‘Supporting Your Journey’

21 September

WelcomeAngela McNab

Chief Executive

Out of area beds

Malcolm McFrederickExecutive Director of Operations

Excellent care in Partnership

A summary of the drivers of demand and our

out of area bed utilisation

Out of area bed usage

2013/14 we experienced unprecedented bed pressures.

Our analysis highlights:• Volatility in out of area bed use • For 14/15 (YA) East Kent over

utilised its commissioned bed base by 8,561 bed days, west Kent by 1,447 and north Kent underutilised its commissioned bed capacity by (1,451)

• We used 8,839 less bed days than in 13/14.

Actions to reduce demand 2014/15Street Triage

Pilot of a MH Nurse and Police Officer, 7 days from

20:00 – 04:00. Provide tactical advice around s136

• S136 – 22% reduction• Improved assessment times • Improved relationships• Improved experience

Developed local approaches to managing demand, from point

of entry into services and transfer to primary care

• 2% reduction in referrals not accepted into secondary care

• 4% improvement in number of referrals assessed within 28 days

Caseload Management

Urgent MH assessment to service users with mental health problems in

A&E / hospital to support better management, avoid admission or

reduce length of stay

• Decrease admissions - 91.7%• Reduce length of stay - 1745 days• Decrease CRHT presentations -

82.9%• Decline s136 presentations - 79.6%

PD Therapeutic House

5 day a week therapeutic group programme, with fast

track access to the personality disorder main outreach group

• Improved 2 hour assessment - average 80%

• Improved relationships• Opportunities to educate Acute staff • Proactive contribution to Acute targets

Liaison psychiatry

GP Training and Education

Developed GP training programmes including:

Dementia - on-line training module Medway – monthly educational

programme for GPs

• Good attendance at workshops demonstrating interest and engagement

• Improved relationships between secondary and primary care

Care Home Support

MDT working to prevent unplanned hospital admissions or

transfers to other care homes, due to challenging behaviour

• No admissions due to behaviour related to dementia

• Non-pharmacological approaches implemented prior to medication for 100% of cases

• Reduced input required • Improved understanding of residents

and ability to manage behaviour

We continue to experience significant pressures on our services

Delayed transfers of care – 2,603 bed days lost for younger adults in the past 12 months, 3,049 bed days lost for older adults in the past 12 months.

• Daily monitoring • CCG/KCC weekly reviews • Active management to ensure patient

receives care in most appropriate place

Crisis teams are under pressure to deliver in a timely manner

• Single Point of Access to go live • Improved working with police and SECAmb• Enhanced liaison service in A&E

CQC identified that we are trying to do too much with too little

• Working with Commissioners to look at • what capacity is needed • what alternatives can we put in place

to avoid admission

Questions?

Open DialogueJane Hetherington

Senior Psychological Practitioner

Origins of Open Dialogue

Initiated in Finnish Western Lapland since early 1980’s

Need-adapted approach – Yrjö Alanen

Integrating systemic family therapy and psychodynamic psychotherapy

a different approach

The patient’s family, friends and social network are seen as "competent or potentially competent partners in the recovery process [from day one]" (Seikkula & Arnkil 2006)

About empowering, not replacing social networks 

Every crisis is an opportunity to rebuild fragmented social networks (friends & family, even neighbours), to step up to the plate 

Staff receive rigorous training in social network engagement

And the same staff group maintains consistency of care throughout the patient journey 

This, therefore, becomes the primary intervention itself (not an afterthought, as in most MH systems)

Immediate Help

• First meeting in 24 hours• Crisis service for 24 hours• All participate from the outset• Psychotic stories are discussed in open dialogue with

everyone present• The patient reaches something of the ”not-yet-said”

Social Network Perspective

• Those who define the problem should be included into the treatment process

• A joint discussion and decision on who knows about the problem, who could help and who should be invited into the treatment meeting

• Family, relatives, friends, fellow workers and other authorities.

Flexibility and Mobility

• The response is need-adapted to fit the special and changing needs of every patient and their social network

• The place for the meeting is jointly decided• From institutions to homes, to working places, to

schools, to polyclinics etc.

