It has long been recognised that the arrangements in London for transporting people to hospital who have been assessed under the Mental Health Act (MHA) or placed under section 136 by a police officer have been inadequate. A key component of the process is ensuring that the service user is transported to hospital in a timely, dignified and safe manner. The challenge we faced in London was that this aspect of the process was hindered by the LAS triage system. We all knew something had to change- so what did we do?
Co-Production
From start: Yes
During process: Yes
In evaluation: No
Evaluation
Peer: No
Academic: No
PP Collaborative: Yes
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Sinead Dervin - Senior Health & Justice Commissioning Manager
It has long been recognised that the arrangements in London for transporting people to hospital who have been assessed under the Mental Health Act (MHA) or placed under section 136 by a police officer have been inadequate. Being detained under the mental health act is probably one of the most distressing experiences that can happen to users of mental health services; affecting young people, working age adults and older people, there is no discrimination. Assessments under the mental health act are complex and involve a number of agencies such as the London Ambulance Service (LAS), the three police forces in London, the courts, & inpatient services, along with a range of professionals such as Approved Mental Health Professionals (AMHPs) doctors, family members and carers. A key component of the assessment and detention process is ensuring that the service user is transported to hospital in a timely, dignified and safe manner. The challenge we faced in London was that this aspect of the process was hindered by the LAS triage system, with its internationally set categorisation of calls that led to lengthy response times to transport people who have been detained under the MHA. This situation was exacerbated by the unprecedented growth in demand being placed upon the LAS. This meant that service users were waiting anywhere from 3- 6 hours to be transported to hospital in often highly distressing situations. AMHP’s, police officers and Drs were often left for long periods of time managing and containing difficult and emotionally charged situations.
We all knew something had to change- so what did we do? In April 2015, led by Health & Justice Commissioners in NHSE and Brent CCG, (the lead commissioner of LAS) , a multi- agency partnership was formed with LAS, the Police, AMHP/social care leads, Her Majesty’s Courts & Tribunal Service, the 9 mental health trusts in London and the Patients Forum for the LAS. We set ourselves the following objectives: To understand the demand for transport across London for people who have been assessed under the MHA; To understand the nature and extent of the issues surrounding the transport pathway for people assessed under the MHA; To define what is required to deliver a safe, dignified and effective transport service to people assessed under the MHA; To provide solutions to improve the pathway currently provided by LAS.
It was apparent very early on that the solution to our challenge was not about trying to ‘fix’ a single component, the solution lay in enabling system leaders to collaborate in order to achieve a system wide solution that provided the best outcome for the user and made the most appropriate use of resources.
It was also apparent that effective stakeholder engagement would be critical to a successful outcome; the transport issue was contentious and many people had many things to say about it. Workshops were therefore undertaken with a range of stakeholders including service users, front line police officers, paramedics, families and carers, AMHPs, section 12 Drs, inpatient staff, managers of section 136 suites and commissioners. One of the questions that came up time and again was ‘are two paramedics and a fully equipped ambulance required to provide transport to people who have been assessed under the mental health act?’ The answer was No- and Yes.
The role of LAS in MHA assessments was highly valued; it was however also acknowledged that on a number of occasions their technical skills as paramedics and the equipment within an ambulance were not utilised. Having said this AMHP’s and police officers recounted occasions where paramedics had offered lifesaving interventions to the patient; we were all aware of the complexity and risk of cardiac and respiratory problems for people with severe mental illness and were cautious not to minimise this risk. What we were hearing is that people were seeking some kind of hybrid model.
We learned that LAS also provided a pan London Non-Emergency Transport System (NETS). It had been set up primarily in response to the demand from Health Care Professionals to have patients transported to hospital who did not require an emergency response. We therefore explored whether NETS could also provide transport to people who had been assessed under the MHA. The service was managed by LAS, provided suitable vehicles and appropriately trained staff and was able to be booked in advanced through a web based system- and it was likely to be cost neutral.
