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www.england.nhs.uk
London Mental Health
Delayed Transfers of
Care Workshop
19 May 2017
9:30 - 16:30
Coin Street neighbourhood centre,
108 Stamford Street,
South Bank,
London SE1 9NH
www.england.nhs.uk
# Item Lead Time
1 Welcome and introductions Andy Graham BEHMT (Chair) 09:30
2 Opening words Simon Pearce ADASS & Greenwich LA
Eileen Sutton NHSE & HLP
09:35
3 Making all inpatient days meaningful Emma Bagshaw , NHSI
Emergency Care Improvement Programme
09:55
4 Questions and discussion Andy Graham 10:30
5 What long hospital stays feel like Sara Litchfield Brown
Enfield Mental Health User Group
10:50
6 Questions and discussion Andy Graham 11:00
Break 11:10
7 What are colleagues doing to reduce delays?
• Tim Miller, Haringey CCG and Henk Vermeulen at BEHMT
• Bailey Mitchell ELFT
• Brent Withers: Lambeth
11:30
Lunch 12:45
8 Legal case studies Peggy Etiebet &
Cornerstone Barristers 13:30
9 National Policy Update Bobby Pratap, NHSE 14:30
Break 15:00
10 Table discussions What can we take away and do? 15:20
11 Plenary: Andy Graham 15:45
12 Close 16:00
Agenda
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1. Welcome and introductions
Please jot down any comments, ideas, and thoughts that spring to mind throughout the day.
No More Time “On Hold”
Reducing delays in Mental Health Trust
discharges
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2. Opening words
London Out of Hospital
Care Closer to Home Programme
6
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3. Making all inpatient days meaningful
#Red2Green Days Moving forward in Mental Health
Focus on the important not just the urgent – waiting isn’t passive
#last1000days #Red2Green #endPJparalysis 8
@ECISTNetwork
Aims • Encourage the implementation of the
Red2Green day approach across bedded and non-bedded areas
• Create a social movement with a compelling story that is clinically led and isn’t performance managed.
• Reduce the number of occupied beds and the number of stranded patients (patients with a length of stay 7 days or greater / need to determine appropriateness for mental health).
#last1000days #Red2Green #endPJparalysis
Red2Green Campaign Journey Approach
9
Red2Green
• Based on the theory of constraints
• Developed in acute physical settings- the compelling story
• Looking at transferability into mental health settings
• Keeping it simple – A to do list, todays work completed today
• MDT board round that is action focussed, flushes out internal and external constraints (top 3 and quick wins)
• Liberates the MDT
Health warning – do not try and performance management the number of red days! Encourage areas to declare them.
“Patients time is the greatest currency in health and social care”
#Red2Green #last1000days #endPJparalysis
@ECISTNetwork
Connect emotionally as well as logically ‘Need to develop the compelling story for Mental Health’
12
#Red2Green Mrs Andrews - https://www.youtube.com/watch?v=Fj_9HG_TWEM
Stanley’s Story – http://fabnhsstuff.net/2017/03/08/time-to-change
Patients time as the greatest currency
“Beds are where patients wait for the next thing to
happen”
Mind set should
be: You only get care from a bed if that is the only way we can deliver your care #last1000days
13 #Red2Green
Red2Green A red day is when a patient receives little or no added value by being in a bed
1. Could the care or intervention be delivered in a non acute setting?
2. If I saw the patient in outpatients would they require an admission
If 1 = yes 2 =No Red day
A green day. A day of added value
Added value care that progresses discharge
Everything planned or requested gets done
A green day is a day when the patient receives care that can only be delivered in a hospital bed
26/05/2017 14
Red2Green Days – Localise the approach • Start each day with all patients marked red
• Stay red if senior decision makers not present
• Stay red if there is not an EDD and CCD (clinical criteria for discharge)
• For discharge tomorrow – TTOs completed?
• Decide what will turn today green for each patient
• Ensure there are internal professional standards in place
• Allocate responsibility for actions
• Identify constraints and resolve within the team if possible
• Escalate constraints that cannot be resolved.
15
Red2Green Days – Mental Health Constraints • Development of a Rapid Improvement Guide
• Make sure discharge focus from day 1 – ABC!
• System Constraints being identified – Waiting for a tribunal
– Patient not willing to cooperate
– Awaiting funding panel
– Awaiting medical decision
– Home visit
– Nursing home decision
16
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4. Questions and discussion
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5. What long hospital stays feel like
Patients experience of long term stays on the wards.
It’s mainly cold and very boring!
Who we are. EMU is a mental health service user led group.
The Trustee Board are all people with lived experience of mental health issues. The majority of our staff have personal lived experience and all have an interest or background in mental health support and provision. We are all pretty passionate about what we do. Most of our volunteers are in recovery or have had lived experience. We do offer placements for volunteering to health care and social care Students, College and School students. We believe that to address stigma and make positive changes you have to start at the beginning and work in partnership.
How we gather feedback We believe that people are more open and honest if they feel they are
in a safe space and are talking to people who are non-judgemental and who have a personal understanding of the experiences they are sharing. We use Peer Mentors to: • Provide mentors on the wards. • Run activities that engage people and gain their confidence. • Mentor people in Recovery and encourage them to build confidence
and support networks. • Talk about their stories and view these in a positive way in their
Recovery and develop WRAPs to support future relapse. • Use their stories and experiences to give feedback to help improve
current services and develop future services that are meaningful and have impact.
Peer Support. • Our Peer Support uses trained volunteers who have personal lived experience of
mental health issues to facilitate groups, act as mentors, provide role models and encourage self-sufficiency and recovery.
• Our training is accredited by Middlesex University. • Training is seen as part of recovery and well-being and most volunteers started by
being encouraged by their Peer Support contact. • Peer Support programs are nationally recognised as http://www.mentalhealth.org.uk/help-information/mental-health-a-z/P/peer-support/
http://eprints.lse.ac.uk/60793/1/Trachtenberg_etal_Report-Peer-support-in-mental-health-care-is-it-good-value-for-money_2013.pdf • And also by Peer review – the Mental Elf!
http://www.thementalelf.net/mental-health-conditions/schizophrenia/peer-led-self-management-for-mental-health-impressive-programme-not-so-sure-about-the-research/
Who did we speak to.