Responsibility

• The one who is first contacted is responsible for arranging the first meeting

• The team takes charge of the whole process regardless of the place of the treatment

• All issues are openly discussed between the doctor in charge and the team

Psychological Continuity

• An integrated team, including both outpatient and inpatient staff, is formed

• The meetings as often as needed• The meetings for as long period as needed• The same team both in the hospital and in the

outpatient setting• In the next crisis the core of the same team• Not to refer to another place

Tolerance of Uncertainty

• To build up a scene for a safe enough process • To promote the psychological resources of the

patient and those nearest him/her• To avoid premature decisions and treatment

plans • To define open

Open Dialogue… a different approach

•Dialogism; promoting dialogue is primary and, indeed, the focus of treatment. “the dialogical conversation is seen as a forum where families and patients have the opportunity to increase their sense of agency in their own lives.”

•This represents a fundamental culture change in the way we talk to and about patients. All staff are trained in a range of psychological skills, with elements of social network, systemic and family therapy at its core

Use of the approach in Finland has shown comparatively impressive results and rates of recovery, including improvement to social inclusion and reduction in

hospitalisation

78% first episode psychosis return to work/study 19% relapsed within

5 years

(Reference: Seikkula et al. 2006)

National Audit of Schizophrenia 2014

• 90% of people were not working• 34% involved in some form of daytime activity• 19% were offered family intervention (trusts

report)• 12% had received/were receiving family

intervention• 50% carers > 30 hours/week support (average 59

hours)

2014 National CQC Community MH service user survey*

“I was involved as much as I wanted to be in agreeing my care”

57%

“A family member or someone close to me was involved as much as I would like”

55%

“I definitely agreed with someone in NHS MH services on what care I’ll receive”

43%

“Mental health services understand what is important in my life”

42%

“Mental health services help me with what is important”

41%

“mental health services help me feel hopeful about what is important”

38%

*16,400 SU respondents from 51 MH Trusts

UK Multi-centre RCT• Pre Pilot - Training- 4 teams for 1 year (55 people)- Kent, North East London, Nottinghamshire, North Essex, • Pilot

- Run pilot for 2-3 years- Compare re hospitalization, medication use, recovery outcomes and

wider service use• Post Pilot

- Publish outcomes

- Liaise with NICE (Steve Pilling possible lead investigator)

- Discuss with commissioners and DoH

- Spread awareness in media (BBC documentary)

• Multispecialty community providers

• Integrated primary and acute care systems

• New approaches to viable smaller hospitals

• Enhanced health care in care homes

The NHS Five Year Forward View: New Care Models

Clinical Engagement

Focus on the quality of the transaction

Focus on meeting local population need

Investment and flexibility

Dissolve traditional barriers to manage systems of care

Patient Involvement

Local Ownership

National SupportCo-design services and apply

learning across health systems

Any questions?

Single Point of Access

Portia Sharpin

Why do we need a single point of access?Where have we got to?Where do we want to get to?What are we going to get right?Questions

The next 15 minutes

The best crisis is one that never happens

5 things you need to know

Why do we need a single point of access

When I need urgent help, I know who to contact at any time

I get support and treatment from people

who have the right skills

…and most importantly, it’s what our service users and carers tell us they need to

help them get well and stay well

It is a must do:•Required in the Crisis Care Concordat •Requested by commissioners

It feels right:•Referrers and people needing help don’t know where to find it•Making a judgement about the right support needs clinical input

What have we done so far?

What will your single point of access look like?

• 24/7 telephone line in place since November – non-qualified staff route calls

• We intend to improve this so that it is staffed by clinical staff –

• Ready to treat – tele-triage and clinical judgement about the ‘next steps’

• Onward coordination of care – effective signpost or onward appointment booking (routine or urgent)

What is 24/7 tele-triage?

How do we make our staff “ready to treat” at the point of first contact? What will we be able to provide that is different? How will this transform the experience for patients?

Phased launches early 2016

What will our Single Point of Access look like?

What will it mean for staff?

Consideration of triage tools, technology, customer care

Change to working hours

Dependant on staff model and promoting the option for other service lines to move to extended hours

Staff Consultation Further SPoA engagement events, SPA to be implemented late 2016

Workforce options Different models to consider – local v’s centralised, dedicated v’s rotational or hybrid staffing options

Training and development

Review of feedback

At the staff workshops in June, staff feedback that the chosen model must: •Provide access to help in a timely way to achieve the right outcome•Support delivery of consistent and safe services

Staff also took part in a number of discussions about the options and staffing arrangements

What we know we need to get right

Dr Nigel AshurstNigel, a Consultant Psychiatrist in a Crisis Resolution Home Treatment team, is the clinical lead for the project. Nigel is also the Assistant Medical Director for Urgent Care and has been involved through NHS England in regional work to review and recommend strategies for improving Urgent Care in Mental Health.  Rheanna MitchellRheanna works in the Programme Management Office and is the Strategic Programme Manager for the Trust’s Transformation Programme. Rheanna has experience in managing complex change programmes and engaging with commissioners.  Caroline BladesCaroline is the dedicated programme manager for the Single Point of Access project. Caroline, a qualified AMHP and Nurse Prescriber, has many years experience working in the community duty function.

