What’s made the difference? Developing and implementing effective pathways across all mental health services. There are clear governance arrangements across all of these connected services including, acute, rehabilitation, community and low secure. Having a project lead and effective governance structures with administrative support/ Effective stakeholder involvement in project planning and delivery including estates, clinicians and service users. Executive level direction and support/ Visiting other areas and benchmarking Sheffield against other services. This allowed us to learn from examples of good practice and to know where to focus our energy, e.g. in reducing length of stay. Joint working across the community and inpatient services so that all staff are able to view changes in the context of the wider system. Every team in the acute system benefits from all of us collectively managing the system. Tight management of length of stay, a focus on outcomes and working together have been key – and, most of all Reviewing and improving ways of working, focusing on both productivity and improving quality - Winning the hearts and minds of our staff and service users.
What We Did
In 2012 acute mental health bed occupancy in Sheffield was running at about 120% and there were large numbers of people out of city. Then, Sheffield had four acute adult psychiatric wards with 24 beds each (96 beds); and two older adult wards with 22 beds (44 beds) and approximately a ward full of people out of town all the time. It was often difficult to admit, with beds frequently blocked due to a lack of access to rehabilitation beds and difficulty accessing social housing. The length of stay was long (50 days Adult, 120 days Older adult). This situation had gradually taken hold over the previous decade, despite numerous initiatives to change this.
In order to address the issues within the acute care pathway several themes were addressed:
1. Reducing length of stay.
Productivity work has taken place and length of stay is managed using a range of methods including: daily bed management for all wards together; daily ward team meetings with the consultant: discharge coordinators based on each ward.
2. Development of crisis care
We commissioned a crisis house (run by Rethink for all age groups over 18 years) and enhanced crisis and home treatment teams across the age range.
3. Established leadership roles in weekly bed management meetings.
The bed management meetings focus on the flow of service users between the inpatient and community services. This supports and encourages the use of alternatives to admissions to the ward such as the crisis house and home treatment.
4. Established a strong senior management team
Thus has a supportive presence across the inpatient pathway, offering a coaching and mentoring leadership focus.
5. Developed a purpose built, 10 bedded psychiatric Intensive Care Unit – Endcliffe
This new unit accommodates the service user demand in city to avoid out of area admissions / treatments. The new environment provides a therapeutic, safe space – the quality of the design.
Impact of interventions.
The impact of the above interventions substantially reduced length of stay from 56 to 31 days and greatly improved pathway management. We now have one older adult ward (18 beds); three adult wards (49 beds in total), each with existing staffing levels therefore increasing the staff to service user ratio. Most importantly, we have eliminated out of area treatments for acute beds and PICU due to lack of capacity for over two years. During this time there has been a maintained or slightly higher level of admissions and much better access to acute care. In April 2016 we closed one adult acute ward.
The total bed reductions over this time, including constant out of area bed use, has gone from160 beds down to a new model in 2017 of 67 acute beds across the age range. There have been no out of area acute admissions due to lack of capacity.
The reductions in inpatient care have been possible due a series of reinvestments, all funded by a reduction in out of area treatments and given to us by our CCG, including
• Same staffing levels in acute wards with less service users
• A crisis house
• Increased access to home treatment across the age range
• Psychologists on inpatient wards
• Improved environments with for example increased de-escalation space
• A new Psychiatric Intensive Care Unit
Working practices continue to be developed to ensure that they are offering recovery focussed and least restrictive interventions. Some of these innovations include:
• ‘Respect’ programme to replace previous managing violence and aggression including elimination of face down restraint and greater emphasis on de-escalation,
• Collaborative Care planning
• Delivering compassionate care
• Reducing restrictive intervention for example the use of seclusion and consistent access to post incident review as well as increased access to activity.
Overall, bed-nights for acute out of area treatment have reduced by a stunning 99.5%.
Over the same period (2012-17), we have also transformed the rehabilitation system by developing an ultra-intensive community rehabilitation team (Community Enhancing Recovery Team), also funded by reducing out of area treatment in locked rehabilitation. The service allows up to 24 hour support for service users if required. We have so far returned over 40 people (the majority to live in their own homes in the community in Sheffield) from locked rehab out of area treatments. The reduced out of area treatment spend has been given to us by our CCG which has funded an investment of £2Million in our new Community Enhancing Recovery Team and still saved considerable sums of money. Out of area treatment bed nights for these patients has been reduced by an equally stunning 99%.
