Transforming services for forensic patients

As the NHS prepares to celebrate its 70th birthday, the New Care Models programme shows how NHS England is working with its partners to transform mental health services and provide equal status with physical health:

The New Care Models programme teams meet at a Knowledge Exchange conference today to discuss the impact of their work in delivering specialist mental health services.

The South London Mental Health and Community Partnership (SLP) will be among those at the event.

We needed to improve services, clinical outcomes and NHS system value for existing forensic mental health patients and new referrals from south London. Forensic patients have mental disorders which make them a potential risk to others, and who may have offended or be judged potentially likely to offend. Services were not provided consistently.

As reported recently in the national media, during 2017 many patients were placed in beds a long way from their communities and families. This doesn’t just detract from their rehabilitation and day-to-day patient experience, it makes consistent assessment and case management difficult. Ineffective pathways and long stays, often in expensive and highly restrictive inpatient units, do not support rehabilitation.

The NHS England New Care Models programme provided the opportunity and impetus. We could manage this budget – providing new, local services through our combined expertise and consistent best practice. Our goals are the right care, at the right time, in the right place. Delivering the best possible support and care, typically closer to their own communities, means better patient experience and outcomes. Savings realised can be reinvested in meeting growing demand and more innovative, community-based services.

In transforming services for forensic patients, we set specific objectives including:

  • introducing consistent care pathways and protocols,
  • repatriating 150 patients over five years,
  • reducing new forensic referrals placed out of area,
  • introducing a shared-bed management system to make best use of our capacity and ensure south London patients can better access south London beds,
  • investing in new services and enhanced facilities in the community to further increase step-down and rehabilitation rates, and reduce lengths of stay,
  • taking a system-wide view to ensure patients are supported to move into less restrictive settings,
  • establishing a small, central operational hub including a clinical team to review and assess out-of-area patients and manage new forensic referrals

It involved much preparation and planning, clinician and service user engagement and involvement, consultation, and often complex development work on new pathways, protocols and processes. We had to be robust and effective to implement new ways of working across three very different trusts, together serving a diverse population of more than three million people.

Equally important to effective systems was partnership working and creating the right culture for change. Key activities included:

  • New teams, clinically-led processes and protocols: a centralised hub including an out-of-area-assessment team which undertook more than 190 assessments of out-of-area patients. This ensured consistent assessments, reviews and ongoing case management. The hub also manages and co-ordinates referrals and bed management,
  • Five new forensic pathways: women’s, acute, assertive rehabilitation, community, and specialist. Consultation and co-design with patients and carers and families was vital as we aimed to rehabilitate and step-down patients whose previous experience was of ‘traditional’ inpatient settings,
  • Single point-of-access referral processes: a service redesign so initial assessment is undertaken by specialist clinicians working across the three trusts. Adherence to agreed criteria and thresholds means we always look for alternatives to admissions. All out-of-area placements are approved by the clinical director,
  • Commissioning: close working with NHS England, including an embedded team member, to ensure effective transfer of data and case information,
  • Clear and measurable performance indicators: evaluating what matters
  • Developing new quality indicators to drive improvement and consistency across all partnership inpatient and community services.

Our three trusts were previously often in competition – whether for funding, contracts or sometimes in new innovations. A collaborative approach to developing new joint pathways, processes and services meant shedding some previous practices. We share resources equally, and we share the challenge of improvements for all south London patients.

Highlights of the transformation of services for forensic patients include 26 per cent fewer out-of-area placements. New placements into the independent sector have fallen from 84 to 18. There has been a 26 per cent reduction in the total out-of-area bed days. System savings of £2.6million have been achieved. Sixty-six forensic patients have been repatriated, stepped-down and some discharged.

We constantly review progress and performance, from peer review of patients to analysing our repatriation and step-down numbers.

Further specific goals include reducing inappropriate out-of-area placements to zero by 2020. Those with highly specialist conditions will still need to be placed in highly specialised facilities which may not be local. We also want to reduce the average length of stay by 3 per cent annually. We will develop more community-based services, reinvesting savings we make. A female forensic step-down hostel is planned for later this year, and we are considering options such as a south London-based clinical decision unit.

Mari Harty

Dr Mari Harty, Clinical Director of the SLP Forensic Programme, is a Consultant Forensic Psychiatrist and Clinical Director – Forensic, Specialist and National services at South West London and St George’s.

She leads a team of psychiatrists and is responsible for end-to-end service delivery.

Mari has published on a range of forensic issues including the needs of patients in the High Secure Psychiatric Hospitals, community forensic services, prison mental health inreach and service provision for women.

Jeremy Walsh

Jeremy Walsh was appointed SLP Director in January 2018, having previously worked at South West London and St George’s Mental Health NHS Trust as Head of Service Delivery for forensic, specialist and national services, and CAMHS.

He is a qualified social worker and holds a Doctorate in Social Work, with a research specialism in the relationships between mental health professionals and carers, family and friends.

Jeremy has led a wide range of mental health and social care services within local authorities and the NHS.

As SLP Director he leads work across programmes including Forensic, CAMHS and Complex Care.