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Mersey Care TDA Board to Board
Joe Rafferty Chief Executive
Joe Rafferty | Chief Executive Mersey Care @jr_merseycare
Our journey to perfect care:
Zero suicide for people in our care
Global trends in avoidable deaths
Suicide rates in the general population, UK
UK_SUICIDE (2005-2015)
© National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved.
Not to be reproduced in whole or part without the permission of the copyright holder.
• Highest rate in N.
Ireland
• Falls in England,
Wales & Scotland
10.0 9.4 9.4 10.1
9.4 9.5 9.6 10.3 10.0 9.6 9.6
15.4 15.0 17.1 16.7
14.9
19.1
16.4 16.9
19.0
17.7 17.6 17.1 16.8 18.1 18.1
16.3
16.6
18.9 17.5
16.9
14.4 14.2
12.0 11.1 11.1 11.3
10.6 11.2
11.9 13.3 13.1
11.4 12.2
0
5
10
15
20
25
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Suic
ide
rate
per
10
0,0
00
po
pu
lati
on
Year
England Northern Ireland Scotland Wales
Patient suicide rates, England
• Falling rates but
problem estimating
patient numbers
• Changing clinical
population
111.5
97.7 96.9 99.9 92.7
98.3
87.7 86.0
76.2
66.9 63.7
156.3
143.9 145.4 149.3 141.8
146.1
136.5 134.9
116.6
94.9 90.1
76.5
60.5 58.3 60.7 53.8
60.4 51.1 47.9
43.8 44.0 41.6
0
20
40
60
80
100
120
140
160
180
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Rat
e p
er 1
00
,00
0 M
H s
erv
ice
use
rs
Year
Total Male Female
ENGLAND_SUICIDE (2005-2015)
© National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved.
Not to be reproduced in whole or part without the permission of the copyright holder.
Patient suicide rates in males by age, England
• Highest rates in
middle age
• Rates falling in all
age groups
ENGLAND_SUICIDE (2005-2015)
© National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved.
Not to be reproduced in whole or part without the permission of the copyright holder.
124.9
146.4 158.8
147.9 145.4
127.4 129.7
121.9
97.7 92.8
213.7
179.8 187.8
178.0 178.5
209.1
167.1 158.6 138.2
121.0
195.4
234.8 227.3
212.6 221.5
193.8 178.3
160.1
121.0
153.8
76.9 81.1 75.2
49.6
67.2 60.2 62.2
52.1 46.5 45.1
0
50
100
150
200
250
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Rat
e p
er 1
00
,00
0 M
H s
erv
ice
use
rs
Year
25-34 35-44 55-64 65+
In-patient suicide, UK
• Slower fall in recent
years:
39% in 2005-10
10% in 2010-15
• Similar pattern in rates
in England (31% &
14%)
• Average 114 deaths
per year since 2011
(89 in England)
UK_SUICIDE (2005-2015)
© National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved.
Not to be reproduced in whole or part without the permission of the copyright holder.
Suicide under CRHT, England
ENGLAND_SUICIDE (2005-2015)
© National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved.
Not to be reproduced in whole or part without the permission of the copyright holder.
• 2x as many suicides
under CRHT as in in-
patients
• ca. 30% under
CRHT for <1 week
• ca. 30% recently
discharged from
hospital
Suicide <3 months of hospital discharge, England
• Downward trend in
England and
Scotland
• In the UK, 23% fall in
2011-2015
ENGLAND_SUICIDE (2005-2015)
© National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved.
Not to be reproduced in whole or part without the permission of the copyright holder.
Suicides per week after discharge, England
• Peak risk in first 2
weeks
• In 1st week, highest
number on days 2 and
3
ENGLAND_SUICIDE (2005-2015)
© National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved.
Not to be reproduced in whole or part without the permission of the copyright holder.
Reason’s (2000) Swiss Cheese Model
Financial as well as a moral imperative
Insight – Listening to understanding; co- production
Foresight - Zero suicide and zero restrictive practice
Oversight - Leading edge transparency & candor
Mersey Care Safety Approach
Knowing is not enough; we must apply. Willing is not enough; we must do.
• Our BHAGs are not targets but establish our ambitious safety culture;
• They are a way of getting to breakthrough thinking;
• They make us examine the proposition from many, sometimes new, angles;
• But they are not just concepts; • For us they are also a set of (developing)
practices.
Mersey Care 4 Cornerstones and
10 practices for Zero Suicide
1. Co-production with service users of materials and resources to
aid self-care.
