A focus on physical health helps keep people out of hospital in Bradford

  • Bradford District’s Transforming Care Partnership (TCP) is working to reduce hospital admissions by focussing on the physical health of people with a learning disability.
  • People with a learning disability can access specialist health clinics alongside other learning disability services.
  • When someone is prescribed anti-psychotic medication they receive a physical health review.
  • A physical health check is one of the first actions if someone’s behaviour starts to deteriorate.

Bradford’s learning disabilities services are reducing hospital admissions by placing an emphasis on looking after the physical health of people with a learning disability and/or autism. The team carry out physical health checks on each person to identify their physical health needs, and what triggers might cause their behaviour to deteriorate. This is a key part of Bradford’s intention to reduce their six inpatient beds for people with a learning disability, as part of their plan to deliver the national Transforming Care programme.

“When someone’s behaviour is deteriorating, we always check their physical health in the first instance,” says Vicky Donnelly, Strategic Health Facilitator for a large multidisciplinary health team based at Bradford District Care NHS Foundation Trust (BDCFT). “People’s behaviour might deteriorate if they are in pain, so by checking out things like toothache or reflux as part of an initial response, we can ensure physical health concerns are addressed and not part of the reason for the change in behaviour.”

Specialist health clinics

Vicky’s team, who work specifically with people with a learning disability who cannot access mainstream health services, have specialist health clinics for ophthalmology, audiology, podiatry, dental services and physical health reviews a few times a week.

“The Waddiloves clinics are specifically for people with a learning disability,” says Vicky. “The building is wheelchair accessible and the clinicians involved have got lots of experience of working with people with a learning disability and understand the reasonable adjustments they may need to make. For instance, it might take someone four or five visits before they even get in the dentist’s chair if they are really anxious and we have the time to do this, which mainstream health services may not.”

The team will accommodate people’s specific needs. “Some people have older family carers, so we have health support workers who help the carers and the person with a learning disability to get to their appointment. We do lots of desensitisation work, using lots of pictures and we will co-ordinate appointments so people can get multiple checks and see the dentist and ophthalmologist at the same time, for example.” The physical health reviews are also given to people who are less keen to go to their GP.

By having long-serving staff, the clinicians generally know people well and can identify changes in their cycles of behaviour and understand the underlying triggers.

Regular reviews

The nurses in the team are also care coordinators for the care programme approach (CPA) and the standard for reviews in BDCFT is every six months, which Vicky believes also helps to keep people out of hospital. “This means we can be more proactive and pick up changes in people’s presentation earlier, which then allows us to put changes in place sooner,” she says.

Vicky also puts Bradford’s success down to a higher than average take-up of annual health checks for people with learning disabilities. The average across the three CCG’s in the Bradford district was 65% in 2014/15. This is the result of a joint effort across primary care and the health support team, with many of the GPs proactively inviting people with easy read letters and the health support team helping people attend who may struggle to attend on their own.

Waddiloves has just started providing physical health reviews when people are newly prescribed anti-psychotic medication, so that clinicians have a baseline to monitor the person’s physical health from. This includes checking bloods, having an ECG and other routine screening and supports the NICE guidance for Challenging behaviour and learning disabilities.

The consultant psychiatrists are also reviewing people’s medication in line with the national Stopping Over-Medication of People with a Learning Disability (STOMP) campaign and so far this has had some positive results.

Positive behaviour support

The team’s nurses, psychologists and other health clinicians will work together to carry out behavioural assessments for people who are presenting with risky behaviours and they will work with the person and their support providers or family to develop a positive behaviour support (PBS) plan from this. The team have also given behavioural training to local support providers which means the local staff are better able to gather and report on information that is crucial to provide evidence for the behavioural assessments.

If a person’s behaviour continues to deteriorate, Vicky’s team will work closely with their counterparts in social care to discuss whether that person and their family need some extra support – such as strategies to help family carers to manage the situation, respite care or extra care staff.

During the week (Monday to Friday, 9-5), extra help is available from the intensive support team, which is specifically for people with a learning disability in crisis. Out of hours, support for people having a mental health crisis can be provided by Bradford’s First Response team, who are available 24 /7. They have a specific pathway in place to support patients with learning disabilities and have had extra training to help them feel more confident working in this area. Their input at weekends or evenings has proved really useful on a number of occasions.