• People who are currently on the wards.
• People who have been recently discharged.
• People who are in Recovery but attending our services.
• Volunteers.
• People who work for us.
• Carers, friends and relatives.
The main messages
• It’s very frightening on admittance. There is a lack of information and you don’t know anyone – you need a buddy or someone that will show you round. I was scared of the other patients.
• It’s really boring. When I’m bored I get more anxious.
• They take away your choice and this makes you very dependant. When I came out I couldn’t even decide what to have for dinner. I lost all confidence
• I didn’t have any clothes. I felt like a tramp.
Main messages • I got really isolated. My friends and family
were scared to visit me and I really felt alone.
• I lost the tenancy on my flat and my benefits stopped. When I was being discharged this caused a massive problem.
• If I’m really honest I didn’t want to leave. I’d lost all confidence and I felt safe there. I didn’t know what to do if I left.
• I needed people to talk to who weren’t ill or staff – just a normal conversation
What could be better? • Better communication with families, carers
and friends.
• Perhaps easier ways to visit. Its sometimes quite scary on the wards and parking and things are very expensive.
• More people to talk to.
• Knowing what will happen on discharge. Knowing what there will be to support me and maybe having a community link. More advice.
Good things. • I don’t want to go back but I do know I would be dead if I
hadn't been on the wards. I wish there was a better way though.
• I made friends – that seems quite strange now but I really did.
• The mentors gave me hope. Now I am a mentor.
• There are very good staff too.
• I was scared my son would kill himself. He was awful and we couldn’t cope but it did feel like he was safe when he was sectioned. It was just over time that he seemed to become so dependant and defeated and this has stayed with him. His volunteering is really a life line.
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6. Questions and discussion
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Break
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7. What are colleagues doing to reduce
delays
Haringey and Work to Reduce
Inpatient Delays
• Henk Vermeulen, Assistant Director, Barnet, Enfield and
Haringey Mental Health Trust
• Tim Miller, Joint Enablement Lead, Haringey Council
and NHS Haringey CCG
Haringey Context
41
Relatively low number of adult acute beds:
Haringey Context
42
Year on increase of referrals into Haringey Secondary
MH services of 15%:
Haringey Context
43
Relatively low rate of admissions:
Haringey Context
44
Highest bed occupancy
Haringey Context
45
Highest proportion of homeless people admitted to
hospital in London
Haringey Context
46
Highest proportion of patients detained under the
Mental Health Act in London
Haringey Context
47
Lowest number of emergency readmissions
Haringey Context
48
Relatively high number of DTOCs
Haringey Challenges
49
External challenges
•High number of homeless clients
•Availability of appropriate Housing Stock / historical development of Supported
Housing within Borough
•Complex housing pathways within Borough
•Dependency on cooperation from other Boroughs if housing duty lies
elsewhere – including escalation processes
•Increasing number of clients with No Recourse to Public Funding / complex
immigration status
•Delays in obtaining proof of benefits
Service / clinical challenges
•No in-house rehab / delays in referral process into Locked Rehab facilities
•Increased admin processes around various pathways, in context of increased
workload in community teams
•Increase in Court of Protection cases – increased awareness MCA and
implications
•Engaging clients who aren’t always willing to engage
Responses
50
Mondays: face to face Haringey DTOC meeting.
Senior Managers BEH inpatients and community and ward managers
Community teams with clients on DTOC list
Discharge Intervention Team
Crisis Response and Home Treatment Team
“Recovery House” representative
Homes for Haringey “Assessment & Referral” Team representative
Social Care / Brokerage
CCG
Thursdays: follow up Haringey DTOC teleconference:
Follow up on actions agreed on Monday
Attendees mainly internal BEH staff
Wednesdays: Trust-wide DTOC escalation teleconference:
Chaired by (deputy) COO
Attendees from all 3 boroughs: BEH ADs, 3 Social Work Leads, CCG,
Housing departments
1. DTOC and Bed Management Process
Responses:
51
• 72 Hour Formulation Meetings to identify at an early stage any issues that
may become barriers to discharge
• Pro-active involvement of Senior Managers from inpatient and
community; ongoing input of community teams during admission
• Creation of Discharge Intervention Team – moving community discharge
workers to work closer into wards
• Development of Accommodation Pathway Guidance
• Training for ward managers on Care Act, Ordinary Residence, s117
• “Adult Pathway” review
2. Improving practice
Accommodation Pathway Guidance
52
Guidance
includes: -
• Eligibility criteria
and referral
processes
• Timescales for
each pathway
• Escalation routes
• Advice and
resources on
common issues
and housing
problems
Responses:
53
3. Local System Response • Agreed Trust-wide DTOC reduction plan and trajectory
• Releasing CAB and floating support capacity to in-reach to wards
• Primary Care Link worker model – catching up to with Barnet,
Enfield
• Better Care Fund Small Grant – scoping a model of Discharge to
Assess into intermediate care / step-down from in-patient beds.
• Improved commissioning of housing support pathway
– Housing First
– Psychologically Informed Environment for women with experiences of
trauma
– Emerging joint pledges with social landlords to create a step change in
share response to tenants with mental health needs, particularly those
who experience crisis
• Emerging improvement plan on discharge and DTOC
management involving all key local partners
Reducing Delays
Newham Centre for Mental Health
The Newham Context • Population of over 340,000
people.
• Young and projected to grow
further due to natural growth.
• Separate provision of Health
and Social Care for Adult
Mental Health Services since
April 2016 with 1 point of entry
for adult mental health referrals
and 1 point of entry for Mental
Health Social Care
London Borough Police Section 136 Detentions Children and Young People Detentions
Borough/U&EC network Total Rate per 100,000
Population
Total Rate per 100,000
Population
City of London 157 2842.7 3 923.1
Hackney 144 78.5 3 13.3
Newham 187 85.1 11 34.9
Tower Hamlets 107 52.3 6 25.7
*Aggregated s136 activity data from London’s three police forces over 2015/16 is outlined below. The data is presented in absolute numbers and also
weighted for the relative size of each borough’s resident population to allow for comparisons that take each borough’s relative size into account.
