Dr Sarah Oke presentation

Improving Mental Health Crisis Care Dr Sarah Oke Consultant Bristol Intensive team and Clinical lead in Crisis for Strategic Clinical Network

Strategic Clinical Network • National and Regional network • Support commissioners and clinicians to provide high quality services across the region • Crisis workstream • 2nd Crisis collaboration conference on 1 st May in Taunton Cricket ground. “Crisis Concordat” • 3rd Conference will be on 1st October 2014

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Background Crisis concordat and the Regional context Bristol Intensive team (and its problems) Where and how do people in crisis present?

5. Place of Safety and s136 6. Challenges for us here

Bristol • Population 430,000 • Mixed – some of the most deprived and most affluent areas in the country • 16% BME • Age profile- younger than England’s average

Bristol’s mental health • Higher rates of depression, self harm A&E presentations, alcohol and drug misuse and people with complex mental health needs compared to national averages • Strong third sector including two Crisis houses (male and female) • And mental health services in turmoil

Bristol’s retendering of mental health services Led from criticisms by service users, GPs and others. These were particularly about the crisis service and included• slow response, inadequately resourced crisis service, no crisis service for drugs and/or alcohol users, poor support to police and ambulance services and poor response to people in emotional distress

Overview 1.

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Background Crisis concordat and the Regional context Bristol Intensive team (and its problems) Where and how do people in crisis present?

5. Place of Safety and s136 6. Challenges for us here

Crisis Concordat • ‘No one in crisis is turned away’ • ‘Responses to mental health crises should be on a par with responses to physical health crises’ (Predictability and quality of response) • Strong working relationships between mental health crisis services, police, ambulance services

Concordat continued • • • • •

Enhanced crisis teams Enhance liaison services POS hospital- based, transport of s136 Speedy of response for MHA assessments Admission to local beds

Overview 1.

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Background Crisis concordat and the Regional context Bristol Intensive team (and its problems) Where and how do people in crisis present?

5. Place of Safety and s136 6. Challenges for us here

Bristol Intensive team • 24/7 • Self referrals accepted • Main tasks – home treatment and gate keep/manage all admissions • Multi disciplinary • Not crisis team but 4 hour response (soon to be 90 minutes)

BIT - problems • Name - ‘Intensive’, not crisis • Inaccessible – telephones unanswered • Underresourced – stretched and unable to answer all the demands • Public face of a system under pressure

Overview 1.

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Background Crisis concordat and the Regional context Bristol Intensive team (and its problems) Where and how do people in crisis present?

5. Place of Safety and s136 6. Challenges for us here

Where do mental health crisis present?

• 999, Ambulance service, Hospitals, police stations and police officers on street, British transport police, GPs (in and out of hours), 111, Bridgemasters, Walk in centres, non statutory help lines, Crisis teams, mental health community teams …….

What is the response?

Case A. •23 year man walks into a police station asking police officers to arrest his delusional (non existent) persecutor. Very distressed. •Arrested, s136, police cells then transferred to POS then admitted under s2.

Case B • 27 year old man walks in to police station asking police officer to stop him going to Clifton suspension bridge where he will commit suicide. • Police phone BIT, take him home and handover to BIT. He is then successfully treated at home.

Case C • 21 year old woman acute psychosis, very disturbed life threatening behaviour • Over 2 weeks- Family call OOH GP, take to GP, take to walk in centre, dial 999, speak to ambulance control, no response, GP again, get referred to 2ary services (lost referral?), police stop on street after running in front of traffic, take to A&E, discharged, police called to shop, s136, police cell, detention eventually admission to hospital under s2.

Case C continued 7 missed oppurtunities for intervention Primary care, ambulance service, police, A&E and mental health services all failed her.

Resulted in •Poor service user experience (and family) •Repeated high risks inadequately dealt with •Wasted resources

Overview 1.

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Background Crisis concordat and the Regional context Bristol Intensive team (and its problems) Where and how do people in crisis present?

5. Place of Safety and s136 6. Challenges for us here

POS and s136 • 4 beds for BNSSG and BANES since February 2014 • 50% Increase in use of s136, particularly intoxication with drugs and alcohol • Partially meets Concordat requirements

However…

• Delays in assessment – 60% over 9 hours.

Main reason – lack of beds • Many not detained, taken on by services or admitted informally (30% admitted, 20% community services) • Cost of MHA assessment approx £500 each • Can we design a least restrictive service by working alongside police?

Overview 1.

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Background Crisis concordat and the Regional context Bristol Intensive team (and its problems) Where and how do people in crisis present?

5. Place of Safety and s136 6. Challenges for us here

Challenges for Mental health services 1. Accessibilty - Support police and ambulance staff dealing with mental health crisis by sharing information and share in decision making. Mental health cop – examples of good practice – Leicester street triage, Lincoln dedicated telephone line 2. Sharing information –duty not a risk

Cont..

3. Contribute to training of police and ambulance staff 4. Increase accessibility to service users and others (real self and carer referral) 5. Widen remit to support emotional distress 6. Provide local beds when admission is necessary

Challenges for General hospitals 1.Treat mental health crises on a par with physical health.

2.Better Liaison services (24/7) 3.Host General hospital based POS in some cases of intoxication and withdrawal and other’ red flag events’

Challenges for Ambulance services 1. Treat mental health crises on a par with physical health crises.

2. Training for paramedics 3. Share information 4. Transport for s136 patients

Challenges for police 1. Promote role of police in mental health crises within police force 2. Share information with other agencies 3. Collaborative working – Leicester, Lincoln models, ‘www.Mental health cop’ 4. Support mental health services when working in risky situations 5. Train work force appropriately

Challenges for Substance misuse services • Provide services to service users in crises

Challenges for commissioners 1. Commission adequately resourced Crisis teams and hold them to task 2. Commission A&E, liaison, substance misuse ‌ 3. PbR? Pay crisis teams to work with the emotionally distressed 4. Commission local beds (and alternative to admission facilities) 5. Hold all agencies to task in signing up to and monitoring outcomes of local concordat

Conclusions 1.

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Background Crisis concordat and the Regional context Bristol Intensive team (and its problems) Where and how do people in crisis present?

5. Place of Safety and s136 6. Challenges for us here

Do more with less Cost savings•Beds- OOH expensive (and bad for SU and carers) •Reduce s136 (and provide less restrictive alternative) •Use technology •Self referrals (eg Case C) •Collaborative working/sharing information and decision making (saving time and resources) – and make better decisions

1st May 2014 Taunton Cricket Club Time

Item

09.30am

Registration and Coffee

09.45-10.00

Welcome and introductions - Dr Adrian James

10.00-10.45

The Ambitions of the Crisis Concordat – Dr Geraldine Strathdee ( National Clinical Director Mental Health -NHS England) & Anne Macdonald (Department of Health)

10.45-11.15

Implementing the Concordat – Mind Team

11.15-11.30

Refreshments

11.30-12.00

IT Support for Clinicians – Tom Griffin

12.00-12.45

Early Implementer Progress Report – Gloucestershire Declaration Task and Finish Group – Eddie O’Neil and Colleagues

12.45.1.30

Lunch

1.30-2.15

Locality Group Work – Developing our Concordat Declaration

2.15-3.00

The Devon Street Triage Project – Karla Palmer-Wilson and Mark Bolt

3.00-3.45

The Leicestershire Street Triage Project – Matthew Wakely and colleagues

3.45-4.00

Reflections on the day

4.00pm

Close