There has been a significant transformation in the Teesside Crisis Service’s ethos and service delivery during 2016, following the successful consolidation of the Crisis Assessment Suite (CAS) as part of the Crisis service model, the adoption of the Purposeful and Productive Community Services (PPCS) ‘Toolkit’ and a greater focus on stakeholder engagement.
Summary.
There has been a significant transformation in the Teesside Crisis Service’s ethos and service delivery during 2016, following the successful consolidation of the Crisis Assessment Suite (CAS) as part of the Crisis service model, the adoption of the Purposeful and Productive Community Services (PPCS) ‘Toolkit’ and a greater focus on stakeholder engagement.
The introduction of the CAS (March 2015) has enabled the provision of prompt, open access assessments in a health based place of safety available 24/7 as an alternative to A&E for individuals with urgent mental health needs who are either detained under Section 136 MHA or who self-present to Roseberry Park Hospital (RPH/CAS). Significant numbers of potential A&E attendees are now diverted from the Acute Trusts as the North East Ambulance Service (NEAS) access CAS directly (232 patients during 2016/17).
The four locally-based Crisis Teams and the CAS provide a flexible approach to assessment and treatment to ensure the patient receives the best possible service in a timely manner to meet their needs with the most effective use of resources. The five teams work increasingly flexibly across Teesside to cross-cover and support each other to meet demand for assessments and also increase capacity in the localities for Intensive Home Treatment. A transformation in team relationships has simultaneously improved patient experience, reduced admissions (by 8.5%) and significantly decreased the amount of overtime paid (by 50%). Increased partnership working is taking place through the Crisis Care Concordat at a strategic level and at an operational level with Liaison Psychiatry, Acute Trusts, Street Triage, NEAS, voluntary sector organisations and the Police.
The service is continuing to develop its role within the urgent care arena eg with the planned incorporation of Street Triage from April 2017 and providing support/education to the new Acute Trust Urgent Care Centre in Teesside.
Quality Improvement.
Prior to the incorporation of the CAS within the Crisis service model, self-presenters and people who were brought informally by the Police would wait in the hospital reception, whilst those subject to Section 136 remained outside in the police vehicle until the unstaffed S136 suite was unlocked. Assessments would be undertaken by the Hospital Duty Manager or staff from the relevant local Crisis Team who would travel to Roseberry Park. The CAS now provides assessments on a 24/7 basis 365 days a year with a dedicated, skilled team based in a ‘least restrictive’ location.
The innovation of the CAS highlighted the importance of effective links across the Tees locality-based Crisis teams and the importance of implementing a ‘whole service’ improvement programme. Following the creation of a Tees Crisis Service Manager post, a greater variation in practice was identified than was previously evident with four separate locality structures. New standard processes have been developed to improve consistency.
The move from monthly to weekly performance management has significantly improved the service’s ability to consistently respond within four hours to all referrals and the teams achieving this KPI for the first time (reported to Commissioners at 99.20%). Complaints have reduced by 83% and levels of overtime by 50%. A ‘daily management’ conference call at midday involving the Crisis Leadership Team, the Shift Co-ordinators for the locality teams and medical staff, addresses any daily or complex patient issues and is further improving the service’s ability to meet demand through movement of staff across teams.
Leadership and Teamwork.
a) Effective leadership.
The Crisis Service Leadership Team is highly visible across the service. It sets the overall direction and ethos for the service, promoting a competent, compassionate and skilled workforce always looking for innovative ways to enhance the service offered. The Leadership team’s commitment to improving communications and flexible working has increased patient-focussed service delivery and the effective use of resources.
b) Good team-working.
The five teams (over 100 staff) demonstrate effective team-working through cross-covering to support each locality/CAS. In addition, the teams have provided out-of-hours support to the Adult In-patient wards covering sickness, breaks and seclusion reviews.
Relationships have transformed, particularly with the Urgent Care Services and stakeholders, including: GPs, 111, local authority and voluntary sector organisations. A recent quality improvement project has promoted collaborative working between Crisis and Community Mental Health teams to ease the transition for patients.
The ‘whole service’ development days in 2016, focused on a ‘coaching approach’ to improving team cultures and attitudes. This annual event is supplemented by a 6-monthly rolling programme of training days with service user participation, covering topics identified by the teams.