The partnership agreed that transferring the activity for transport for MHA assessments from the LAS emergency response to NETS would bring about many benefits namely: A dignified and safe method of transport provided by the same provider that could arrive within a dedicated time slot minimising the distress for the service user; A dramatic shift in waiting times for transport from 3-6 hours to 30 minutes; A significant reduction in time spent by AMHP’s, front line police officers and section 12 Drs in coordinating and completing MHA assessments; An increased capacity and ability for front line paramedics to respond to life threatening Category A calls within the national standard of 8 minutes. • An enhanced focus on developing parity of esteem for people with mental health problems
The partnership therefore agreed that a phased roll out across London would commence from April 2016. Although the project roll out is only two months in its operation, the planning, partnership working and consultation had been a year in the making and the results of the first two months are striking. The KPIs that the service works to are: 95% of journeys to arrive on time; 100% of journeys thereafter to arrive within 30 mins.
The first 2 months data (for 2 boroughs) shows that in the vast majority of cases transport has arrived within the time that it was booked for or within 30 minutes of the booking time; this is a dramatic improvement.
KPI 95% on time 25 Journeys 62.5% 100% booking time + 30 mins 12 Journeys 92.5%
Outside KPIs 3 Journeys 7.5%
We have also surveyed AMHPs for their experience of the new system; their comments below highlight the very real difference that the project has made to their day to day job: “My assessment was booked for 12 noon and NETS were there in 20 mins…overall all I would give the new service 10 out of 10”.
“The ambulance crew (NETS) were helpful and flexible and sensitive towards the service users…the whole system is so much more efficient and user friendly and helps reduce the stress and uncertainty for the service user”
“Extremely helpful to the patient to have NETS on standby today. Patients are often quite unwell and can become quite disturbed during a MHAA. Keeping them in an unsafe environment for extended periods waiting for an ambulance is unethical, they were ready today to take an unwell and distressed patient straight to hospital. This was of enormous benefit to the patient, the police and the AMHP and it should continue”
“I did a MHAA today in the community at Kings Cross singulair tablet. What can I say, the NETS service was excellent, the vehicle looked like an ambulance, went like an ambulance and had two members of staff who looked remarkably like they were paramedics in green uniforms. A great improvement!”
Due to the complex circumstances in which the patients use the service we are actively working with the LAS Patient Forum to develop a suitable and sensitive method of understanding the difference that the new service has made to patients and how they can influence its development.
For the first time, NETS will be able to accurately collate data on transport requirements for all mental health act assessments across London. This will enable the partnership to: accurately understand the numbers of mental health act assessments being undertaken across London; provide a forward look at the subsequent demand for beds in a locality over a given time period; understand the potential demand on policing partners; enable adequate capacity and demand planning for the non-emergency transport system. This will in turn enable the leadership across the mental health system in London to respond to and adequately meet the continued demand for assessments under the mental health act and the subsequent demand for beds whilst providing a tool to assist with planning for alternatives to admission to hospital.
Wider Active Support
The outcome of the project was always going to rest on the success of the partnership. From the outset all the partners that were approached actively wanted to collaborate to find a solution to what was seen as a very long standing problem. The partnership has overseen the life of the project through a steering group and smaller work streams that continue to support the delivery of the new service. Stakeholder workshops were also undertaken with a wider range of partners to fully understand the transport pathway from all perspectives.
Members of the steering group and overall partnership are as follows: Sinéad Dervin – Senior MH commissioner, Health & Justice, NHSE; Ursula Gallagher – Former Director of Patient Safety, Brent CCG; Briony Sloper- Deputy Director of Nursing, London Ambulance Service; Nic Daw- Head of PTS, Modernisation and Performance, London Ambulance Service; Chief Inspector Dan Thorpe- Metropolitan Police Service; Alison Greenhalgh – Chair of the London AMHP Forum; District Judge Green – Camberwell Green Magistrates Court; Malcolm Alexander- Chair of LAS Patient Forum; Maria Kane – CEO Barnet, Enfield & Haringey Mental Health Trust.
