Case study summary
In February 2015, Bradford District NHS Care Foundation Trust (BDCFT) commissioned a productivity analysis of its Adult Mental Health Acute Inpatient Wards and began a 19-week transformation programme to improve the flow of patients through the service, decrease the average length of stay and reduce out of area placements.
Awarded “Highly Commended” at the Positive Practice Awards 2016.
Wider active support for the project / service
Historically the wards had over 100% occupancy of acute beds and, as a result, averaged around six people placed out of area per day, costing £1.8 million a year. With productivity experts the teams worked to assess what was not working, what the barriers to care were, and how this affected the flow of patients through the wards. The productivity experts came into the wards to monitor daily work and procedures. This allowed the teams to analyse how efficiently they worked, to eliminate duplication and streamline processes.
The objective was to improve service delivery, manage the length of stay of patients, ensure they were being discharged in a timely manner and improve the flow of patients through the service; freeing up bed capacity for emergency admissions and avoid out of area placements.
The ward staff developed these processes, changing practice within handovers, ward rounds and staff meetings. One key development was a ‘10 point’ discharge tracker. At the first clinical review after admission all patients are set a target discharge date. Variance against this date was then monitored within nursing handovers and tasks allocated to prevent any delay. The 10 points required to enable discharge include mental state, accommodation, mental health act, and financial status of the person. Each of these is RAG rated to ensure they can be given priority, as appropriate.
The primary objective has been achieved through the ward staff owning and developing these systems and applying them on a consistent basis. Through this approach they are working more efficiently, with better discharge planning and reviewing. Only acutely unwell patients are being treated on the wards and the patients that are no longer in crisis are transferred to an environment more appropriate to their situation.
Involvement of service users, carers or staff
Throughout this project service users helped with the development of the discharge tracker tool. Staff feedback was central to development.
Challenges faced and how they have been overcome
A change in culture around the way consultant psychiatrists and nursing staff operate was the biggest challenge. Through talking to all the staff, they understood the reasons and value of the work underway, particularly after the first benefits became visible. Very early success enabled staff and service users to see the benefits of this new way of working.
The new systems and checks are monitored on a daily basis through daily discharge meetings and handovers. A weekly dashboard is in place that reports to executive team, covering admissions, discharges, and lengths of stay so early action can be taken if required. On a monthly basis it is considered during Quality and Safety meetings and reported to committees within the trust. The ward staff are now fully behind this and are working together with consultants to ensure patient experience is paramount. From the day of admission, service users are part of that process, working to their discharge date and clear communication around any potential barriers are addressed early to ensure delays are eliminated.
Evaluation two years on
The benefits and outcomes have been varied and many relate to behaviour, changes in culture across the wards around assessment and treatment, and renewed and refreshed staff perceptions. Information began to be collated in 2015 and the past 23 months have been the longest period with no out of area placements.
- All people requiring acute care have been treated locally.
- The lowest recorded bed occupancy (with leave) in the past five financial years.
- Introduction of discharge planning from the point of admission.
- Robust review process of patients on the wards.
- Staff working together, strong relationships and partnerships formed outside of the ward environment with primary care, local authority and housing providers, Intensive Home Treatment Team and Community Mental Health Team to enhance care and treatment and safe discharge.
- Clear vision and objectives that all staff are proud to work to around efficient care that is value for money and puts patients first.
Over the last two years we have developed alternatives to hospital.
The Haven service is a new 365 day a year service developed in partnership with The Cellar Trust. It opens 10am – 6pm and has a specific aim to prevent A&E admissions. The emphasis on peer support from people with lived expertise, as well as support from the Intensive Home Treatment Team, who base the duty team within the Cellar Trust to support people who may need additional support. The service aims to support people in distress and work with them to develop their plans to stay well and improve coping strategies to manage distress in the future.
The Sanctuary has been developed in collaboration with Mind in Bradford. This service is open 365 days a year from 7pm – 1am. The Sanctuary is open to people who may need additional support but not admission to hospital.
Safer Spaces is a service for children and young people, in collaboration with Creative Support. It is available seven days a week, 365 days a year, from 10pm to 10am and offers support for young people under 18 years of age, in crisis and struggling with emotional distress living in Bradford, Airedale, Wharfedale or Craven and is an alternative to hospital admission.
BDCFT has been working closely with West Yorkshire Police colleagues and have piloted a Police Employee Assistance Programme, recruiting six mental health nurses to be trained as Police Special Constables. They are working two days a month alongside West Yorkshire Police to improve the service delivery to people in crisis, to avoid use of the 136 suites and divert people to alternative support being offered within the city. The introduction of nurses within the police control room, receiving emergency calls has also been a success in managing people in crisis and signposting to the correct service.