Older People’s Mental Health (OPMH) services in Harrogate and Rural District Service redesign proposal

Who are the users of older people’s mental health services ? People over 65 years who have developed a functional mental illness (e.g., depression, prolonged grief reactions, anxiety, phobias, drug and alcohol dependency) people who have had a long-term mental illness (e.g. schizophrenia, bi-polar disorder, personality disorder) and who have reached 65 years older people with organic illnesses (dementias, e.g. Alzheimer’s disease, vascular dementia) People under 65 years with dementia

Why has demand for in-patient services changed? National policy drivers from in-patient to more community based care Older people prefer to be supported at home and in the majority of cases this environment is best for their mental health Rapid Response and Intermediate Care Team for EMI (RRICE) new service set up from April 2004 Reduction in the number of older people mentally fit for discharge but waiting for long-term placement (delayed transfers of care) – Reduction in admissions – Improved joint working between health and social care – Increase in independent sector long-term care beds

Background Part of an ongoing service improvement process Proposal for refurbishment of the in-patient unit at the Orchards was approved by the CHaRD PCT Board in March 2006 with agreement to examine bed capacity and demand Evaluation strategy was agreed by the Harrogate and Rural Strategy and Planning group in Summer 2006 following engagement with stakeholders OPMH service has been working with 36 beds since October 2006 Data collected for 4 month evaluation period, the evaluation period was considered by the clinicians and managers to be representative of the true situation, but to ensure we have closely monitored information since Proposal scrutinised by SHA following the DoH new service change assurance process

Service provision since October 2006 Over the past 15 months people requiring in-patient beds for assessment, rehabilitation, booked medical respite or emergency respite have continued to receive a service at either Rowan ward or Alexander House. Orchards day hospital continues to provide a service, CMHT and MDT use office space. No requests received from carers for support with transport for visiting Service has enough in-patient beds to meet referrals – December 2007 Alexander House had 76% occupancy and Rowan ward had 72 % occupancy – Current delays as of January = 7, over the last month delays have ranged between 4 - 7

How has the PCT engaged with people affected by the proposals? A range of engagement approaches have been used – March 2006 letter to users and carers – April 2006 meetings at the Orchards and Alexander House – Telephone calls and meetings with users / carers when requested – May 2006 and October 2007 Older People’s reference group – July 2006 meeting organised by Alzheimer’s – September 2006 Public meeting in Ripon – Contact with service user who sits on Mental Health Local Implementation Team – December 2007 letters sent out to users / carers – January public consultation meetings – In 2006 and 2007 had staff meetings and 1:1 meetings with staff affected – In 2006 and 2007 held meetings with NYCC and voluntary services staff

Proposal for in-patient beds Remain at a capacity of beds remain located on Rowan ward at Harrogate District Hospital 16 beds remain located at Alexander House community unit – Consideration given to stakeholder feedback: 1. How could more beds be provided in future if needed to meet change in referrals? 2. Travel distance for people accessing the beds the most (for booked medical respite)

Favoured option – Alexander House Following a detailed option appraisal the PCT favours this option because: access to regular respite admissions allows an older person with severe / complex mental problems to remain living at home. Alexander House historically has provided more booked and emergency respite beds the layout of Alexander House means that we could fit more beds in if we need to in response to increase demand in future it has bigger bedrooms and better wheelchair accessibility Alexander House is nearer to acute OPMH Services, such as the Rapid Response and Intermediate Care Team and CMHT base The Orchards has a layout and room sizes that could lend it to different uses that are being explored by the PCT commissioners.

Approach for determining redesign Local unmet and ill met needs Best evidence for outcomes, e.g. – Treatment of Choice in Psychological Therapies and Counseling: Evidence Based Practice Guideline Policy drivers, e.g: – NSF for Older people and NSF for Mental Health – Everybody’s business service delivery guide – Who Cares Wins – Improvement, Expansion and Reform: The Next 3 years-Priorities and Planning framework – Our health, our care, our say: a new direction for community services – New ways of working for psychiatrists, NWW for mental health nursing – Mental Health: New Ways of Working for Everyone Developing and sustaining a capable and flexible workforce – Mental Health: Britain’s Biggest Social Problem – Organizing and Delivering Psychological Therapies

Proposal for redesign If beds remain at 36 then sum available for redesign = £536,400 The proposal is that the full amount saved by reducing bed capacity is to be reinvested within OPMH services locally to meet identified unmet or ill met needs.