2. Collaboration with primary care, Emergency Department clinical
teams, and the police to ensure effective joint approach taken at
critical risk points
Service user
and partner
engagement 1
3. Integrated community services
4. Intensive care following inpatient care and in times of crisis
5. Medicine safety
6. Restriction of access to means and modification of other risk
factors
Safe and
effective care
and treatment 2
7. Develop and implement a learning strategy across whole
organisation, including competency based suicide prevention
training for all staff commensurate with their level and role
8. Ensure adequate staffing skill-mix
A competent
workforce 3
9. Standardise post-incident reviews
10. Collect, analyse and disseminate data on suicides and near
misses
Research and
Evaluation 4
1. Foresight - Creating the future we want through Perfect Care, Zero Suicide, Zero Restraint
0% readmission to IP ward fully implementing MC Safety Plan &
a 50% reduction in presentations to ED for all those discharged
with a safety plan 2016-date.
Clinical Outcomes in Routine Evaluation (CORE) have been
collected prior to HOPE therapy sessions for ED self harm
patients. Seeing a mean reduction in total CORE scores
comparing pre/post therapy of 5.35. A 5 point or more reduction
in score indicates a clinically significant improvement in clinical
outcomes. The number of days between referral to 1st
appointment offered – an average of 14.71 days (comparable to
Cancer Care).
Clinical trial recruiting now
Using machine learning/AI, we identified some patterns in
complex self harming behaviour. Using design thinking inputs
we have seen a 43% reduction in incidents of self-harm on IP
wards since the programme began with total roll out due
2017/18.
Trust-Wide reduction in early indicators
Progressive reduction in suicide rate
No ordinary problem…what to
measure…?
Trust-Wide reduction of physical restraint
Since all wards engaged
in Force First in April
2016 Reductions of:
• Restraint by 37 %
• Assaults on staff by
49%
• LT sickness by 80% on
best implementers
Patient satisfaction avg
93.25% last 20 months.
Estimated cost savings of
£3M due to reduction in
litigation, injury and
sickness absence.
Set the standard for NHS
& CQC. Working with
many trusts, HMPS, and 5
sites internationally
2. Insight - co-production & listening to understand
+500 volunteers
65% with lived
experience
• 22k contacts in 1 year
• 50 courses (not interventions)
• Networked with 40 VCOs
• Taking social prescribing referrals from
40 GPs
• 25% cheaper with higher satisfaction
• Reducing traditional OP slots
• Co-production is our only ring-fenced budget
• User/Carer led induction for all staff
• Last 3500 staff employed has SU/C on panel
• Involvement in care planning v high
Launch of Zero Suicide Alliance in House of
Commons 16th November
• Almost 100 national organisations signed up
• Simple 20 min mobile supported awareness training
• 1 million people awareness trained is our target
0
10
20
30
40
50
60
70
80
90
Selfish act Inevitability
pe
rce
nta
ge
Early evidence of culture/attitude change post awareness training
Professionals Before
Professionals After
Corporate Before
Corporate After
3. Oversight - leading edge openness, candor & transparency
Learning Through Transparency
3. Oversight - leading edge openness, candor & transparency
• Delivering our ambition for Perfect Care depends on the development of a non-punitive culture;
• We have found that learning can only flourish when responses to
mistakes are compassionate;
• Personal responsibility and professional accountability drives the organisational learning;
• It’s not about 'blame-free' or being tolerant of absolutely anything;
• It’s a careful balance of accountability and learning;
• A prospective outlook rather than a retrospective bias;
• Ask what and how, not who because a bad system will always beat a good person.
A Just Culture (from Sidney Dekker)
• Brings out information about improvement to levels/groups able to do something about it;
• Allows the organisation to invest in improvements that have a safety dividend, rather than deflecting them
into legal defence and liability protection;
• Simultaneously satisfies demands for accountability and the need to learn and improve.
Candour and Early Resolution
• Bereaved people
involved rapidly –
CEO or MD available
within 24h;
• Reports shared well
ahead of coronial
process;
• Early resolution for
compensation; we
have very low
litigation exposure.
33 29 29
22 22 22
18 18
13
11
9
7
4 3
1 1 1 2
1 1
0
5
10
15
20
25
30
Jan 16 Feb 16 Mar16
Apr 16 May16
Jun 16 Jul 16 Aug 16 Sept16
Oct 16 Nov 16Dec 16 Jan 17 Feb 17 Mar17
Apr 17 May17
Jun 17 Jul 17 Aug 17
Disciplinary Cases: Jan 16 - Aug 17
Live Cases
Just and Learning Culture in Action
Savings associated with this trend = circa £500k
Partnering with Sydney Dekker, who is on today’s programme
What is orthodoxy one day
becomes apostasy the next.
Shifting Sands of
NHS Regulation
Can we do this without more resource?
• Ultimately it has to be about re-engineering and
reallocating our current spend;
• But this cannot happen without an investment in
changing culture ahead of changing services;
• Historically we have not invested enough in sustainably
tackling the ‘submerged part of the iceberg’;
• That has a cost but it would be true investment;
• That said, we need to understand the distinction between
resources and resourcefulness – the latter can take us a
long way.
