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The vital role of social care in reducing detentions and out-of-area-placements in mental health services
Mark Trewin, Bradford Council’s mental health service manager, and social care advisor for NHS England’s adult mental health team, discusses how effective partnerships with social care are essential to the delivery of the Five Year Forward View.
One of the objectives within the implementation plan of the Five Year Forward View for Mental Health is the need to reduce the number of out-of-area placements. Local authorities are an important part of this process, supporting the discharge and aftercare of service users through the Care Act and aftercare arrangements.
For two years, the mental health services in Bradford district have been treating people who need acute inpatient care locally, reducing the use of out-of-area-placements and private sector hospitals to zero. Delayed transfers of care numbers are low. This was achieved by a redesign of the acute care pathway by the mental health trust and undertaken in a partnership with the local authority, police and voluntary and community sector, delivered through the Crisis Care Concordat.
Out-of-area-placements are stressful to service users, their families and professionals. Each clinical commissioning group (CCG) has a responsibility under s140 of the Mental Health Act to ensure inpatient facilities are available for urgent admissions. A lack of beds and a lack of alternatives to hospital can mean that placements may be sought many miles away. The impact for the detained person and their family can be traumatic.
People are detained under the Mental Health Act following a decision by a local authority-authorised Approved Mental Health Professional (AMHP), supported by two doctors. For AMHPs, a lack of beds is very challenging. They cannot detain until they can name the admitting hospital and may be unable to convey the detained person until a bed is found. They often find themselves waiting for hours with a distressed person while the placement and transport is resolved.
Local authorities often need to undertake another assessment within a month; if the client is 200 miles away that can be a major logistical problem.
One answer is to ensure each area has enough specialist mental health units to support its population and urgent need. Whilst important, increased bed capacity is not always the best use of resources – especially where a least restrictive, preventive and strengths-based approach to supporting service users could be more effective.
An option is to reduce bed occupancy. This requires fewer detentions under the Mental Health Act, reduced length of stay, resolving the reasons people remain in hospital longer than necessary and improved discharge planning. My experience is these solutions are best met within a partnership with the local authority. Mental health social workers, local authority commissioning and housing are key to some of these issues.
The reasons some people stay in acute wards longer than is necessary vary, but can include: service users being refused access to housing due to complexity of need or their capacity to live independently, and access to NHS and local authority-funded services.
Local authorities have a vital and statutory role that is of equal importance, and complementary to, the role of the NHS. Local authority social workers are committed to prevention, supporting independence, and respecting the human rights of vulnerable people. Many of the services local authorities have to provide for people can be integrated or jointly commissioned and delivered alongside similar NHS services.
In Bradford social care is integrated with the mental health trust across acute and community mental health services, to prevent admission, or to discharge when appropriate. The following are just a few examples of many integrated solutions in which our mental health social workers are involved:
- The 24/7 first response crisis service – social workers support assessments of people in crisis.
- AMHP service co-located with First Response Service and Intensive Home Treatment to ensure the least restrictive option is followed. Close joint working with the bed manager.
- The Haven & Sanctuary – non-clinical community alternatives to A&E and community crisis.
- The Intensive Home Treatment Team
- The Police Hub – NHS and social care staff advising police to support vulnerable people.
- Shared Lives – respite and support to avoid admission to hospital.
- Specialist housing social worker who supports ward staff, housing and service users by working to resolve housing issues soon after admission.
- Supported Accommodation and Residential Frameworks – includes step-down accommodation and housing for people with high needs and developing care homes that can support community rehabilitation to independence.
- An integrated NHS and local authority approach to funding decisions.
- Regular joint reviews of discharge arrangements for inpatients.
Bradford has found that partnership working across the NHS, local authority, voluntary and community sector, police and housing has transformed the way we care for vulnerable people and that the local authority should be at the heart of mental health services.
Read more about how Bradford District Care NHS Foundation Trust redesigned its acute service and developed First Response.
All well referring to s140 MHA 1983 and yes CCG’s have a responsibility to inform Local Authority AMHP where the beds are for urgent admissions in one’s local area,Yet thousands of patients are sent out of area but when there are no beds locally then OOT &OOA will occur.
As a nearest relative I refused a couple of years ago admission to Yorkshire from the south west for my son, quoting s140 to the AMHP and requested that s5(4)MHA 1983 nurse holding power be used until the AMHP & Mental Health trust bed manager sorted out a bed locally, two hours later a bed was made available locally, the AMHP agreed to not sign and name the ward in Yorkshire on the paperwork to affect the s2.
More awareness of s140 required by patients,service users, carers and in particular nearest relatives required.
CONGRATULATIONS to all concerned with this groundbreaking project.
Given the very serious social and financial difficulties being faced by so many post-industrial towns and cities in the Leeds to Liverpool Textile Mill belt, Bradford is indeed living up to its reputation for seeking, finding and implementing people-centred solutions to so many challenges.