Inpatient Care in Newham • Mixed Gender Triage Ward (15 beds) with an average length of
stay of 5 days and maximum stay of 14 days.
• Those that require a longer term admission are transferred to
one of four single gender wards (34 female beds and 36 male
beds).
• One Adult Male PICU on site (12 beds).
• Admissions average 121 per month. Discharges average 116
per month.
• Average Length of Stay: 25 Days (including Triage: 19)
• Average Occupancy: 79%
Pre-Bed Management Weekly internal pre-
bed management
meeting with all ward
matrons and
managers in
attendance and
Consultant
Psychiatrists invited.
Chaired by Borough
Lead Nurse and
Associate Clinical
Director. Borough
Director or Deputy
Borough Director in
attendance. All
admissions discussed.
Bed Management Weekly bed management
meeting with matrons and
managers in attendance.
LBN senior management
and hospital assessment
team in attendance.
Chaired by Borough Lead
Nurse and Associate
Clinical Director. Borough
Director or Deputy
Borough Director in
attendance. DToCs and
requests for DSTs agreed
in this meeting. Only
those cases where there
is a barrier to discharge
are discussed.
Key Relationships
• Service level agreement with Local Authority Housing
department to assess and offer accommodation
where appropriate within 14 days. Housing officer
attends the wards regularly to assess directly.
• A robust interface with LBN mental health social care
with regular reviews of systems and processes.
Sharing of admission information and links with no
recourse worker (NRPF Connect).
• Strong links with the Home Office and 3rd sector
organisations (Routes Home, Open Doors).
Lambeth Barriers to Discharge Group
- Meets fortnightly
- Group coordinated and led by SLaM Acute Care Pathway Lead
- Group focuses not only on DTOC patients but all inpatients who have potential and real barriers to discharge
- Ward managers identify inpatients on ward who have real and potential barriers which forms focus of fortnightly meetings
- Also focuses on those in private overspill
Membership of Group
• Statutory Sector
• Acute care pathway lead
• Inpatient ward managers
• Home treatment team representation
• Social care panel chair/co-chair
• Complex care panel chair/co-chair (IPSA)
• Commissioning
• Supported Housing pathways coordinator
• Kings Health Partners Homelessness project (work with inpatients on the ward who have a history of homelessness)
• Voluntary Sector
• One Support – provide practical support in benefits, tenancy and purchasing of furniture and appliances. Also coordinate deep clean of flats and liaise with Lambeth housing/RSL to facilitate repairs
• Lorrimore Home and Dry – work in partnership with One Support in undertaking deep cleans of flats
Barriers to Discharge
• Housing repair, deep clean and other practical issues related to patient’s accommodation
• Tenancy issues – unable to return to accommodation because of ill health or circumstances and therefore needs to give tenancy – requires court of protection
• Delays in putting together necessary paperwork through to completion of the panel process
• For complex inpatients availability of suitable supported accommodation/residential care home
• Awaiting void in identified placement i.e. supported housing
• Lack of ID paperwork that prevents access of housing benefit
• Complex personal circumstances
Process of the group
• Discussions are brief and action focussed
• Action holder and timescales are identified
• Meeting chair oversees that actions have been completed
• Cases are brought back until the barrier to discharge has been resolved
Benefits of Group
• Early identification of barriers – leading to discharge planning at point of admission
• Very practical and patient focussed
• Collective expertise across all sectors
• Track through patients from potential / real delay to successful discharge
• Gain insight into system wide issues that can be addressed long-term i.e. panel delays
• Case Study
• Patient delayed because of repairs that needed to be done to flat i.e. One support liaised with Council to facilitate the completion of the repairs, as well as attained funding for furniture and cooking utensils. Patient also required 7 hours personal support package to assist with tasks related to daily living i.e. cooking, cleaning and prompting around medication. Barriers to discharge group assisted in the planning & coordination, assertive follow-up and monitoring of the key tasks required to successfully discharge patient.
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Lunch
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8. Legal case studies
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9. National policy update
Reducing Delayed Transfers of
Care from Mental Health Settings
Bobby Pratap, Senior Programme Manager, Crisis and Acute
Mental Health Care
Mental Health Clinical Policy & Strategy Team NHS England
70
Contents
1. Policy background – CAAPC and FYFV-MH
2. Delayed transfers of care and mental health: what do
we know about the data?
3. Crisis Resolution & Home Treatment Teams
4. Acute mental health care, including out of area
placements
5. Annex: London Region – CRHTT and OAPs
indicative data
71
CAAPC (Crisp commission) – what did it say? Some of the recommendations
• End the practice of sending acutely ill patients long distances for treatment by October 2017
• Strengthening CR/HTs, with a particular focus on ensuring that home treatment teams are adequately resourced to provide a safe and effective alternative to acute inpatient care where this is appropriate
• A single set of measurable quality standards needs to be created spanning the acute care pathway, including a maximum four-hour wait for admission to an acute psychiatric ward for adults or acceptance for home-based treatment following assessment
• DTOC data – national data poor quality on DTOCs – RCPsych thinks figure is around 16% national unify data shows somewhere around 2-4%?
• Housing, social care, community MH services – biggest reasons for DTOC
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Recommendation 17:
• By 2020/21 24/7 community crisis response across
all areas that are adequately resourced to offer
intensive home treatment, backed by investment in
CRHTTs.
Recommendation 22:
• Introduce standards for acute mental health care,
with the expectation that care is provided in the least
restrictive way and as close to home as possible.
• Eliminate the practice of sending people out of
area for acute inpatient care as a result of local acute
bed pressures by no later than 2020/21.
72
Mental Health Task Force – acute mental health
2. Delayed transfers of care and
mental health: what do we know
about the data?
