A choose and book system was developed, working with colleagues in the referral management system. When a patient with a mental health problem is referred to Royal Cornwall Hospital for an appointment or procedure their General Practitioner, with the persons consent, can refer to the Mental Health and Wellbeing team who will contact the patient prior to their appointment being booked to offer reasonable adjustments.
What We Did
Pilot cases were undertaken offering reasonable adjustments to people with mental health problems accessing secondary healthcare. During the pilot cases it was recognised that by providing reasonable adjustments patients who had not attended for previous appointments were able to attend their appointments and have their healthcare needs met. Length of stay was reduced. In addition the patients and the staff treating and caring for them reported their experiences to have been positive as a result of the additional support and reasonable adjustments.
• A choose and book system was developed, working with colleagues in the referral management system. When a patient with a mental health problem is referred to Royal Cornwall Hospital for an appointment or procedure their General Practitioner, with the persons consent, can refer to the Mental Health and Wellbeing team who will contact the patient prior to their appointment being booked to offer reasonable adjustments.
• The patient is offered support during their contact with the hospital in addition to a range of reasonable adjustments which facilitate access and engagement. Reasonable adjustments are made in advance of the patient’s appointment, reassuring the patient resulting in a reduction of missed appointments. In addition this can result in a reduction of bed days due to advance planning of support at home post procedure, as required, reduction of crisis during admission and the availability of the mental health and wellbeing team to trouble shoot any issues as they occur.
One example is of a gentleman who had no input from Community Mental Health Teams but had Obsessive Compulsive Disorder (OCD), body dysmorphia and trichotillomania. He required a hip replacement but had not been attending his appointments due to anxiety which resulted in increased OCD symptoms. He always wore a hat and had not been seen without one for 2yrs (even by his family). Following several non-attendance I was contacted. I spoke with him on the telephone and discussed his concerns. He was sent surgical hats at home so he could trial them and feel confident he would not have his head exposed. He was given a side room so he did not feel anxious about other patients looking at him (because of his body dysmorphia), he was given an unopened box of surgical gloves to reduce anxieties caused by his OCD. He was also able to manage his own meals and portion size (due to historic anorexia food was an issue for him). As a result the gentleman had successful surgery and a 5 day admission. He gave valuable feedback following his admission that the reasonable adjustments made the difference with regards to him attending for his surgery and remaining in hospital post procedure.
Wider Active Support
General Practitioners throughout Cornwall were informed of the Mental Health Choose and Book system via letter and through the GP Forum meetings. GP were made aware how the system works and the benefits to their patients. Often these can be patients that GP have found challenging to manage due to their non-compliance with secondary healthcare and complex presentations and needs.
Mental health services were made aware via letters that they could refer any patients who require care or treatment within RCHT -weather they were inpatients in mental health facilities or being supported in the community by mental health services.
The Kernow Commissioning Group are being informed and updated about the services and the benefits to patient care and experience.
Prior to the development of the service we discussed it’s development with service users from Cornwall Rural Community Council.
We have some Service users who continue to support the service and provide feedback on any documents produced or changes being made to the service.
We had a service user sit on the interview panel and devise an interview question when appointing a support worker for the mental health and well-being service.
We seek feedback for people who use our service.
Looking Back/Challenges Faced
There were concerns about providing a services, which is not yet commissioned by the local commissioning group, for fear that is would not be able to meet demand or would not be able to be maintained in the current footprint. By taking on pilot cases and testing demand we were able to offer reassurance. Also by making the service ‘lean’ and more efficient we were able to take on the additional choose and book referrals.
It would have been useful for GP’s to be provided with more information about the service prior to launch so that they were aware of the correct referral criteria – there was some confusion about patients being referred who required support in the community therefore signposting was required to the correct service. This has been clarified by follow up letters to GP and we now receive very few referrals which are rejected. In the event of a rejected referral we always explain why and signpost to the appropriate team o the GP and patients are not left without a next step.
We have an electronic referral service set up within the larger safeguarding team, access is available to the wider team so days off and annual leave can be cross covered.
The team currently have two permanent members of staff, any leavers would be replaced.
