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

NHS England and NHS Improvement

Addressing Out of Area Placements: National Webinar Mental Health Team, NHS England and NHS Improvement 6th December 2019

Chaired by Claire Murdoch, National Director for Mental Health

Agenda

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Aims of the session Claire Murdoch, National Director for Mental Health 10:30 Reflections on the work to date to reduce OAPs Dr Mike Hunter, National Specialty Advisor for Adult Mental Health 10:35 Examples of local progress

• South London and Maudsley

NHS Foundation Trust

• Nottinghamshire Health Care

Foundation Trust

• Norfolk and Suffolk Foundation

Trust 10:40 Q&A for local areas All – please submit questions via the chat box 11:10 Overview of enhanced assurance and support Bobby Pratap 11:20 Final questions and wrap up All – please submit questions via the chat box 11:25 Close 11:30

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
• f 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.

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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
• f being sent out of area for care currently experienced by thousands of people each year.

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• The analysis shows the

OAPs activity trend (by rolling quarter) up to August 2019/20.

• The blue line is the rolling

national total

• The orange line removes

the most challenged 5 providers in 2019 to date, and the grey line removes the most challenged 10.

Inapproriate Out Area Placement Bed days data comparison for Sep 17 - August 19 (rolling quarter)

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

• f 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 community services to sustainably manage capacity and demand across the system.

• Senior leadership and a clear shared local vision

focused on the quality of care are critical for delivering change.

This graph shows that OAPs (the orange bars) occur across providers with highly variable bed bases (blue bars).

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www.slam.nhs.uk

SLaM Right Care Programme NHSE/I Update

Wednesday 4th December 2019

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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

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www.slam.nhs.uk

OAP Reduction Trajectory – actual v target

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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

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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

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

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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

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What we did

Work together to tackle the wicked problem

• Better use of improvement methodology – used the data

to identify the issue

• Joint CCG and provider recovery action plans developed
• Training programmes developed for staff to improve risk

management and increase home treatment options

• Multi agency OOAP taskforce Chaired by medical

Director Management changes

• Admission processes reviewed
• Weekly performance Huddles
• Flexibility with bed stock

Subcontract arrangements – focused on the area with the biggest demand

• 2017 -2019– first subcontract arrangements agreed 5

beds increased to 40 in May 2019- in areas of highest demand.

• 2018 Continuity of care principles agreed with

commissioners and NHSE Increase funding /resources

• Crisis House
• Step down unit
• Investment into Crisis to Core fidelity levels
• Street triage expansion
• Bed management team

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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.

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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

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Our performance journey

1818 1941 1790 1682 1722 1793 1926 1229 770 892 1162 1265 920 802 833 861 812 412 254

1770 1829 1770 1550 1550 1500 961 930 961 868 784 868 1131 1169 1131 682 682 660 589 570 589 491 459 491 apr may jun jul aug sep

• ct

nov dec jan feb mar apr may jun jul aug sep

• ct

nov dec jan feb mar 18/19 Qtr 1 18/19 Qtr 1 18/19 Qtr 1 18/19 Qtr 2 18/19 Qtr 2 18/19 Qtr 2 18/19 Qtr 3 18/19 Qtr 3 18/19 Qtr 3 18/19 Qtr 4 18/19 Qtr 4 18/19 Qtr 4 19/20 Qtr 1 19/20 Qtr 1 19/20 Qtr 1 19/20 Qtr 2 19/20 Qtr 2 19/20 Qtr 2 19/20 Qtr 3 19/20 Qtr 3 19/20 Qtr 3 19/20 Qtr 4 19/20 Qtr 4 19/20 Qtr 4

Acute Mental Health: Monthly Performance - Out of Area days vs trajectory (green actual, blue target trajectory)

Inappropriate Out of Area Placements

All data is collated from existing reports visible to services and stakeholders as of the 30th November 2019

How we compare to the rest of the country

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• Between February and April this year, Norfolk and Waveney was within the top

three areas for the highest numbers of out of area placements.

• A Deep Dive with NHSE/I and system partners was held on 24th July 2019 and the

national position below was discussed for context.

Top 10 providers > 60% of activity Top 5 providers > 40% of activity

What is happening with OoAPs now?

• Inappropriate out of area placements (bed days) for adult mental health services is at it’s lowest point for this financial
• year. A system-wide action plan has been developed and supported by CCGs and NHSE/I. A new 16 bed mixed sex adult

ward opened at the end of September 2019.

• NSFT, Norfolk & Waveney CCGs and NHSE/I have collaborated through a new Patient Flow Mobilisation group to review

and approve, monitor and challenge a number of change projects designed specifically to positively impact on the OoAP

• position. NSFT Executives are monitoring the position on a weekly basis.

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10 20 30 40 50 60 70 80 90

Out of Area Placements by number of individual service users (excluding specialist placements)

0.0 500.0 1000.0 1500.0 2000.0 2500.0

Out of area placements for adult mental health services (excluding specialist placements) - Total bed days

What next?

• The work so far has had a big positive impact on OoAPs. However more

steps are needed to ensure that in the future no one is inappropriately placed in an acute mental health bed far away from home.

• There are now three key areas of focus:
• Community mental health services capacity and transformation – with

plans to deliver as much mental health care as possible at a Primary Care Network level.

• Crisis responses – additional funding is being used to strengthen crisis

team services in NSFT and increase mental health support within the QEHKL and JPUH.

• Reducing DToCs – working with housing, social care, district councils

and wider services to support people to leave hospital at the right time.

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What more can we do to support delivery?

Enhanced Assurance

• With the limited time remaining to deliver our commitment, we must make the most of the new funding

secured in the LTP and maximise our focus and efforts on reducing OAPs.

• As such, we will be asking for more regular updates and for key information from those system which

are not demonstrating sustained improvement.

• The areas with the highest challenges will be asked to engage directly with Claire and the national

team on a regular basis, providing an opportunity to review progress and to help address any ongoing support requirements. Enhanced support

• Following feedback from local systems and regional teams about additional support requirements, we

are aiming to establish formal buddying arrangements between provider organisations, which will enable peer-to-peer longer term support provided by areas that have recent experience of reducing

• OAPs. The offer will be made initially to those systems which are experiencing the highest pressures.
• We also intend to develop some further options for support in partnership with the NHSE/I

Improvement Directorate, based on feedback from systems which we will obtain through the regular engagement outlined above.

• Is there anything specific that you think would be particularly helpful?

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Q&A?

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Suggestions for additional support from NHS England and NHS Improvement?

If you have further question or feedback following this webinar, please contact: ENGLAND.mentalhealthperformance@nhs.net