74
National DTOC data: Mental health, what do we know?
• At least 20% (probably more) of all NHS delays are from MH providers
(unify) – it is not just about older people!!
• More are attributed to social care for mental health that non-MH delays
However……..
• Unify national reports do not even differentiate between mental health
and community providers delays. Just ‘acute’ and ‘non-acute’
• ……Let alone differentiating between MH bed types. e.g. if you have a
high secure hospital, delays likely to be much higher
• Targets: when Monitor’s risk assessment framework had a target of no
greater than 7.5%. Most reported DTOCs at……….. 7.4-7.5%!!!
• In conclusion, national data for MH DTOCs we have very little confidence
in being able to understand pressures / comparisons between providers
75
What are we doing to improve data?
• Proposal to move to MHSDS only for mental health providers (currently
providers submit to unify and MHSDS)
• Crucially, MHSDS will allow analysis by bed type for the first time at a
national. Will give a truer picture of delays, understanding where pressures
are highest
• New categories for MH delay reasons from this April that are more
suitable for mental health (see next slide)
• However, because they are submitting to unify, many providers are not
submitting MHSDS returns – so we need to drive data quality via
MHSDS from 2017/18
• Will be a challenge politically to ‘switch off’ unify for MH, e.g.
taking MH out of national unify statistics will remove 20% of total
delays
improving data quality will probably show a rise in delays
DToC – new MHSDS v.2 data categories
Categories Attributable to…
A: Awaiting Care coordinator allocation NHS
B: Awaiting public funding NHS/ social care/ both
C: Awaiting further non-acute (including community and mental health) NHS care (including intermediate
care, rehabilitation services etc.) NHS
D: Awaiting Care Home With/Without Nursing placement or availability NHS/ social care/ both
E: Awaiting care package in own home NHS/ social care/ both
F: Awaiting community equipment, telecare and/or adaptations NHS/ social care/ both
G: Patient or Family choice (category expanded with large number of explanatory reasons to select from) NHS/ social care
H: Disputes NHS/ social care
I: Housing - patients not covered by Care Act (number of explanatory reasons to select from) NHS/ social care / housing
J: Housing - Awaiting supported accommodation NHS/ social care / housing
K: Housing - Awaiting emergency accommodation from the Local Authority under the Housing Act NHS/ social care / housing
L: Child or young person awaiting social care or family placement NHS/ social care
M: Awaiting Ministry of Justice agreement/permission of proposed placement -
N: Awaiting outcome of legal requirements (mental capacity/mental health legislation) NHS/ social care / housing
These expanded categories acknowledge the range of factors that can lead to delays, attributable to the NHS, social care and housing. The enhanced transparency around the number and causes of delays, will enable them to be addressed at a national and local level. Please see MH SDS to MSitDT Guidance and Mapping for more information on MHSDS categories
Inpatient activity – split by bed type for the first time:
For inpatient and HTT
• Referrals / referral rates
• Gatekeeping
• Admission / admission rates
• Readmission
• NICE-recommended interventions
• Average length of stay
• Follow up post-discharge
• Time from decision to admit to admission
Delayed Transfers of Care - by bed type
• With new categories for mental health
Out of area placements – MHSDS to replace special interim collection
• Numbers, bed days, reasons, distance, duration
Mental Health Act
• Including waiting times
77
Data: new national reports coming in 2017-2019 for inpatient acute care
78
Out of area placements: new data collection - a better indicator of acute MH pressures for now?
79 www.england.nhs.uk
Headline Data Q4 2016/17
Inappropriate OAPs started in period
Total no. of OAP days over the period
Total recorded costs over the period
No. of OAPs that ended in the period with a length of 31 or more nights (1)
No. of OAPs active during the period with a distance of 100km or greater
Average recorded daily cost over the period (2)
England 1,853 52,577 £18,792,900 316 790 £530
North 530 13,476 £2,466,090 90 115 £505
Mids & East
420 15,113 £6,298,090 90 345 £525
London 305 7,462 £3,847,700 40 25 £525
South 565 14,375 £5,582,340 85 250 £580
Unknown 30 2,145 £598,653 10 25 £530
• The regional data in this table for ‘Inappropriate OAPs started in period’ is subject to NHS Digital’s suppression rules -
counts have been rounded to the nearest five.
• (1) Only includes OAPs that ended during February and that started on or after the 17th October 2016. This means
that the current maximum duration for an OAP included in the March report is 166 nights. It is not yet known what
percentage of OAPs last longer than this, but it will become clearer collection runs for more time.
• (2) Recorded Cost – since January cost has only been recorded where a provider has been charged by a different
organisation for making the placement. (There are some scenarios where an OAP may take place within a provider
organisation where the provider covers a very large geographical patch). As such the costs reported for 2017 should
not be compared with those in 2016.
3. Crisis Resolution & Home
Treatment Teams FYFV Deliverable: By 2020/21, NHS England should
expand Crisis Resolution and Home Treatment Teams
(CRHTTs) across England to ensure that:
- a 24/7 community-based mental health crisis
response is available in all areas
- these teams are adequately resourced to offer
intensive home treatment as an alternative to an acute
inpatient admission.
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“By 2020, there should be 24-hour access to mental
health crisis care, 7 days a week, 365 days a year –
a ‘7 Day NHS for people’s mental health’.”
81
Spending Review – Headlines for Crisis & Acute Care
• over £400m for crisis resolution and home
treatment teams (CRHTTs) to deliver 24/7
treatment in communities and homes as a safe
and effective alternative to hospitals (over 4
years from 2017/18);
• £247m for liaison mental health services in every hospital emergency
department (over 4 years from 2017/18);
• £15m capital funding for Health Based Places of Safety in 2016-18 (non-
recurrent)
Intensive home treatment:
• Short term intensive care spell: aims to transfer patients according to an ongoing plan of care
• As many visits as necessary, 24/7, likely to need visits of up to three times per day initially, with frequency reducing as patient recovers
• Visit duration that meets the person’s needs and allows for therapeutic care
• Multi-professional team approach with effective handover (at a minimum, daily), which allows case-load sharing and the offer of a range of interventions
• Partnership working with other community services to facilitate ongoing care
• Facilitate early discharge from inpatient settings.
