The Deputy Nursing Director, together with Senior Nurse Managers at Bradford District Care NHS Foundation Trust led on the development of collaborative multi-agency partnership approaches to ‘out of hours’ mental health crisis services to improve outcomes, experience and use of resources.
Where to look
Bradford District Care NHS Foundation Trust provides mental health, community and learning disability services, caring for both physical and mental health needs.
Mental health needs are widespread, at times disabling, yet often hidden (NHS England 2016). In a review by the Care Quality Commission of crisis care, it was reported that only 14% of adults felt they were provided with the right response when in crisis. Indeed, only approximately half of community teams were reportedly able to offer adequate 24/7 crisis services, which can lead to possible delays in treatment and care (CQC 2015). Crisis examples include mood changes, withdrawal from people, self-neglect, having increased thoughts about life not being worth living, hearing voices or seeing things others can’t and thinking of harming oneself or others.
At Bradford District Care NHS Foundation Trust, the Deputy Nursing Director identified this unwarranted variation in the provision of 24/7 mental health crisis services across the Trust. The ‘out of hours’ mental health crisis service provision was limited which was resulting in people accessing accident and emergency departments, rather than being able to access community-based crisis services. This was particularly apparent when comparing the available services for service users in crisis during ‘in hours’ mental health service provision.
What to change
The Deputy Nursing Director and the senior nursing team identified that this was leading to increased pressures on the emergency department and the inpatient mental health wards which was resulting in poorer service user experience. This unwarranted variation within services provided by time of day and day of the week meant there was an opportunity to re-design the mental health services at the Trust, notably to streamline the care pathway and support people who are experiencing a mental health crisis to have a single point of access. This would be an optimal, standardised approach to supporting people to get the help they need, closer to home and in a timely way.
How to change
A partnership group, the ‘Crisis Care Concordat’ was developed with key partners including the Police, Local Authority, Occupational Health services, volunteer and third sector mental health support services, the Clinical Commissioning Group (CCG) and leads from local acute hospital accident and emergency care departments. The partnership group shared a vision to enhance the mental health services locally and subsequently developed clinical pathways to be available ‘out of hours’ for mental health service users.
The re-design encompassed all mental health services, to ensure a coordinated joined-up approach across health and care was achieved. The approach focused on providing First Response Services 24/7, closer to home. This was targeting providing support earlier to prevent crisis and support people to stay out of hospital, where appropriate.
The Crisis Care Concordat looked at other crisis models across the country and agreed funding streams with the local Commissioners to fund a pilot for a First Response Service, providing a 24/7 crisis assessment service. The nursing managers led on the re-design of the Acute Care Pathway and brought the acute mental health services across providers together under one structure.
The newly re-designed services offer 24/7 support, advice and assessment to people of all ages living in Bradford, Airedale, Wharfedale or Craven, who are experiencing a mental health crisis.
Further service updates included a single-point referral line for members of the Crisis Care Concordat to dial in to, as well as developing training programmes to support partner organisations to have full understanding and confidence in navigating the redesigned services and how to utilise them.
Better outcomes – Initial assessment of the new service pathways has identified a reduction in admission rates to mental health wards. This is attributed to appropriate support and management of people in community settings. Since March 2015, no-one in Bradford, Airedale, Wharfedale and Craven has travelled out of area for urgent mental health care. There has also been a 60% reduction in people needing to attend the emergency department, suggesting support is available in the community setting as desired. Approximately 50% fewer people have been placed under the care of the Mental Health Act since the introduction of the new clinical pathways, which may suggest people are getting the right care earlier, to meet their needs.
Better experience – Service user feedback on the new service pathways available to them has been very positive. They have appreciated that the services have been developed in partnership with service users, their families, carers and others. Anecdotally, the way the partnership group have improved access to crisis care, in the right place, at the right time, has reduced the need for escalation to mental health sectioning which positively impacts the experience and outcomes for service users.
Better use of resources – The reduction in the use of out of area mental health care has saved more than £1.8 million in the programme’s first year. People are now getting timely care, closer to home.
Challenges and lessons learnt for implementation
It is important to establish baseline data before you implement a change. This allows you to evidence the effectiveness of the services you go onto deliver.
An agreed, shared vision with partners is crucial before you begin, in order to routinely monitor progress towards the agreed goals.
Engagement, investment and empowerment of partners is key for integrated, holistic services within a community.
Allow time for reflection and review as you progress. This will enable all partners to evaluate and adjust as needed.
Find out more
For more information contact:
- Christopher Dixon, Clinical Lead of Acute Community Mental Health Services, Bradford District Care NHS Foundation Trust, Christopher.Dixon@bdct.nhs.uk