Through an investment programme and support from the Clinical Commissioning Group we have been transforming our inpatient care environments. The first step of this was the creation of our stunning, Psychiatric Intensive Care Unit (Endcliffe Ward) which opened in January 2016. This new unit provides three outdoor spaces, de-escalation/green room, dedicated multi-faith room, sensory room and activity spaces which includes an cardio wall to promote physical health. The new unit also includes improved facilities for staff including separate staff rooms away from the ward, shower room and individual alarm systems to be able to request immediate assistance from anywhere on the unit. The unit won the Refurbishment Project of the Year, Design in Mental Health Awards.
We continue to monitor the impact of the changes using quality measures. All indicators suggest that quality is being enhanced by the reconfiguration.
We are really proud to be part of these transformational changes that are delivering a higher quality of care with increased access to talking treatment as close to home as possible. For those who do need inpatient care this is being provided in dramatically improved healing environments with rapid access to inpatient beds when they are needed.
It has taken 4 years to get these changes in place.
What’s made the difference?
Developing and implementing effective pathways across all mental health services. There are clear governance arrangements across all of these connected services including, acute, rehabilitation, community and low secure.
Having a project lead and effective governance structures with administrative support
Effective stakeholder involvement in project planning and delivery including estates, clinicians and service users
Executive level direction and support
Visiting other areas and benchmarking Sheffield against other services. This allowed us to learn from examples of good practice and to know where to focus our energy, e.g. in reducing length of stay
Joint working across the community and inpatient services so that all staff are able to view changes in the context of the wider system.
Every team in the acute system benefits from all of us collectively managing the system.
Tight management of length of stay, a focus on outcomes and working together have been key – and, most of all
Reviewing and improving ways of working, focusing on both productivity and improving quality
Winning the hearts and minds of our staff and service users.
Crisis House – in order to transform our acute care pathway we commissioned a 6 bedded crisis house and 24 hour helpline which is provided by Rethink mental health charity. We have worked collaboratively with Rethink to provide a service which meets the needs of the diverse population of Sheffield. Our Home Treatment Teams work proactively into the Crisis House to provide joint service user recovery focused care.
Wainwright Crescent – another example of joint working is, providing step down and respite provision as Wainwright crescent. We have further developed relationships with the council and housing partner an example of this is the discharge facilitator role which has now been developed in this service and is having an impact on reduction of the length of stay for the service users.
Community Enhancing Recovery Team– Another example of joint working is with the development of our Community Enhancing Recovery Team. We have worked in Partnership with South Yorkshire Housing Association to develop this ground breaking service. This includes the living well programme with provides individualised tenancy support for service users in their own accommodation
Psychiatric Intensive Care Unit, Endcliffe Ward (Award winning) – Joined up working with our estates department and clinical team has been vital within the Endcliffe ward project. Regular communication and sharing of information has ensured that decisions have been made and acted upon in a timely and efficient manner. Our trust has worked collaboratively and creatively with our selected design team, this can be evidenced by winning the Refurbishment project of the year award at the Design in mental health awards 2016, accepted by Cath Lake from P+HS architects. Endcliffe Team won the Team of the Year Award from the National Association of Psychiatric Intensive Care Units (NAPICU).
In order to ensure regular involvement with staff, service users, carers and families, we hold frequent engagement/involvement events. This enables updates to be provided and to encourage suggestions about projects and developments and aid decision making. These include SUN:RISE service user network, The Mental Health Partnership Board and regular events at our Inpatient Forum. Meetings also take place regularly with commissioners. Specific meetings with MPs have also taken place both as requested and as arranged by us for specific issues.
When we design new services we ensure all our stakeholders are involved and have celebratory events with a wide range of guests. An example of this is Endcliffe PICU. We carried out a wide range of engagement including questionnaires, focus groups, walk rounds. The opening event was led by one of our service users who jointly unveiled the plaque with our chairman. The service spoke about her experiences and hopes for the new service. Service users and carers are shaping the next stages of the Longley Design for our refurbished acute and older adult wards. This is an exciting project, we are learning from good practice in other areas and designing the unit so it is a central and integral part of the local community.