• Subject to similar ‘bed management’ approaches as inpatient care
82
CRHTTs – what are their key functions?
Community crisis assessment:
• Accessible 24/7
• Rapid assessment to the community and people’s homes for urgent and emergency referrals
• Gate-keeping function (managing access to local acute inpatient beds)
• Initial treatment package (medical and brief psychological intervention)
• Management of immediate risk
The UCL Core study has a 39 point
fidelity scale for teams to assess
themselves against
24/7 access to mental health crisis services Timely assessment in an appropriate place Avoids unnecessary admission when home treatment may be more suitable Therapeutic care to support recovery: in people’s home environment, social
triggers to crisis, and barriers to independent living can be more visible, and therefore assessed and acted upon in situ, providing potential for more sustainable coping skills - including for instance family relationships, shopping, banking etc. As such, teams should be multi-disciplinary, not just doctors, nurses but psychology, pharmacist, social work, OT input in the skill mix
Usually people report a more positive experience of care than for inpatient care Facilitate early discharge / supports people to go home on leave from the ward Avoid A&E attendances, free up acute hospital liaison service for ward in-reach When part of tight bed management process and acute care pathway, can help
reduce out of area placement Where teams implemented with high fidelity, that incorporates gatekeeping and
has 24-hour community-facing provision have been associated with reduced admission rates with an associated reduction in costs
Published evidence of impact (1) ; Evidence (2) ; Evidence (3) ; Evidence (4)
83
Benefits of CRHTTs when implemented in line with
evidence base as part of well managed acute system
84
Early considerations from the ERGs on quality benchmarks:
response times and interventions for emergency referrals
• 24/7 UEMHC/crisis lines - calls should be answered within a maximum of 2
minutes
• Within a maximum of 1 hour of contact, the urgent and emergency mental
health service should provide the person who contacted the service with an
update/feedback on care and support to be provided;
• Within 4 hours of a request for help, the person in crisis should have been
provided with an assessment and have an urgent and emergency mental
health care plan in place (the assessment should be biopsychosocial, but if
this is not possible, an initial face-face crisis assessment should be
undertaken as a minimum), and
- been accepted and scheduled for follow-up care by an appropriate
service (this could include support provided at home),
or
- been discharged because the crisis has resolved; or
- started an assessment under the Mental Health Act.
85
Early considerations from the ERGs on quality benchmarks:
response times and interventions for emergency referrals
• As well as the initial emergency response to a crisis within 4 hours, services
should ensure continuity of ongoing care outside of the 4-hour response
(this could include further assessment if necessary, for example to complete a
biopsychosocial assessment if this was not possible within 4 hours)
• Advice should be sought from an appropriately trained and competent mental
health professional immediately in the event of a mental health crisis. Each
professional should ensure that they:
• provide a kind, compassionate and empathetic response
• plan for the short-term safety of the person, if necessary
• undertake an initial risk assessment
• plan appropriate observations for both mental and physical health
• access any existing mental health Plan, where available
• notify the local authority if the person is an ‘at risk’ adult or older adult.
Response time targets
• 45.4 % have target to commence an assessment in under 4 hours
• 20.0 % have target to complete an assessment in under 4 hours
86
What do we know about CRHTTs – selected stats from
UCL survey, 2016 (1/2)
PR PSCSUANRNH
SANRH VCSAH
Adults 92.6 91.1 84.7 67.4 69.5
0102030405060708090
100
% t
eam
s
CRHTT 24/7 offers PR Phone referral
PSCSU
Phone Support to current CRHTT Service Users
ANRNHS
Assessment of New Referrals on NHS premises
ANRH
Assessment of new referrals at home
VCSAT
Visit current CRHTT Service users At Home
87
Eligible Referrer Adult CRHTTs n/N (%)
Psych Liaison 180/184 (97.8)
GPs 148/184 (80.4)
NHS 111 108/184 (58.7)
Police 132/184 (71.7)
Self referral (known patient)
127/184 (67.4)
Self-referral (new patient)
79/184 (42.9)
Staffing and caseloads
• 35.4 – mean caseload of CRHTTS
• Around 55-65% of teams have staffing: caseload ratio in line with 2000 policy
implementation guidance
What do we know about CRHTTs – selected stats from UCL
survey, 2016 (2/2)
4. Acute mental health care, inc.
out of area placements
FYFV Deliverables:
- the practice of sending people out of area for acute
inpatient care due to local acute bed pressures
eliminated entirely by no later than 2020/21
- standards for acute care introduced
- full response to the Independent Commission on
Acute Adult Psychiatric Care, established and
supported by the Royal College of Psychiatrists
89
Early considerations from acute care ERG – quality
benchmarks: time from referral to admission
• Any person requiring acute mental health care in an inpatient setting
should receive orientation onto the ward as well as verbal and written
information about who their named care team will be within 4 hours of
referral.
• Any person requiring acute mental health care in a community-based setting
should be accepted for care within 4 hours of referral and receive their
first face-to-face NICE Concordant treatment contact within 24 hours of
referral.
1. A comprehensive physical health assessment made within 24 hours of the start of treatment;
2. A care plan to be initiated within 72 hours of the start of treatment
3. A Care Act-compliant assessment to be completed within 72 hours of the start of treatment to identify any social care issues
4. The discharge destination to be considered within the first 72 hours of care for those who have housing needs
5. Access to daily meaningful and recovery-focused activities while receiving care
6. One-to-one face-to-face time with a care professional that the person knows, every day
7. Feedback on service experience to be sought to improve the delivery of care
8. Follow-up after discharge from an acute mental health inpatient setting to be made within 48 hours.
90
Early considerations from acute care ERG - what is NICE
recommended acute mental health care? (inpatient and community)
91
Case study: Sheffield (1/2) – headlines
In 2011 bed occupancy 120%, 142 beds, almost 3000 bed days out of area Wards now reduced in size, (69 beds) staffing has stayed the same, so patient-to-staff
ratios have improved, zero out of area . Because of the reduction of wards, SHSC has been able to significantly reduce the use of
agency staff, £2 million was invested in community services to ensure its sustainability. This included
investment in IHTTs and new services for people with highly complex problems often associated with a diagnosis of personality disorder. In addition to this reinvestment, cost savings of over £1.5 million were made
No increase in incidents, close monitoring of quality markers – which have improved.
