholders and reviewed evidence and data with the service, before awarding accreditation. PLAN is an initiative of the Royal College of Psychiatrists’ Centre for Quality Improvement (CCQI). PLAN works with services to assure and improve the quality of psychiatric liaison in hospital settings.
How will you ensure that your service continues to deliver good mental health care?
The service works closely with Commissioners to ensure that positive relationships are fostered and open communication is encouraged. The funding for the CORE 24 service is recurrent and fully supported by Commissioners. Due to maternity leave within the team, there have been opportunities for Band 6 staff to develop themselves into the Band 7 role by acting up. The unsuccessful applicants are also being supported so that in the event of further opportunities they will be better prepared and experienced to be successful in the role. The Band 8a manager is fully supporting the Band 7 practitioners to enhance their skills and knowledge so that they gain maximum benefit from the opportunity and gain confidence in their practice. The Team Manager strongly believes that positive supportive leadership is critical to the well being of the team and sets the culture and values of the team. Happy staff deliver high quality care to the patients they see.
What aspects of your service would you share with people who want to learn from you?
The most significant challenge has been meeting the needs of all staff during the expansion period as the service transitioned to providing a service to the whole adult age range and operating 24/7. The service wanted to offer staff as much flexibility as possible to accommodate personal preferences and achieve a good work/life balance for all staff. To this end approximately half of the staff were given the opportunity to trial working 13 hour days, 3 days a week. This proved to be unworkable as staff reported feeling extremely tired, their resilience dropped and sickness absence increased. This negatively impacted on the staff rota resulting in difficulty in maintaining a safe and effective service. The trial lasted for 3 months. While individual staff reported liking the working pattern and that this improved their work/life balance, they were also clear that they were extremely tired.
The Team Manager carried out audits of activity which evidenced that the longer shifts were resulting in a drop in productivity, particularly in the final 4 hours of the shift. Following discussion with staff a compromise was agreed that would retain the 13 hour night shifts, but reduce the day shifts to 10 hours, thus safely covering the rota and improving productivity while helping staff to maintain a positive work/life balance. On reflection, the Team Manager considers that the 3 month pilot negatively impacted on the resource of the service, however, it was important for the staff that the pilot took place as they were keen to trial this way of working and if it had not been tested, staff would have felt unheard and disrespected. Following the introduction of the 10 hour day shift, the majority of staff have acknowledged and reflected that the 13 hour day shifts had resulted in them being extremely tired and that the whole staff team are benefiting from the move to 10 hour day shifts.
The new system means that there are more staff on duty during core hours to progress work, productivity has increased and sickness absence has decreased. The Team Manager passionately believes that fostering a positive, happy culture within the service is vitally important within a stable team structure. In a service such as the Liaison Service where there is constant change, expansion and pressure, this is absolutely critical. The Team Manager has created a culture where staff voices are heard and ideas, suggestions and innovation are encouraged, supported and embraced. The Liaison Service is committed to a programme of continuous quality improvement and constantly seeks out ways in which to improve the service it offers. Developments currently in progress include a ‘frequent attendees clinic’ to fully address the reasons that patients might make frequent attendances to the Accident & Emergency Department, with the aim of working collaboratively with patients on a plan of care which will support them better. This is a key piece of work to understand the root cause of what drives an individual’s need to attend the Accident & Emergency Department frequently and will enable the Service to support patients better while also supporting a reduction in the impact and activity for colleagues in the Accident & Emergency Department.
A significant part of this work will include working in partnership with a wide range of agencies, services and third sector providers in order to develop comprehensive packages of support for these patients. The service is also developing a robust offer of teaching and training to colleagues at Sheffield Teaching Hospitals NHS Foundation Trust. The service already offers a programme of teaching and training, however, it has recognised the difficulties that hospital staff face in releasing staff to engage in learning opportunities, therefore, they are developing ‘bite size’ training which can be slotted into existing training schedules. The aim is to support a change in attitude, culture and the knowledge and skills of staff who are delivering direct care to patients on the general wards and in the Accident & Emergency Department. The service is also supporting Sheffield Teaching Hospitals NHS Foundation Trust to develop a mental health e-learning package to improve the mental health awareness of all Sheffield Teaching Hospitals NHS Foundation Trust staff. Bespoke training provided by ‘in reach’ to the general wards is also available from the service to Sheffield Teaching Hospitals NHS Foundation Trust staff on request.
The Sheffield Liaison Service experience constant change both within Sheffield Health & Social Care NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation Trust, alongside this they work with the most challenging and risky of patient groups. They are extremely resilient and witness life’s hardships all day, every day. Frequently they bear the brunt of colleagues’ frustrations but this only services to make them more determined to do the very best they can for both patients and the acute staff at Sheffield Teaching Hospitals NHS Foundation Trust. They are wonderful ambassadors for Sheffield Health & Social Care NHS Foundation Trust and are held in high esteem by colleagues in both organisations. The staff show enormous respect, support and empathy for their patients and for each other and their camaraderie is evident in all that they do. Despite the relentless demand and hard work in difficult circumstances they never fail to be compassionate and caring, they never complain and are openly proud of their service, welcoming other professionals to take part and taking every opportunity to teach and share their experiences. They raise the profile of mental health every day in Sheffield Teaching Hospitals NHS Foundation Trust and provide training to educate and reduce stigma and discrimination around mental health issues.
Hours the service operates *
Brief description of population (e.g. urban, age, socioeconomic status):
City of Sheffield and surrounding area of South Yorkshire and North Derbyshire
Size of population and localities covered:
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): *
NHS Sheffield Clinical Commissioning Group
Provided by (e.g. name of NHS trust) or your organisation: *
Sheffield Health & Social Care NHS Foundation Trust
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