Redesign proposal: CMHT and Psychology Increase capacity of community mental health teams (CMHT) by: (£192,080) 3.5 whole time equivalent (wte) mental health (MH) professionals 3 wte healthcare assistants Increase Psychology assistant 0.5 wte to 1.0 wte (£11,370)

Redesign proposal: Primary care mental health service Increase capacity of PCMHS: (£113,360) 1 x 0.5 wte MH professional (Band 7) Cognitive behaviour therapist (CBT) 1 x 0.5 wte MH professional (Band 6) CBT 2 x 1 wte MH professional (Band 5) Primary Care Link worker 1 x 0.5 wte Band 4 Graduate Worker Post 1 x 0.5 Band 3 Secretarial

Redesign proposal In-patient services Increase capacity by: – 2 wte registered mental nurse (RMN) on Rowan ward (£62,200) – 2 wte RMN for Alexander House in-patient service (£62,200) Increase Mental Health Liaison RMN – from part time (26 hrs) to 1 wte (£11,540) Increase secretary for consultant psychiatrist to 1 wte – 12.5 hours Band 4 secretarial time (£6,700)

Redesign Proposal Day care partnering with voluntary services Joint service based in PCT premises, using a day hospital that is not open at weekends Extension of Day Services to include weekend working by providing an additional 1.00 wte Band 5 Registered Mental Health Nurse (£32,100) PCT plans to invite tenders to partner to deliver this service Budget allocated for delivering service in partnership with 3 rd sector (£44,850, with remaining balance to be allocated to 3 rd sector commissioning)

Role of voluntary services PCT already engaged in interagency work on pathways, role clarification, role development Example: carers resource worker attached to memory clinics, role expanding to all out- patient clinics Example: Role of Alzheimers with people diagnosed with a dementia such as jointly provided Memory Activity and self help group

Future use of in-patient space at the Orchards Commissioners at the PCT are looking at reutilizing the unit to support people with mental health problems Commissioners evaluating the needs of older people with mental health problems and younger people with dementia who currently receive treatment and care out of the PCT area If this type of proposal was to be supported by the PCT Board the Orchards would continue to have beds for older people with mental health problems.

What happens if we don’t make these improvements? Insufficient referrals to fill 16 extra beds People with common mental illness (e.g. depression) will continue to go unrecognised, only have access medication from their GP or experience a long wait for CMHT input waits for community mental health teams, psychology assessment, mental health liaison and funded nursing care assessment inadequate staffing levels of RMNs on in-patient services to meet the acute mental health needs of patients and for effective 1:1 intervention Negative impact the ability of RRICE to transfer so more people admitted to hospital unnecessarily.

Summary of benefits of redesign earlier assessment and diagnosis in PCMHS, out- patient clinics and through CMHTs more people to be effectively treated as an in-patient both in OPMH and medical settings, through PCMHS and through CMHT More capacity for CMHT to provide interventions to enable people to remain living at home for longer More responsive service for funded nursing care assessments and reviews Another option for day care for people with complex needs More robust commissioning with the voluntary sector

Questions and comments

Delayed Transfers of Care (DToC)

Length of stay

Bed occupancy

Average weekly occupancy rate for baseline period ( – ) Average weekly occupancy rate for evaluation period ( – ) % difference in average weekly occupancy Alexander House 89.9%88.6% 1.3%  Rowan ward 91.7%86.8% 4.9% 

Readmission rates There was a reduction in readmissions during the evaluation period, from 3 readmissions during the baseline period to only 1 readmission in the four months following the reduction to 36 beds. 66.6% reduction. Conclusion: The hypothesis that a decrease in bed capacity, from 52 to 36 beds, would lead to an increased readmission rate was NOT supported by the data.

Bed capacity the hypothesis that a decrease in bed capacity would lead to an increased pressure on capacity resulting in more incidents of beds not being available for an admission or for a transfer from other wards when required was NOT supported.

Respite bed capacity During the evaluation period all respite needs were addressed. the hypothesis that a decrease in bed capacity would lead to an increased incidence of required respite admissions being delayed or cancelled was NOT supported during the four month evaluation. 22 people receiving booked respite as of February Working on an allocation of 6 / 16 CUE beds for respite then as of 11 Feb 2007 there were 112 respite care weeks available until 31/12/07 This is considered sufficient to meet current and projected levels of demand.

Staff short term sickness

RRICE referrals

Harrogate and Wetherby CMHT

Rural CMHT waiting list

Capacity for Funded Nursing care reviews

HypothesisResult of Evaluation That DToC would  Not supported % of bed capacity occupied by DToC would  Not supported bed days lost 44.6%  That length of stay would  Not supported, slight increases That readmission rate would  Not supported 66.6%  That bed occupancy rates would  Not supported 1.3%  - 4.9%  That staff short-term sickness rates would  Supported. average increased 2.98 to 4.3% That RRICE referrals would  Not supported 19.2% 

Impact of redeploying staff HypothesisResult of Evaluation That CMHT waiting lists would  Supported  38.1% and  9.7% That outstanding FNCC reviews would  Supported  80.2%

Conclusions Positive benefits have been achieved by the redeployment of staff. This had lead to: the filling of some vacant posts on in-patient areas leading to better consistency of care and a reduced spend on agency nursing the enhancement of community mental health team staffing, with a positive impact on waiting lists and an improved ability to triage new referrals and to increased capacity for funded nursing care assessments which had resulted in a dramatic reduction in the number of outstanding reviews