92
Case study: Sheffield (2/2) – how did they do this?
Risk-sharing agreement between SHSC and the Sheffield CCG. SHSC took responsibility for the budget for out-of-area placements.
Efficiency programmes reduction in average length of stay from 56 to 31 days. Work focused on improving time spent with patients on the wards, discharge facilitators on every ward, planning for discharge on admission, particularly in relation to social factors and daily bed management meetings with consultants.
Quality initiatives : included: psychology posts on wards; reflective practice supervision for staff; reduction in seclusion and restraint; service user-led, all-staff training programme to improve the management of violence and aggression.
Bed management weekly bed-management meetings chaired by the clinical director, and including all consultants, ward managers, discharge coordinators, partner services (crisis house, respite provision, community teams). Meetings use live data and focus on patient flow.
Investment in intensive home treatment bed-management processes were applied to manage the flow of people. Fewer people accessing home treatment, smaller team caseloads but more intensive treatment for those in HTT.
Whole system approach - vital. Rethink crisis house and helpline, Wainwright Crescent respite and step-down beds; joined-up management/governance between inpatient and community services, live data showing flow across the whole system; and engagement with service users, carers and staff throughout.
93 www.england.nhs.uk
Common themes from other areas that have / are
attempting to reduce out of area placements
Intensive focus on OAPs as a priority – agreement of system priority at all levels
• Agreement at all levels that OAPs are a priority
• Principle that bed / HTT must always be available where that is the right
choice
• Board-level responsibility
• Clinical and/or Service Director who is personally responsible
• Strengthened community services, savings reinvested back into MH
• Financial risk/benefit sharing agreement between providers and
commissioners
• Whole system coming together in partnership to redesign pathways and
agree processes – inpatient staff, CRHTTs , social care, AMHPs, CMHTs,
vol sector, patients, IAPT, primary care
• Intensive focus on flow, bed management
• Community and inpatient teams attend regular MDT discharge meetings
• Use of real time data, including info on bed availability, capacity of HTTs,
community alternatives (e.g. crisis houses)
• Info on patients who have passed discharge dates, reviews / new
discharge dates
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
No
rth
Eas
t Lo
nd
on
NH
S Fo
un
dat
ion
Tru
st
Barking & Dagenham (B&D) & Havering HTT
Y Y Y 65 38.60 0.59
0 0 Redbridge HTT
Y Y N 60 37.50 0.63
Waltham Forest HTT
Y Y N 60 30.55 0.51
North East London FT – CRHTTS and OAPs Indicative Data
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Oxl
eas
NH
S Fo
un
dat
ion
Tru
st
Bromley N N N 25 16.50 0.66
2713 £1,519,940 Bexley N Y N 33 14.40 0.44
Greenwich Y Y N 52 24.50 0.47
Oxleas – CRHTTS and OAPs Indicative Data
96 www.england.nhs.uk
East London NHS Foundation Trust Tower Hamlets acute mental health service
Camden and Islington NHS FT, Drayton Park Women’s Crisis House
Mersey Care NHS FT has introduced No Force First, an award-winning restraint reduction
initiative.
South London and Maudsley NHS FT Gresham Unit Carers’ initiative
Addressing inequalities in acute mental health
Resources from Joint Commissioning Panel on mental health for people from:
• BAME backgrounds,
• older people
• learning disabilities
• physical health needs
Case study: African Caribbean Community Initiative, Wolverhampton
Further positive practice case studies: acute care
97 www.england.nhs.uk
Sheffield – blog from clinical lead, Dr Mike Hunter – now associate national clinical director at
NHS Improvement. Further detail can be found here.
North East London Foundation Trust – highlighted in RCPsych Commission on adult acute
psychiatric care (p27) – NELFT has eliminated out of area placements for many years, with one
of the lowest bed bases in the country - through investment in community services and
intensive focus on acute pathway management.
Leeds and York Partnership NHS FT: Efforts underway in ‘Leeds mental health flow’ project
with write up of the how the whole system is coming together to reduce out of area
placements to save £1.5m for the local health economy.
Bradford: adopted an approach with similar principles to Sheffield. Highlights include:
Vital partnership working with social care and local authority services – detail overleaf!
Whole system approach to eliminating out of area placements in Bradford.
Focus on acute inpatient ward flow, DTOCs, including a 10 point discharge tracker (below):
Further OAPs case studies and resources
98 www.england.nhs.uk
Take a look at Mark Trewin’s (Mental Health, Service Manager at Bradford Council and Social Care
Advisor to the NHSE Adult Mental Health Team) blog on the importance of partnership working
with social care and local authority services to reduce DToC, MHA detentions, admissions, OAPs
and support recovery in the community.
In Bradford, social care is integrated across a range of acute and community mental health
services and people are supported at home wherever possible using collaborative work between
health, social care and voluntary services to achieve the least restrictive and most appropriate
care through a single point of access.
Mental health social workers are based or involved in: The 24/7 First Response crisis service ;
The Haven (non-clinical community alternative to A&E); the Intensive Home Treatment (IHT) team;
the Police Hub; the AMHP service; Specialist housing social worker; Community mental health
teams, Early Intervention teams, Assertive Outreach teams and community support services;
Supported Accommodation. There are also joint commissioning arrangements in place and
increasingly joint decisions are being made between NHS and LAs around funding (e.g. s117).
Key advice for any CCG, Trust or LA struggling with OAPs or private sector bed usage - join
together all NHS, local authority, VCS, police, housing and service user groups, and review how
integrated working and joint commissioning together might change the way that people are cared
for locally.
