6 th December 2019 Chaired by Claire Murdoch, National Director for - PowerPoint PPT Presentation

Addressing Out of Area Placements: National Webinar Mental Health Team, NHS England and NHS Improvement 6 th December 2019 Chaired by Claire Murdoch, National Director for Mental Health NHS England and NHS Improvement

Agenda Aims of the session Claire Murdoch, National Director for 10:30 Mental Health Reflections on the work to Dr Mike Hunter, National Specialty 10:35 date to reduce OAPs Advisor for Adult Mental Health • Examples of local progress South London and Maudsley NHS Foundation Trust • Nottinghamshire Health Care 10:40 Foundation Trust • Norfolk and Suffolk Foundation Trust All – please submit questions via the Q&A for local areas 11:10 chat box Overview of enhanced Bobby Pratap 11:20 assurance and support All – please submit questions via the Final questions and wrap up 11:25 chat box Close 11:30 2

Aims of the session 1. An opportunity to focus collectively on the complex challenge that out of area placements (OAPs) presents as we move into a critical phase of delivery against our ambition to end the practice by April 2021. 2. Hear from some local areas that have made significant progress in tackling this challenge in recent months. 3. Share information on our enhanced approach to assurance and new offer of support going forward, which both aim to ensure we are making the most of the Long Term Plan funding for Mental Health and maximising our focus and efforts on reducing OAPs. #

The current position: Headlines • The national view hides significant variation - for the last year, a small minority of the most challenged areas have been responsible for the majority of the OAPs activity. • However, Q1 this year saw a small but notable increase resulting from: • a worsening position in a small number of trusts • paired with a lack of consistent improvement across the majority of trusts . • We know there is a huge amount of positive work going on locally, which we need to support and share to reduce the negative impact of being sent out of area for care currently experienced by thousands of people each year. Inapproriate Out Area Placement Bed days data comparison for Sep 17 - August 19 (rolling quarter) 80000 70000 • The analysis shows the 60000 OAPs activity trend (by rolling quarter) up to August 50000 2019/20. • The blue line is the rolling 40000 national total • 30000 The orange line removes the most challenged 5 providers in 2019 to date, 20000 and the grey line removes 10000 the most challenged 10. 0 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 4 All Providers Excluding Highest 5 Excluding Highest 10

Reflections to date • The dialogue has dramatically changed in 2 yrs: shift away from focusing on solely on bed numbers and it is now widely recognised that OAPs are an indicator of whole a system under pressure and require system-wide solutions. • Variance is not explained by some areas having fewer local acute beds than others . If admission becomes the default due to lack of community services then even very large local bed bases will not suffice to meet demand. • There has been widespread agreement with key principles of bed flow and that specific focus is needed on the three main phases (admission, care received and discharge). • In particular, there is now lots of work going on looking at the broader pathway, crisis and This graph shows that OAPs (the orange community services to sustainably manage bars) occur across providers with highly capacity and demand across the system. variable bed bases (blue bars). • Senior leadership and a clear shared local vision focused on the quality of care are critical for delivering change. 3

SLaM Right Care Programme NHSE/I Update Wednesday 4 th December 2019 6 / www.slam.nhs.uk

Right Care – Context ➢ High mental health need and high levels of deprivation in the areas served by SLAM ➢ Acute bed capacity below London average and bed base in bottom third nationally (16.5 beds per 100,000 weighted population against 19.5 beds national average) ➢ Stretched community services ➢ Mental health expenditure per weighted population is in the bottom 20% nationally 7 / www.slam.nhs.uk

OAP Reduction Trajectory – actual v target 8 / www.slam.nhs.uk

Right Care – Challenges to address ➢ Use of acute out of area placements ➢ Delays accessing inpatient care once decision to admit made ➢ Average hospital length of stay above national average ➢ Lack of alternatives to admission ➢ Home Treatment Teams not fully deployed ➢ Timely access to appropriate placements or ongoing care, particularly for complex patients ➢ Repeating crisis presentations from the same service users ➢ Variability of practice across inpatient wards ➢ Effectiveness of community care 9 / www.slam.nhs.uk

Right Care – Areas of Focus ➢ Ambitious Trust aim - Right Care, in the Right Place at the Right Time ➢ Overall refresh and development of plans: ❖ Appointment of Right Care Director and local flow teams ❖ Focus on cohort of medically fit for discharge patients ❖ Enhancing crisis provision – ARC, CAT, HTT, RR provision ❖ Review of alternatives to admission e.g. crisis café ❖ Review of frequent attenders e.g. Crisis Plus in Lewisham ❖ Early liaison input in ED at the front door ❖ Purposeful implementation of QI initiatives such as Red2Green ❖ Standardisation of care - inpatient and community care process models ❖ Development of Step Forward Housing offer ❖ Community service transformation ➢ Review of balancing measures (ED/s136/MHAA delays) ➢ Using robust data effectively to build a shared Trust narrative and target areas where improvement is required ➢ Use of a Daily Dashboard and quality SPC Charts all linked to the Trust Performance and Quality process to drive ‘Floor to Board’ buy in and cultural change 10 / www.slam.nhs.uk

Nottinghamshire Healthcare Trust Crisis Pathway Development and Inpatient Continuity of Care Principles 11

Challenges • Closure of 42 acute beds in 2014 and 5 female PICU beds in 2017 • Reduction in local community rehabilitation beds in 2012-2015 • Distribution of Trust bed stock not aligned to demand • Wicked problem – system paralysis – wider system cuts • Our services unable to meet demand – no 24/7 provisions • Lack of robust admission protocols and longer than average Length of stay • Personality disorder pathways not able to manage growing demand and more complex presentations • Patients with Learning Disabilities, substance misuse issues accessing services with limited support available • Transitions across children's to adult services not managed in a coordinated way 12

What we did Subcontract arrangements – focused on the area with Work together to tackle the wicked problem the biggest demand • Better use of improvement methodology – used the data • 2017 -2019 – first subcontract arrangements agreed 5 to identify the issue beds increased to 40 in May 2019- in areas of highest • Joint CCG and provider recovery action plans developed demand. • Training programmes developed for staff to improve risk • 2018 Continuity of care principles agreed with management and increase home treatment options commissioners and NHSE • Multi agency OOAP taskforce Chaired by medical Director Increase funding /resources Management changes • Crisis House • Admission processes reviewed • Step down unit • Weekly performance Huddles • Investment into Crisis to Core fidelity levels • Flexibility with bed stock • Street triage expansion • Bed management team 13

Our Performance Journey • 2017 – average of 56 inappropriate OOAP per day • 2018 – average of 52 inappropriate OOAP per day • 2019 – So far average of 25 OOAP per day • Sept 2019 daily average 13 per day • Oct 2019 daily average less 10 per day (mainly PICU) • Nov 2019 daily average 5 per day all PICU – no inappropriate acute out of area admissions • Police Opel report significantly improved – Opel 1 63% of the time in Q3 so far compared to 31% of the time in Q2 • Reduction in s136 – 41% reduction during Sept/ Oct/ Nov compared to same time period 2018 • Reduction in MHA • Reducing subcontract beds. 14

Ongoing Challenges • Sustaining the impact – cultural ways of working -reducing the reliance in inpatient care • Embedding the new ways of working • Continued demand around personality disorder and complex presentations • Patient expectations • Reductions in wider support systems eg, third sector social care • Recruitment challenges – medical and qualified staff are a particular issue • Specialist services available to support patients with substance misuse issues and Learning disabilities etc. • Management of transitions • Local PICU availability 15