We collect audit data and feedback so we can demonstrate the need and demand for the service, the amount of reasonable adjustments made and the benefit to accessing healthcare services and patient experience
Evaluation (Peer or Academic)
Since the system went live on May 1st 2016 there have been 76 referrals from GPs across Cornwall requesting support and reasonable adjustments for patients with a mental health problem.
Over 100 reasonable adjustments have already been made for people with mental health problems, these include the patient being either first or last on the list, a reduced wait, desensitization visits, support during appointments, support with travel arrangements, pre-med medication taken at home prior to arrival in hospital, provision of a side room, extended visiting times and distraction support.
Feedback from patients indicates that the reasonable adjustments have made a significant difference to their ability to access healthcare. Patients self-report that without the service they would have not been able to attend, resulting in a missed appointment.
“ I wouldn’t have been able to come in for the operation without the support of the service as she would have been worrying at home and not been able to leave the house to attend. Being contacted and given information and having arrangements made for transport really made the difference.”
“The team came to my aid when I attended the Accident and Emergency Department at the Royal Cornwall Hospital as I had chest pains they spoke to the doctor’s and wrote in my notes thankfully the chest pains wasn’t cardiac it was a past muscle injury from a RTA 8 years ago previous. I am so thankful to as I have Complex PTSD, Asperger’s syndrome and Dyslexia. I could not have coped without the help and support”
“I feel more confident about using the general hospital services in the knowledge that the mental health service is there to provide a bit of extra support. It can be quite daunting attending the hospital due to negative experiences up country. When I attended A&E I was allocated a sympathetic nurse who went out of her way to look after me. Also when I had an outpatient appointment the team made the staff aware of my problems and had a chat with me before I went in. It really helped me.”
In addition, appropriate pro-active planning of appointments and aftercare for people with complex needs as a result of a mental health problem can result in reduced length of stay, a reduction in complications and a reduction in readmission rates due to better compliance with treatment and aftercare instructions.
Patients supported by this service are patients who frequently attend the Emergency Department in crisis. Effective engagement with these patients in a way which is adapted to their needs allows their healthcare needs to be met and results in a reduction of Emergency admissions. In addition there is a reduction in the use of Ambulance and Police services who are often called to convey the person when in crisis.
All staff within the Trust receive updates on the service via the all user daily bulletin. Specifically during national campaigns such as ‘time to talk’ day and ‘world mental health day’, ‘mental health awareness week’.
GPs within Cornwall are updated via their GP Forum and GP newsletter.
Partnership agencies across Cornwall are informed via a range of forums including the countywide Crisis Care Concordat Group.
We have recently attended the ‘Treat as One’ NCEPOD report launch in London and took the opportunity to share details of our services.
We have entered the HJS value in healthcare award which we have been shortlisted for. We have asked service users to help us plan the presentation for the judging panel.
Is there any other information you would like to add?
People with mental health problems often report poor experiences when accessing healthcare services such as “feeling sidelined, and that people with physical health needs have been given priority over me. Being able to access the help you need when you need it and being treated with respect and compassion is so important” (service user voice). This is not acceptable, we are passionate about people having positive experiences and having their needs met in a way that is individual to them. In a way which is professional and friendly and inclusive.
People with mental health problems are dying 10-15 years younger than the general population form potentially preventable causes. They have difficulties accessing secondary health care and require reasonable adjustments to facilitate their appointments, care and treatment and to improve their experiences. We can make a change to the access for people with mental health problems – make it easier and less frightening for them to come to hospital and have their health needs met. If they do not attend the first time we can try again and make adjustments, we will not give up on people.
Reasonable adjustments are a duty within the equality Act 2010. A scarcity of services, physical barriers to accessing services, and failures to make reasonable adjustments have been identified as organisational barriers inhibiting access to care. Overt or covert discrimination and diagnostic overshadowing may also lead to inequalities in healthcare for people with mental health problems. We aim to reduce discrimination and stigma, supporting staff to care for people with mental health problem in a holistic and compassionate way. Supporting awareness raising and education for hospital staff of all positions from senior consultants and members of the board to healthcare assistants, security and porters.