Daniel LeeDan is an experienced psychiatric nurse who has been working in a crisis team for a number of years, most recently as an operational manager. He joined in May 2015 and is leading on implementation.

Portia SharpinPortia joined in June 2015 and is also an experienced clinician who has worked on large scale projects for KMPT in the past. Her focus is engagement and communication.

Introducing the project team

Getting involved If you have any thoughts or questions please contact Singlepoint.access@kmpt.nhs.uk  

Any Questions?

DiscussWorking with Primary Care

How can we work with Primary Care to improve your experience?

Time for a break

Feedback

Peer Support

“If she can do it, so can I”Service user feedback from INSPIRE

What is Peer Support?....

It is a therapeutic relationship that is an equal one with mutual respect and empowerment between

people that have lived experience of mental health illness not based on the traditional model of ‘helper’

and ‘helpee’.The approach is simple; the sharing of

understanding, empathy, transparency and hope informed through lived experience. Working

collaboratively with others to make positive changes for a happier healthier future.

8 core principles of Peer Support1. Mutual2. Reciprocal3. Non-directive4. Recovery Focused5. Strengths Based6. Inclusive7. Progressive8. Safe

How many and where?....

•Embed the serviceTo encourage and share trust-wide the uniqueness of this role “that together Peer Support and professional staff bring a richness to the client experience not present in either one alone” Service Line training and promotion of Peer Support RolePeer Workers ultimately in every service and group in the trustThrough the communications department with articles in publications around innovation and best practice

•Evaluation of Peer Support Practice•Providing a clear career structure for Peer Support Workers•Increase the workforce•Be involved with National developments and communicate these through the trust•Peer Support Workshop Meetings to provide continued support and training to our Peer Workers•To carry out research on the impact of Peer Support

Through Vocational Rehab – job taster programmeGroup Work – via KMPT Bank – Catherine Powell

Voluntary WorkKeep an eye out for the new posts as they come

up on the NHS Jobs sitePlease come and talk to either Natalie Livesey or

myself Louise Jessup, Joint Peer Leads

Question Not At All Not Much Somewhat Quite A Lot Very Much 1. I feel Appropriately supported by other people 1 6 10 18 302. I am encouraged to have hopes and dreams for the future 0 2 10 24 293. I am encouraged to feel good about myself 0 4 6 26 294. I am supported to do things that mean something to me 0 0 9 20 365. I am encouraged to feel in control of my life 0 1 16 16 32

INSPIRE Feedback

INSPIRE Feedback“I am on track, to the point I will be discharged soon. That’s due to my peer support worker”

“My worker helps me keep a balance”“I can see a better future for me, because I can see how far my peer support worker has come”“I feel able to get my life back- I can understand

a new life ahead- thank you 100%”“I feel more in control of my life - my peer has

shown me never to give up hope”

Care Planning

Guy PowellNick Dent

Appreciative enquiry based on 2 important principles:

1) those involved in operating and participating in a given system are best placed to determine how that system can be improved;

2) whatever is the focus of an investigation tends to increase, both in terms of significance and commonality.

4/5 D cycle

DiscoveryThe best of what is

Appreciating

DreamWhat might be?Desired future

Envisioning

Results

Design What should change?

Co-constructing

DestinyHow to empower, learn and adjust/improvise?

Sustaining

4-D Cycle

Focussing on 3 areas of care planning national patient survey

results indicate we need to improve

• Ensuring peoples views are taken into account when planning their care

• Including the goals that the service user would identify for themselves in care plans

• Ensuring service users are ‘given enough time to consider their condition and treatment’

Recommendations and Actions

The Approach

Strength based approachHolisticGoal setting

Training

• Principles already imbedded within online training/ basic training (training DVD)

• 1 day training (mandatory for some)• Service user involvement• Start October 2015• Post graduate training (student)

Process

• Care planning competency test at interview

• Care planning champions• Peer audit• CPA review checklist and leaflet • Care plans specific to memory clinic• Ensuring that care plans within letters are

recognised as care plans (Psychiatrists)

Systems

• Revising RiO care plan (following feedback event)

• Considering use of carbonated paper/ digital technology

• Patient Portal

What are your priorities in

care planning?

Moving forward

Thank you for joining us.