Role of social care and the voluntary sector in managing
the acute MH system
99 www.england.nhs.uk
Cheshire and Wirral Partnership NHS Foundation Trust, Complex Recovery Assessment and
Consultation service that has contributed to the elimination of out of area placements
Cornwall Partnership NHS FT, Fettle House rehabilitation service
Northumberland Tyne & Wear NHS FT Rehabilitation and Recovery Services
Mental health supported housing examples
St Martin of Tours Housing Association, Islington
Living Well, South Yorkshire Housing Association
Mental health rehabilitation service examples
www.england.nhs.uk
Community MH Care
IAPT
Crisis Care
Acute Care
Rehab Care
Secure Care
Primary
Care
Recognition
& referral
PC treatment
Primary Care
Physical health, dental health
Primary
Care
Step-down
care
Sustaining
recovery
So
c C
are
+ H
ou
sin
g +
SM
S +
Vo
l S
ecto
r +
Le
isu
re S
oc C
are
+ H
ou
sin
g +
SM
S +
Vo
l Se
cto
r + L
eis
ure
Social Care + Housing + SMS + Vol Sector + Leisure
Social Care + Housing + SMS + Vol Sector + Leisure
…. thank you and questions
Bobby Pratap Senior Programme Manager, Crisis & Acute Mental Health, NHS England Twitter: @BobbyPratapMH Email: [email protected]
5. Annex: London Region –
CRHTT and OAPs indicative data
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
No
rth
Eas
t Lo
nd
on
NH
S Fo
un
dat
ion
Tru
st
Barking & Dagenham (B&D) & Havering HTT
Y Y Y 65 38.60 0.59
0 0 Redbridge HTT
Y Y N 60 37.50 0.63
Waltham Forest HTT
Y Y N 60 30.55 0.51
North East London FT – CRHTTS and OAPs Indicative Data
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Oxl
eas
NH
S Fo
un
dat
ion
Tru
st
Bromley N N N 25 16.50 0.66
2713 £1,519,940 Bexley N Y N 33 14.40 0.44
Greenwich Y Y N 52 24.50 0.47
Oxleas – CRHTTS and OAPs Indicative Data
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Bar
net
, En
fie
ld a
nd
Har
inge
y
Barnet Y Y N 80 30.40 0.38
313 £166,680 Haringey Y Y N No data 28.00 No data
ECRHT Y Y Y 86 31.00 0.36
Barnet, Enfield and Haringey – CRHTTS and OAPs Indicative Data
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Ce
ntr
al a
nd
No
rth
We
st L
on
do
n N
HS
Fou
nd
atio
n T
rust
Hillingdon Y Y N 25 19.00 0.76
1138 £388,593
Westminster
Y Y N 60 30.20 0.50
CNWL – CRHTTS and OAPs Indicative Data 1/2
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Ce
ntr
al a
nd
No
rth
We
st L
on
do
n N
HS
Fou
nd
atio
n T
rust
Brent Y N N 75 27.00 0.36
1138 £388,593 Harrow Y N N 52 16.00 0.31
Milton Keynes
N N N 25 17.55 0.70
CNWL – CRHTTS and OAPs Indicative Data 2/2
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Cam
de
n a
nd
Isl
ingt
on
NH
S Fo
un
dat
ion
Tru
st
South Camden Y Y N 35 15.80 0.45
1135 £660,225 North Camden Y Y N 35 19.60 0.56
Islington N Y N 70 31.60 0.45
Camden & Islington – CRHTTS and OAPs Indicative Data
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
East
Lo
nd
on
NH
S Fo
un
dat
ion
Tru
st
Tower Hamlets
N N N 45 19.80 0.44
298 *
Luton and South Bedfordshire
Y N N 45 28.50 0.63
City and Hackney
Y N Y 80 26.50 0.33
East London FT – CRHTTS and OAPs Indicative Data 1/2
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
East
Lo
nd
on
NH
S Fo
un
dat
ion
Tru
st
Psychiatric Acute Community Treatment
N N Y 65 20.30 0.31
298 *
Bedford Y N Y 35 20.00 0.57
East London FT – CRHTTS and OAPs Indicative Data 2/2
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Sou
th L
on
do
n a
nd
Mau
dsl
ey N
HS
Fou
nd
atio
n T
rust
Lambeth Y N N 45 18.00 0.40
1745 £879,430
Southwark N N Y 50 34.30 0.69
Lewisham Y N N 45 23.60 0.52
Croydon N N N 45 34.00 0.76
SLaM – CRHTTS and OAPs Indicative Data
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
Sou
th W
est
Lo
nd
on
an
d S
t G
eo
rge
s M
en
tal H
eal
th N
HS
Tru
st
Kingston Y Y N 25 5.00 0.20
No data submitted
No data submitted
Wandsworth N N N 44 23.60 0.54
Sutton Y N N 39 11.00 0.28
SWLSTG – CRHTTS and OAPs Indicative Data
Trust HTT Team/ Catchment area
Can the CRHTT visit current CRHTT service users at home 24/7?
Does the team accept self-referrals from new patients?
Does CRHTT have a 4 hour target for all new assessments?
CRHTT Caseload upper limit
CRHTT staffing (FTE)
FTE staff to upper caseload ratio
No. of OAP days Q4 16/17
Total recorded cost Q4 16/17
We
st L
on
do
n M
en
tal H
eal
th N
HS
Tru
st
Crisis Assessment & Treatment Team Y
N Y N 35 34.00 0.97
257 £146,019
Crisis Assessment and Treatment Team 2
N Y N 50 32.80 0.66
Ealing Y Y Y 100 43.00 0.43
West London MH Trust – CRHTTS and OAPs Indicative Data
www.england.nhs.uk
10. Table discussions
Please introduce yourself to your table colleagues.
On your tables agree a facilitator and use the post-it notes to capture:
• What will you take away and do?
• What do you think would add value regionally?
• What will you lead on or contribute to affect change?
