Leading change

The nurses at Pennine Care NHS Foundation Trust led on the introduction of a new Stockport Team for Early Management (STEM) service for people within the borough of Stockport. This service has led to better outcomes for people using the service, better experiences and better use of resources.

Where to look

The Royal College of Emergency Medicine (2018) identified that high quality, timely treatment of patients with mental health problems, when they present to accident and emergency (A&E) departments in crisis, can be difficult to deliver. The number of patients in mental health crisis in A&E departments continues to rise by around 10% per year. A survey by the Royal College of Emergency Medicine in 2016 showed that 31% of respondents felt that crisis care overall had improved whilst 26% felt it had got worse which indicates an opportunity to improve mental health care provision in A&E departments and this is particularly apparent during traditional out of hours care.

Pennine Care NHS Foundation Trust provides mental health and community services employing approximately 5,500 staff and providing care to 1.3 million people across six boroughs of Greater Manchester. The nurse leaders at the Trust conducted analyses on patient data and identified unwarranted variation with higher than expected levels of short stay admissions for ‘adults of working age’ (18-65 years) coming through the accident and emergency department. Of these short stay admissions identified within a 6-month analysis period, approximately 78% of these patients were admitted out of hours. This evidence was supported by feedback from clinicians including front line practitioners, medics and ward managers.

What to change

The baseline audit conducted by the nurses provided a comprehensive evidence base of Trust admissions for mental health patients over a 6-month period, specifically focusing on admissions by time of day and day of the week as well as length of stay (0-5 days). This audit was utilised by the nurse leaders to understand the practice across the Trust.

The data demonstrated that a significant proportion (65%) of inpatient admissions occurred between the hours of 21:00 and 09:00, with 78% of admissions also occurring between Thursday and Monday.

Based on this evidence, the nurse leaders at the Trust worked in collaboration with local Clinical Commissioners to trial an out of hospital transformation scheme called ‘Short Stay Admission Improvement Programmes’. These programmes set out to reduce unwarranted variation in the admission pathway, streamlining the care process for all individuals requiring care, regardless of the day or time of admission. The change also targeted providing care closer to home, where appropriate. The nurse leaders ensured they engaged with service users, their families and carers to develop the service.

How to change

A nurse led STEM (Stockport Team for Early Management) Service was established. The nurses were provided with enhanced Psychological Therapy training to enable the nurses to provide brief solution focused intervention to the patients when they presented at accident and emergency. This initiative was underpinned by comprehensive risk assessment and contingency planning.

Patients are offered support, with their families/carers if appropriate, to develop personalised safety plans to reduce their risk at home and are facilitated to access a range of community based mental health and emotional wellbeing services as needed. When ready, patients are then discharged to their own homes.

The service operates over 5 nights a week between 21:00hrs and 09:00hrs to include weekends. The service is based within the adult mental health inpatient service on an acute hospital site. The main objective for the nurse led STEM team is to offer further assessment and therapeutic care throughout the night to targeted individuals presenting to accident and emergency in crisis. The team strive to support individuals to return home with a safety plan in place before 09.00hrs, if appropriate.

Adding value

Better outcomes

• The STEM service, to date has seen more than 300 patients, the majority of whom have not required an inpatient admission as they have been able to access timely services suited to meet their needs;
• The offer of enhanced mental health crisis support at nights as an alternative to admission has reduced the number of service users needing to attend accident and emergency and be admitted for short stays;
• Within a 6-month period there has been a reduction in the number of out of hour admissions;
• Local accident and emergency services have also reported a positive secondary outcome whereby there has been a reduction in patients attending for initial assessments due to STEM offering this service;
• This has positively impacted on the overall waiting time in accident and emergency for those patients who require urgent care and admission to hospital.

Better experience

• Service users have reported high levels of satisfaction with the service which is positive;
• A full feedback questionnaire has been circulated to Service Users, families and other areas of work and has overwhelming shown positive feedback of the service.

Better use of resources

• The new service has resulted in a reduction in the number of admissions for short stays (under 5 days) supporting patients to be seen in the right place, at the right time;
• Anecdotal staff feedback within urgent and emergency care services locally have reported improved confidence in the services offered to service users;
• The additional training for nurses within the service has resulted in enhanced therapeutic knowledge and skills which is positive.

Challenges and lessons learnt for implementation

• Data and collaboration is key to successful implementation;
• Engaging with service users, their families and carers when developing the service is crucial;
• Due to the success of the service, the Trust is looking at rolling it out to seven days a week.

For more information contact

Matthew Pattison, Inpatient Manager,
Pennine Care NHS Trust
Matthew.pattison@nhs.net