The TCP are currently looking at how they can change the way the community team works across the week – to further support the reduction in inpatient beds. They are also discussing how more support can be provided in the community such as extra respite care and step-up, step-down beds for people who do not need to be in hospital, but need additional short-term support such as rehab.

Vicky says it’s really important that families are involved in the assessment process and the team will provide extra support where needed including using interpreters – particularly for Bradford’s large BME population. They also work really closely with advocacy services and have good input from the speech and language therapists within the team to ensure that people are involved in their plans and care as much as possible.

Although it’s early days yet, the number of beds being used in the hospital has reduced in the last year, and the six beds in place are only occasionally all full. Vicky hopes that with much more of a holistic approach to care, a focus on reducing hospital admissions and care and treatment reviews both in the community and in hospital this downward trend will continue and build better support in the community.

This relies on close working and involvement from the person and their family, health and social care clinicians, advocacy and skilled community providers. “I think transforming care has focused people’s minds on how we can do things better,” says Vicky. “It’s definitely made us try and avoid hospital admissions as much as possible and keep people well at home in the community.”

Respite care and support at home stops Sarah going into hospital again

Bradford TCP used Sarah’s CTR to plan for respite care and extra family support, which stopped her going into hospital when her behaviour escalated.

 

Sarah (not her real name) had been into hospital on three separate occasions because each time she went into crisis, her family saw hospital as somewhere safe for her to go. By using her care and treatment review during her last admission, her care team changed her care package and planned that the next time Sarah’s behaviour escalated she could go into respite care and she and her family would also receive more support at home.

The next time Sarah started exhibiting very similar behaviours, the team had all the strategies in place to support her at home rather than in hospital. Knowing she was prone to physical health issues including urinary tract infections and constipation, the support team were able to manage them closely and give her pain relief. They provided overnight respite care in the family home so that Sarah’s family carers could sleep while she experienced sleeplessness through the night. With this and some extra nights at respite care, the family were able to support her to stay at home rather than have another hospital admission. This helped meet the Transforming Care aim that people with a learning disability and/or autism should be supported to live in the community.

The team are now investigating whether they can use a personal health budget for her when she needs additional support in the future, which would give Sarah and her family the flexibility to receive extra support when it’s needed.

Engagement with people and their families leads to visitor rooms and more activities in the assessment and treatment unit.

  • Bradford TCP engages people with lived experience, families and carers through the Transforming Care Reference Group.
  • To get extra input from people with experience of the Assessment and Treatment Unit (ATU), they wrote to all the people and their families who had been through the unit in the last two years and met with those who were interested.
  • Family feedback means they now provide visitors’ rooms with activities for families in the ATU and offer carers a carer’s assessment.

Bradford Transforming Care Partnership (TCP) sees engaging with service users and families as a high priority and have set up a Transforming Care Reference Group to support this. It has good input from local self-advocacy groups but needs more input from people who actually have lived experiences of the services in question. New members are always welcome. “We’re trying engage people with a learning disability in all aspects of transforming care,” says Strategic Health Facilitator Vicky Donnelly.

Vicky has been trying to get the perspective of people with complex needs who have spent time in ATUs. “When we first started the transforming care work I wrote to everybody that had been in the ATU in the last two years and their families and asked if they wanted to be involved,” she says. “Some families didn’t want to be involved in big groups, but were happy to be seen on an individual basis. I went and visited all the families who responded and we talked about how services could be improved.”

She continues: “The families we spoke to told us they did still want some learning disability beds because they didn’t want to be admitted to a mental health bed or sent out of area if they did need inpatient care.

“They also told us they wanted us to make the ward environment better, and to provide more activities for people to do, particularly when families are visiting. The ward has taken this on board and changed the use of rooms around to provide two visitors’ rooms with music, games, books and other activities. They are also planning to purchase a drinks machine so visitors and patients can have a bit more freedom during their visit.

“We are also offering carers a carer’s assessment as some of them said they would appreciate the opportunity to talk to a counsellor about their recent experiences.”