We have also recently undergone a consultation programmes with the staff in our teams, in which regular meetings occurred chaired by the clinical and service director to provide an opportunity for staff to ask any queries or raise any concerns the may have. All staff involved were offered 1:1 meetings and they all received these. We have had positive feedback from staff about how this process was carried out. We have also had effective joint working with Staff side.
We have made changes in our rehabilitation services and have been proactive in the way we engage with service users as carers. This has included establishing specific support and information groups. Meetings have taken place on a monthly basis and where requested we have met with carers / relatives in their own homes to discuss the changes and any concerns.
In order to develop and implement the next stages of transformation pathway engagement events are being planned and delivered by senior clinicians / managers to gather feedback and ideas. The first of these was very moving and thought provoking. Service users were able to share their views on the pathways and services. This gave valuable insights and opportunities for problem solving.
Looking Back/Challenges Overcome
We are proud of the way that we have combined productivity work with the delivery of compassionate care. Looking back at how this combination evolved we could have been more explicit with staff at the outset of the work about how these two approaches could have been combined.
We have learnt a lot from introducing a crisis house into our acute care pathway, on reflection if we were to begin this process again we would have been clearer about some of our expectation particularly in relation to risk management and admission avoidance. We have had some very positive examples of joined up working, in hind sight we could have held more events to celebrate this and consider sharing learning and best practice in relation to the connections between the teams involved.
A general learning regarding a number of projects within the programme in hindsight we could have gathered more data and feedback which would have enabled comparisons to be made more easily.
With these projects we have tried to include all relevant stakeholders. It is a challenge to continually identify and engage with all stakeholders. Having all relevant stakeholders involved is vital to ensure service user flow across the care pathways; we are overcoming this by continuing to revise and restructure our meeting arrangements. For example, the creation of the community flow meeting which occurs weekly in which senior leads and team managers across the inpatient and community services gather to discuss admissions, discharges length of stay and review of case loads. This forum provides an opportunity for the discussion of complex cases and problem solving.
It is a challenge to deliver projects alongside continuing safe provision of day to day care. We have minimised this impact by rationalising meetings and using technology to support this where appropriate such as, secure datastore for information sharing and conference calling with partners.
We are aware that the changes have impacted on staff with concerns about ward closures. It has been important not to underestimate the sense of loss for teams and service users.
Having all relevant stakeholders involved is vital to ensure service user flow across the care pathways; we are overcoming this by continuing to revise and restructure our meeting arrangements. E.g. weekly community flow meeting with senior leads across the inpatient and community services to discuss admissions, discharges length of stay and review of caseloads. This forum provides an opportunity for the discussion of complex cases and problem solving.
It is a challenge to deliver projects alongside continuing safe provision of day to day care. We have minimised this impact by rationalising meetings and using technology to support this where appropriate such as, secure data store for information sharing and conference calling with partners.
We are aware that the changes have impacted on staff with concerns about ward closures. It has been important not to underestimate the sense of loss for teams and service users.
Looking back at how the combination of productivity work with the delivery of compassionate care evolved, we could have been more explicit with staff at the outset of the work about how these two approaches could have been combined.
Introducing a crisis house into the acute care pathway- if we were to begin this process again we would have been clearer about some of our expectation particularly in relation to risk management and admission avoidance. We have had some very positive examples of joined up working, in hindsight we could have held more events to celebrate this and consider sharing learning and best practice in relation to the connections between the teams involved.
During the programme of change we have developed effective and robust project management structures and processes for example each project has specific mobilisation plans which identified key timeframe, goals and leads. These are shared within the agreed project teams and discussed to ensure that decisions are made collaboratively and these are presented to the trust boards for accountability. Actions are communicated to all key stakeholders
We have shared our experiences and outcomes with other organisations who have been keen to see what they can learn from us. This is often initiated by them due to our positive benchmarking but we find we are learning as much from them and their services too.