No More Time “On Hold”
Reducing delays in Mental Health Trust
discharges
www.england.nhs.uk
11. Plenary
The Care Closer to Home programme
Staying home longer and coming home sooner
The Care Closer to Home programme emerged from a growing awareness of the need for health and social
care organisations to partner and put structure, governance and resource around a plethora of targets,
deliverables and initiatives relating to out of hospital care.
It builds on work already underway across London in CCGs, Local Authorities, with A&E delivery boards
and Trusts.
The programme has three key components
1. Working to improve outcomes in key areas: Hospital to Home, so that people can stay at home for
longer and get home quicker, End of Life Care and aspects of Ambulance performance
2. An understanding of the capacity required to support a shift in the focus of care into community
settings – and what that means for the system , social care, health, housing and others
3. Engagement and collaboration with key partners
117
www.england.nhs.uk
Appendix: DToC data
Source: NHS England Monthly DToC Situation Report
Data excludes organisations representing lowest 1% of delays
0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000
WEST LONDON MENTAL HEALTH NHS TRUST
ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
SOUTH WEST LONDON AND ST GEORGE'S MENTAL HEALTH NHS TRUST
SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST
ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST
ROYAL FREE LONDON NHS FOUNDATION TRUST
OXLEAS NHS FOUNDATION TRUST
NORTH EAST LONDON NHS FOUNDATION TRUST
LONDON NORTH WEST HEALTHCARE NHS TRUST
HOUNSLOW AND RICHMOND COMMUNITY HEALTHCARE NHS TRUST
EAST LONDON NHS FOUNDATION TRUST
CENTRAL LONDON COMMUNITY HEALTHCARE NHS TRUST
CENTRAL AND NORTH WEST LONDON NHS FOUNDATION TRUST
BUCKINGHAMSHIRE HEALTHCARE NHS TRUST
BARTS HEALTH NHS TRUST
BARNET, ENFIELD AND HARINGEY MENTAL HEALTH NHS TRUST
NON-ACUTE BED DAYS
All London Boroughs
A_COMPLETION_ASSESSMENT
B_PUBLIC_FUNDING
C_FURTHER_NON_ACUTE_NHS
DI_RESIDENTIAL_HOME
DII_NURSING_HOME
E_CARE_PACKAGE_IN_HOME
F_COMMUNITY_EQUIP_ADAPT
G_PATIENT_FAMILY_CHOICE
H_DISPUTES
I_HOUSING
NHS12M
Non-acute bed days by provider and reason for delay (12 months)
Non-acute bed days by provider and reason for delay (12 months)
Source: NHS England Monthly DToC Situation Report
Data excludes organisations representing lowest 1% of delays
0 1000 2000 3000 4000 5000 6000 7000 8000 9000
WEST LONDON MENTAL HEALTH NHS TRUST
THE WHITTINGTO N HOSPITAL NHS TRUST
ST GEO RGE'S UNIVERSITY HO SPITALS NHS FOUNDATION TRUST
SOUTH WEST LONDON AND ST GEORGE'S MENTAL HEALTH N HS TRUST
SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST
ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST
ROYAL FREE LONDON NHS FOUNDATION TRUST
OXLEAS NHS FOUNDATION TRUST
NORTH EAST LONDON NHS FOUNDATION TR UST
LONDON NORTH WEST HEALTHCARE NHS TRUST
HOUNSLOW AND RICHMOND CO MMUNITY HEALTHCAR E NHS TRUST
EAST LONDON NHS FOUNDATION TRUST
CENTRAL LONDO N COMMUNITY HEALTHCARE NHS TR UST
CENTRAL AND NORTH WEST LO NDO N NHS FOUNDATIO N TRUST
CAMDEN AND ISLINGTON NHS FOUNDATION TRUST
BAR TS HEALTH NHS TR UST
BAR NET, ENFIELD AND HARINGEY MENTAL HEALTH NHS TRUST
NON-ACUTE BED DAYS
All London Boroughs
A_COMPLETION_ASSESSMENT
B_PUBLIC_FUNDING
DI_RESIDENTIAL_HOME
DII_NURSING_HOME
E_CARE_PACKAGE_IN_HOME
F_COMMUNITY_EQUIP_ADAPT
H_DISPUTES
ASC12M
0
200
400
600
800
1000
1200
AP
RIL
MA
Y
JUN
E
JULY
AU
GU
ST
SEP
TEM
BE
R
OC
TOB
ER
NO
VE
MB
ER
DE
CEM
BE
R
JAN
UA
RY
FEB
RU
AR
Y
MA
RC
H2016-17
NO
N-A
CU
TEB
EDD
AYS
All London Non-Acute Providers
A_COMPLETION_ASSESSMENT
B_PUBLIC_FUNDING
C_FURTHER_NON_ACUTE_NHS
DI_RESIDENTIAL_HOME
DII_NURSING_HOME
E_CARE_PACKAGE_IN_HOME
F_COMMUNITY_EQUIP_ADAPT
G_PATIENT_FAMILY_CHOICE
H_DISPUTES
I_HOUSING
NHS12M
Source: NHS England Monthly DToC Situation Report
Data excludes organisations representing lowest 1% of delays
0
200
400
600
800
1000
1200
1400
AP
RIL
MA
Y
JUN
E
JULY
AU
GU
ST
SEP
TEM
BE
R
OC
TOB
ER
NO
VE
MB
ER
DE
CEM
BE
R
JAN
UA
RY
FEB
RU
AR
Y
MA
RC
H2016-17
NO
N-A
CU
TEB
EDD
AYS
All London Non-Acute Providers
A_COMPLETION_ASSESSMENT
B_PUBLIC_FUNDING
DI_RESIDENTIAL_HOME
DII_NURSING_HOME
E_CARE_PACKAGE_IN_HOME
F_COMMUNITY_EQUIP_ADAPT
H_DISPUTES
ASC12M
Source: NHS England Monthly DToC Situation Report
Data excludes organisations representing lowest 1% of delays
www.england.nhs.uk
View full reports on the LondonADASS website:
https://londonadass.org.uk/dtoc/londonadass-sitrep-analysis/