Effective use of resources.
The Tees GP list population aged 18-64 years (unweighted) is 360,253 compared with a PRAMHS weighted population of 471,263, reflecting the unmet need and health inequalities of the area. The implementation of the CAS and the parallel re-design of Tees Crisis service model is enabling more appropriate pathways and services for those people experiencing a mental ill health crisis and requiring assessment, home treatment, admission or referral/signposting to another agency/organisation. Overall, there is easier access to services for patients and for emergency services escorting patients. The service changes have resulted in 97.91% of patients being seen by Crisis prior to admission with a view to offering an alternative to admission.
The introduction of the CAS followed the award of £1m annual funding by NHS England/South Tees/HAST CCGs from 2015/16. The Trust is now investing resources to co-locate the CAS and Middlesbrough Crisis Team within the RPH site to offer a better environment for patients/carers and enable voluntary sector organisations to offer sessional support. The Crisis service is committed to making better use of resources to meet service needs, improve patient experience overall and increase staff satisfaction with their roles.
Evidence of improvement from the teams work:
1. Average wait time for S136 MH Assessment reduced from average 4 hours to 30 minutes.
2. Median Police wait time from over 4 hours to 20 minutes.
3. Total number of Complaints reduced by 83%.
4. CAS assessments increased by 3.9% from 2219 to 2306 in 1 year.
5. Inpatient admissions reduced by 8.5% in 1 year.
The five teams (over 100 staff) demonstrate effective team-working through cross-covering to support each locality/CAS which means patients referred to the service are seen in a much more timely manner. In addition, the teams have provided out-of-hours support to the Adult In-patient wards covering sickness, breaks and seclusion reviews.
Relationships have transformed, particularly with the Urgent Care Services and stakeholders, including: GPs, 111, local authority and voluntary sector organisations. A recent quality improvement project has promoted collaborative working between Crisis and Community Mental Health teams to ease the transition for patients.
The ‘whole service’ development days in 2016, focused on a ‘coaching approach’ to improving team cultures and attitudes. This annual event is supplemented by a 6-monthly rolling programme of training days with service user participation, covering topics identified by the teams.
We have had involvement from partner organisations both internally and externally to our trust throughout this service development by encouraging active involvement in the focus and steering groups. We have seen increased partnership working taking place through the Crisis Care Concordat at a strategic level and at an operational level with Liaison Psychiatry, Acute Trusts, Street Triage, NEAS, voluntary sector organisations, fire and the Police.
The service is continuing to develop its role within the urgent care arena eg with the planned incorporation of Street Triage from April 2017 and providing support/education to the new Acute Trust Urgent Care Centre in Teesside.
Engagement of patients and carers.
The service strives to have service user and carer involvement in all service and team developments in order to shape the ways in which the teams work. ‘Experts by Experience’ are involved in project steering groups, including the CAS, focus groups for repeat attenders, interview panels and on team training days. The ‘Triangle of Care’ has been adopted and the service has received positive feedback from the Positive Practice in Mental Health Collaborative.
This proposal for the new CAS responds to the experience of service users in addressing environmental issues and at the outset an expert by experience has shaped the development of the project.
Some of the issues experienced in the current Tees Crisis Assessment Suite include:
– It is remote from the inpatient areas and as such means that staff can be working in isolation, particularly at night when there are fewer staff on shift across all teams within the hospital site
– It comprises of 2 small rooms which limits capacity and makes the environment unwelcoming for services users
– Access for both pedestrians and vehicles is indiscrete and isolated
– There are no facilities currently to provide refreshments for service users, their carers or staff from partner agencies and services
– Should the service user require admission, the route to access the wards is indirect and requires access via public areas.