Co-Production
The Chair of the Patients Forum for the LAS, Malcolm Alexander has been involved in the project since the outset; Malcolm actively campaigns for improvements in responses to people with mental health problems and has been able to witness first-hand the significant improvements that the partnership and NETS have been able to deliver; in his recent bulletin to the 32 London CCG’s
Malcolm stated: “However, new services like NETS for patients requiring mental health assessments….. are examples of some successful service transformations” We have also had service users involved with the workshops and one current inpatient at a forensic service was able to attend our stakeholder feedback session and provide an account of his personal experience of the mental health and transport system.
Looking Back/Challenges Faced
We perhaps underestimated the scale and breadth of the project and the resource required to coordinate the various work streams. We had to change the project management support mid-way which created some delay. However, the overall strength of the partnership enabled us to deliver what we had set out to.
Project roll out. Although the partnership and consultation has led to an improved model of delivery; the biggest challenge is the roll out which will require AMHP’s changing practice across the 32 London boroughs and internal changes to operational procedures within LAS. To manage this we have chosen to roll the service out over a mental health trust footprint working with the lead AMHPs from each borough which broadly aligns with the NETS transport hubs in London. Joint training has taken place between the NETS and AMHPs and key members of the partnership are holding weekly or fortnightly conference calls to oversee the continued roll out.
Section 136 pathway.There was much debate about the 136 pathway at the workshops and between partners and it was apparent that much progress had been made in London with regards to the dramatic decrease in people being detained in police custody under section 136 and the increase in LAS response times to 136 requests. Due to the national guidelines on the 136 pathway from the National Ambulance Mental Health Group and the progress made in the LAS and MPS partnership it was agreed that the 136 pathway would remain within the emergency contract. The data for this pathway is regularly reported at the forums listed below in the dissemination section.
Prison pathway. Through the stakeholder consultation it became apparent that there were unique problems within the prison pathway. Some prisoners with mental health problems were not able to be transferred to hospital within their sentence due to time frames and were being assessed under the mental health act on the day of their release; this presented particular challenges to the transport pathway. As an interim solution, H&J commissioners agreed to fund a 3rd party private contractor that could be secured via the NETS contract. This allowed for suitable transport to be secured for the small numbers of prisoners who required assessment under the mental health act on the day of their release. As a wider system solution H&J commissioners are engaging with the MoJ about the processes for transferring people to hospital from prison under the mental health act.
Out of London beds Due to the demand on inpatient beds across London there is at times an increase in the use of beds outside of London; this again creates challenges to LAS and or NETS who are not commissioned to travel outside of London for this activity. As an interim solution the partnership agreed with the 9 London Mental Health Trusts that on these occasions the Trusts would allow NETS to utilise a 3rd party provider to undertake these journeys. The Trusts have also committed themselves to a wider transformational piece of work to reduce bed occupancy that will support patients being admitted to hospital within their locality.
Sustainability
A key objective of the partnership was always to deliver a change that was sustainable, cost neutral and that utilised existing resources through a system wide leadership. The word ‘pilot’ was deliberately avoided with a focus on transformation instead. The breadth of the partnership has enabled the change to take place at a system level rather than an individual level.
Evaluation
As the project and partnership was about driving transformational change we avoided seeing the work as a pilot that would be subject to a full evaluation. We will however continue to monitor the effectiveness of the new service through contract management, the LAS Patients forum and via AMHP and police feedback
Sharing
The project has been presented at a number of forums in London namely: The London Mental Health Transformation Board; The Mental Health Partnership Board; The London Strategic Clinical Network for Mental Health; London wide AMHP forum; The London Health & Justice Service User Forum.
The partnership is also looking to disseminate the work through NHSE clinical networks and the National Ambulance Association
