1. EAST MIDLANDS REDESIGN OF ADULT SECURE SERVICES
NEW CARE MODEL (IMPACT) PROGRAMME TEAM

2. Purpose of this Session
To provide you with information around the changes to the commissioning of specialist mental health services including timescales
Information about the East Midlands new care models programme for adult secure services
The proposed new clinical model for adult secure services and how it is being developed
Further information is available via the Nottinghamshire Healthcare NHS Foundation Trust website.

3. The National Picture

4. Overall Aim:- Provide better support in the community, less reliance on secure beds to achieve improved outcomes for service users and their families
How we will achieve this:- Shorter lengths of stay, reduced admissions, improved community infrastructure

5. New Care Models in Adult Secure Maps of Coverage

6. New Care Models: National Progress
There are 8 wave 1/2 sites for adult secure
All have identified savings through less use of inpatient beds by providers working together
They have each reinvested into community services including step down, intensive community support and adult mental health services such as crisis.
They have introduced new ways of working such as:
Streamlined assessment systems for example through Trusted Assessor
SPA into secure services for a region
Introduced new care pathways

7. Redesign of Services: National Update
NHSE are aiming to delegate its specialised commissioning functions and budgets for all adult secure services across England by April 2020 (CAMHs & adult ED April 2021)
They are in the process of developing guidance and proposals as to how this will happen during 2019
“Provider Collaboratives” are working together to identify what a new model will look like in their regions. Within this a Lead has to be agreed to take this work forward with NHSE; for the EMs it is Nottingham Healthcare NHS FT
A business case will be submitted to NHSE later this year that outlines a new clinical model; new partnership for the EMs; financial arrangements and how all of this will be monitored in terms of quality and success.
New contracts will be awarded by December with sites live across most of England by April 2020.

8. The East Midlands Programme

9. East Midlands Programme
We are using this as an opportunity to completely redesign adult secure services in the East Midlands (5.1m population)
Potential inclusion of all adult secure services in terms of pathway redesign and interfaces
Inclusion of transforming care (secure services) people and associated budgets
More focus on early intervention, prevention and enhanced primary care as part of a more robust community offer
The organisations involved are:
NHS Trusts
Independent Sector
Derbyshire Healthcare
Leicestershire Partnership
Lincoln Partnership
Northamptonshire Healthcare
Nottinghamshire Healthcare
Cygnet Healthcare
Elysium Healthcare
Priory Group
St Andrew’s Healthcare

11. Proposed Benefits of the Programme
Better quality of life and experience for service users and families
More people being effectively supported within community settings (and not readmitted into either forensic inpatients or adult acute services) with access to educational and employment opportunities
Avoidance of people entering into forensic mental health services without a negative associated impact on other services such as adult mental health
Faster admission into a secure unit if required without any unnecessary delays through improved gatekeeping and assessment processes on a regional basis.
Reduction in time spent in an inpatient unit
People being repatriated from placements out of area and a reduction in people going into inappropriate placements
Reinvestment into new community services.

12. East Midlands Region
558 East Midlands Patients in Adult Secure Care (including high secure)
472 in Region
86 patients placed out of area

13. East Midlands Region 1 - High Secure Hospital 4 - Medium Secure Units
13 - Low Secure Units
340 - High Secure Beds
293 - Medium Secure Beds
410 - Low Secure Beds
Bed total : 943

14. The Clinical Model

15. Development of a New Clinical Model: What does a good secure service look like?
Based on a set of guiding principles for example: 
Person centred and personalised care and support
Recovery focus
Least restrictive environment and care
Place based ie closer to home
Safe community alternatives to inpatient care
Focus on evidence based outcomes across new pathways of care
Innovative and proactive approach to preventative care
Inclusion of families and networks
Focus on empowerment, self-reliance and building resilience.

16. Clinical Model: What do we want to achieve?
More community focused model
Less inpatient beds
People spend time in an inpatient facility only when needed; at the right level of security and for the right length of time
Admission when required without undue delay
Through:
Developing a single point of access across the region for referrals into secure services
Streamlined assessment systems: “approved assessor”
Regional bed management system
Improving transitions including not conducting access assessments at every security move
Multi-disciplinary and organisational oversight of all people in secure services through a clinical hub- single point of exit
Improving learning disability and autism pathways for secure care
Improved community infrastructures (new CFS bid)

17. Clinical Model: Component Parts
Improved admission: regional single point of access (SPA); access assessments; trusted assessor; regional bed management system
Care & treatment: new care pathways; assessment; trauma informed approaches; improved therapeutic interventions; service user and family involvement
Improved transitions and discharge arrangements
Service developments: inpatient developments and reconfigurations; assertive transitions service; step down services; step up services
Community infrastructure: enhancement of community forensic services including core functions and role across the region; enhanced primary care model; prevention and early intervention
Integrated governance arrangements for clinical care: risk management; clinical outcomes measures.

19. Co-Production Workshops

20. Co-Production Workshops: Guiding Values/ Principles
Around 40 people attended the first workshop from across the region; this is what people said as values & principles for any new model:
Patient, carer, significant other and support network experience
Personal goal focused
Supporting reduction of stigma
Knowing what opportunities are out there
Creating an environment where people want to work, including educating the community about the risks / benefits of working in forensic services
Supporting places to employ ex-offenders
Community centred approaches, resulting in capable, confident communities

21. January Session: Challenges & Solutions
General themes were:
Need for a more rapid single assessment process as opposed to long waits and multiple assessments: action “approved assessor”
Lack of service user choice where placed
People are often “stuck” in secure services; lack of consistency with monitoring people for their whole journey
“Single point of exit” seen as a solution to this ie closer oversight of people when in inpatient services
Do we need levels of security? Move away from this?
Need to target support very early on when an inpatient to support discharge
Extended period of support needed on discharge
Need to be much more community focused and use community resources- access to meaningful employment & education
Consistent theme around use of peer support and support workers both in inpatient and in community teams; use of care navigators
Access to mental health care when in prison- can this be done differently?
Tensions between NHSE and CCG funding.

22. February Workshop (1)
62 people attended from across the EMs including a number of service users. Cygnet Derby service user group and NHCFT did a presentation about the work they have done around values and what is important to them around this service redesign. The improved admission T&F group did a presentation on the work so far which was discussed in small table groups. The afternoon focused on peer support developments in forensic services. In terms of learning/ issues people took away from this session, the overwhelming response was around peer support ie taking this back into respective organisations and developing the role. A lot of people said they felt enthused around doing more work around service user involvement.

23. February Workshop (2)
“Joint working between service users and “professionals” really changes the quality of the conversation in positive ways.” Attendee “Informative and passionate approach to moving forwards” Attendee (service user) April 24th Workshop Focus is on facilitating discharge and effective support in the community. There will be service user groups presenting their work on this subject area and service user experiences as well as the national Recovery & Outcomes lead (Ian Callaghan) presenting. (

24. Our Proposed Name for the East Midlands New Care Model
IMPACT
Improving Mental Health Pathways and Community Teams
Having a positive IMPACT on our future.

25. Key Messages
NHSE specialised commissioning is fundamentally changing across England; the responsibility and money is moving to groups of Providers by April 2020
The EM programme is about major transformational change; it means that inpatient beds will likely reduce- they may be realigned across the region. But we do not have a plan around this yet.
The focus will be around developing better community support
Providers will be working together to make changes including better pathways of care and streamlined processes.

26. Documents
Exploring the lived experience of women in secure care services 2018 Carer support & involvement in secure mental health services: a toolkit (NHSE)

27. Discussion & Questions
Further information available via Nottinghamshire Healthcare NHS Foundation Trust website