Evaluation (Peer or Academic)
There are a range of methods by which evaluation is carried out. These include:
•Service user focus groups including the crisis house and PICU
•Quality and Dignity surveys, carried out regularly. Service user leads visit the services and carry our the survey with existing service users
•Review of key performance and quality indicators through regularly service meetings as well as the reconfiguration programme board.
•Regular updates to Trust Board about progress and review data. This includes the levels of restrictive interventions, incidents and levels of acuity.
•All progress in actively monitored
•Service user flow is monitored and managers weekly through bed management and the community flow meeting
•Our first new build, the PICU was evaluated and received the best refurbishment award at the Design in mental health awards – a fantastic acknowledgement of the quality of this unit.
Data suggests that all is going well with no increase in the number of incidents. The reduction in length of stay has allowed a reduction in bed numbers. This in turn has released funding to improve staffing levels on the inpatient wards and enable investment into community alternatives.
SHSC performs well in national benchmarking with low numbers of admissions and emergency readmissions. We are proud that we continue to not place people out of town due to a lack of capacity for acute beds and to have dramatically reduced the number of people out of town in locked rehabilitation. Our recent CQC inspection rated our wards as Good, we are now striving towards the services being outstanding.
The CQC inspection reports identified the following:
• “The wards had scored above the national average in all areas of the patient led assessment of the care environment”
• “The Trust had effective systems for managing inpatient admissions and discharges. This meant they had managed to reduce the overall number of beds in the acute care pathway but could increase capacity as demand increased.”
• “Because of good capacity and demand management of inpatient beds, no patient had been admitted to an acute admission bed outside of the Sheffield area in the last two years.”
• “There were detailed and comprehensive care plans and risk assessments in place and these were being regularly reviewed. Patients told us they felt involved in their care planning and discussions about their progress.”
• “Each of the wards had a sensory room. Patients who were upset or agitated could use this dedicated room. The rooms had comfortable relaxing cushions and chairs, muted lighting and soft music. The rooms gave patients somewhere safe to go where they could implement a range of strategies, based on mindfulness, to help them through their crisis.”
• “Regular audits were being undertaken and improvements made based on the outcomes identified in those audits.”
• “Patients and carers told us that staff treated them with respect and kindness.”
• “We observed professional behaviours and interactions at all times.”
• “Patients felt involved in their care planning and discussions about progress.”
• “Carers told us they feel involved and included in their role as a carer.”
The project to transform acute care used the existing budgets for acute inpatient care and out of town spend which was approximately £10million to improve services. This has involved increasing the staffing ratio and the skill mix on the remaining wards. The skill mix now has more registered nursing staff and psychological input.
Capital money, saved through efficiencies was used to build the Psychiatric Intensive Care Unit. The cost of this and enabling works was £6.1 million. This is the start of our capital investment programme to develop the inpatient wards and establish healing environments.
Money released from the inpatient system, (the closure of 2 inpatient wards) has allowed £2.3 million investments into our community services to enhance the home treatment teams and develop further the personality disorder services.
The transformations in our rehab system have been focused on releasing the £6.1million spent out of area on locked rehabilitation per year. Our rehabilitation system has been developed and we now have the Community enhancing recovery service. This has relocated care of service users back into their locality and into the community.
In the first year this released a system saving of over £1million.
We continue to contribute to a range of forums, writing up about our progress and presenting at relevant conferences and events. Information is shared regularly at out inpatient forum. Regular newsletters have been developed and circulated to keep all stakeholders informed. We have also visited other areas to learn from their good practice and share our experiences. We are also open to visits from other areas, regularly having visits to our services.
Sheffield Health and Social Care NHS Foundation Trust hosted the regional launch of the Positive Practice in Mental Health Collaborative Directory in March 2017. This was a great opportunity to share the good news about our transformation programmes and provide an opportunity for networking and joint working with other organisations and their stakeholders.
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Message from Kevan Taylor, Chief Executive, Sheffield Health and Social Care.
I am incredibly proud of the transformations that have been occurring to the acute care system in Sheffield. The impact of these changes means that no patient needs to be transferred around the country for care when they are at their most vulnerable and in an acute crisis. I would be happy for any of my relatives to be treated in any part of the acute care system in Sheffield.