The proposed Mental Health Urgent Care Centre for CAS, Middlesbrough Crisis and the Tees wide Crisis night shift will:
– have increased assessment capacity within the Tees Crisis Assessment Suite allowing access to support before crisis point where people with mental health problems can get help 24 hours a day and when they ask for help, they are taken seriously
– enable joined up working between the services and partner agencies in a central location
– prevent future crises by making sure people are referred to appropriate services and offered follow-up appointments and/or home treatment as needed
– be a more secure environment with greater access to qualified staff response
– provide a far more pleasant care setting and workplace
– allow better accessibility to the public and emergency services from a prime location with clear signage
– deliver an internal separate route to the inpatient wards maintaining service users’ privacy
– and dignity in a therapeutic environment
– ensures Health and Safety regulations are met
Additionally to enhance the second stage, a robust transport plan will be developed which will require a suitable vehicle. This will enable the safe and secure conveyancing of service users from A&E Departments at Acute Hospital Sites across Teesside and transport of those service users detained under Mental Health Act to the Mental Health Urgent Care Centre
The new CAS/Urgent Care centre is due to Open Summer 2017.
We have four locally based Crisis Teams with one Manager and one Advanced Practitioner for North Tees and the same for South Tees, plus one Manager for CAS. One Service Manager reporting to a Locality Manager. We have weekly performance meetings and ‘Daily management’ through lunchtime Tees-wide conference call involving managers, Shift Co-ordinators, staff and Medical Staff to match capacity/demand and address any complex patient issues or communicate any important information with the teams. This ensures that the service is open, includes the whole team in developments and would be sustained should any one of the management team move.
Quality improvement through adopting a ‘whole service’ ethos (including Service Development Days focussed on ‘Coaching’ approach), adapting the Purposeful and Productive Community Services (PPCS) ‘toolkit’ and encouraging flexibility/cross-cover as the ‘norm’.
The Crisis Assessment Suite, Middlesbrough Crisis team, and Tees-wide Crisis night service are already fully funded and operational. Provision of these services will continue for as long as they are commissioned.
The service has been evaluation for a further funding bid for the additional developments by the crisis care concordat group and is monitored on a monthly basis to ensure it is delivered in a timely manner to the desired specification.
Evidence of improvement from the teams work:
1. Average wait time for S136 MH Assessment reduced from average 4 hours to 30 minutes.
2. Median Police wait time from over 4 hours to 20 minutes.
3. Total number of Complaints reduced by 83%.
4. CAS assessments increased by 3.9% from 2219 to 2306 in 1 year.
5. Inpatient admissions reduced by 8.5% in 1 year.
6. Staff feeling more confident to cross cover across the service, staff supporting each other more which has reduced levels of sickness.
7. Staff having up to date skills and knowledge since the development of 6 monthly rolling training days designed specifically to suit the needs of our staff and patients.
8 Levels of overtime reduced by 50%.
9. Significant numbers of potential A&E attendees are now diverted from the Acute Trusts as the North East Ambulance Service (NEAS) access CAS directly (232 patients during 2016/17).
10. The move from monthly to weekly performance management has significantly improved the service’s ability to consistently respond within four hours to all referrals and the teams achieving this KPI for the first time (reported to Commissioners at 99.20%).
The project and its developments are shared regularly with;
– Cleveland Police
– Cleveland Fire Brigade
– NHS Hartlepool and Stockton-on-Tees Clinical Commissioning Group
– NHS South Tees Clinical Commissioning Group
– Tees, Esk and Wear Valleys NHS Foundation Trust
– North Tees and Hartlepool NHS Foundation Trust
– South Tees Hospitals NHS Foundation Trust
– North East Ambulance Services (NEAS) NHS Foundation Trust
– NHS England Durham, Darlington and Tees Area Team
– Middlesbrough and Stockton Mind
– Hartlepool Borough Council
– Stockton-on-Tees Borough Council
– Middlesbrough Borough Council
– Redcar and Cleveland Borough Council
We are also due to hold a GP Crisis Conference for teaching, education, sharing of information and partner working scheduled to run on 30th May 2017, all Teesside GP’s and practice staff have been invited to this event.
Charts available on request;
Chart 1: Referrals into CAS: Chart shows that referrals into CAS have increased since its opening to an average (after 18 months) of around 200 referrals per month.
Chart 2: Self-referrals into CAS: Chart shows that the number of self-referrals into CAS are consistently increasing to around half of all referrals into the CAS.
Chart 3: Referrals from Police into CAS: Chart shows police usage of CAS.
Chart 4: Referrals into Crisis Teams: Shows reducing trend in referrals into Crisis teams, main referrers into Crisis are now GPs and community mental health teams. The reducing numbers of referrals has allowed for more capacity for intensive home treatment.
