Item 11

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Date Wednesday, 23 September 2015

Presenter Tessa Sandall, Acting Managing Director

Author Cath Attlee, Head of Integrated Commissioning

Responsible Director

Tessa Sandall, Acting Managing Director

Clinical Lead Serena Foo, Mental Health Lead

Confidential Yes ☐ No ☐Items are only confidential if it is in the public interest for them to be so

The Committee is asked to: Approve investment of £404,000 in the urgent mental health assessment and care pathway in 2015/16 and £987,000 in 2016/17 recurrently; and

Agree to work with WLMHT and CNWL, with the other CCGs in North West London and with the Metropolitan Police to consider future investment in a Street Triage approach to consider its potential impact and whether it is appropriate for West London.

Summary of purpose and scope of report

Over the past two years partners across North West London have been working to co-produce improvements to the secondary care urgent mental health assessment pathway, agreeing key principles such as ease of access and speed of response.

The NWL journey towards achieving better mental health crisis care began in April 2013 with a series of large-scale co-production events involving GPs, service users, carers, secondary health clinicians and managers, local authorities and third sector. This culminated in development of a clear set of standards for assessment, available to all referrers, 24/7/365, standardised processes and ‘paperwork’, a requirement to create a single point of referral and that when a crisis assessment in the community was requested it was provided within these standards.

The development of this business case has been supported through the establishment of an Urgent Care Expert Reference (jointly chaired by the GP Mental Health lead for Hammersmith and Fulham CCG, Dr Beverley McDonald), a 2014/15 contractual CQUIN and support from Northumberland Tyne and Wear NHS Trust (commissioned by NWL Strategy and Transformation Team). On-going review has been undertaken with the oversight of West London Mental Health Transformation Board and the Urgent Care Sub-group.

The attached paper brings together that work, including the proposal for additional

Title of paper Mental Health Urgent Care & Assessment Pathway Redesign

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investment in West London Mental HealthTrust (WLMHT) to deliver the required changes. It sets out the rationale for investment in new, more effective urgent care pathways for people in mental health crisis which will improve the quality of care and outcomes for patients and value for the local health and social care economy. It represents the first stage in transforming the way in which mental health services are delivered locally.

Earlier this year the Clinical Executive Committee and the Finance and Performance Committee considered the business case submitted by West London Mental Health NHS Trust and supported the model proposed. However, they asked for some additional information on the benefits to be achieved through the model and how it would deliver the proposed changes. NWL CCGs commissioned Northumberland, Tyne and Wear NHS Trust to work with WLMHT on the business case, since they are already well advanced in developing a similar model.

The revised business case has now been considered by clinical leads and commissioners from the three WLMHT facing CCGs and approved by the relevant CCG Finance and Performance Committees (31st July in Ealing CCG). While further work will be undertaken with stakeholders to model demand and capacity during the preparatory phase, this paper seeks approval for the Trust to commence implementation of the proposals with a view to full implementation from April 2016.

A high level implementation plan and risk log are attached along with a benefits realisation plan and a detailed breakdown of costs.

Quality & Safety/ Patient Engagement/ Impact on patient services:

The driver for the business case is improving the quality and effectiveness of the urgent care pathway through developing a single point of access for mental health crisis, delivered by a newly formed Home Treatment and Rapid Response Team, available 24/7/365 delivering to the following standards:

• Emergency < 4 hours• Urgent <24 hours• Routine plus< 7 days• Routine < 28 days

The benefits to patients will include:

• Referrals will be consistently triaged and where required given a timely appointmentand assessment

• People will have timely specialist assessment that meets the new standards• Continuity of care will be improved• There will be a reduction in people presenting to A&E with a mental health crisis• People will be cared for in the least restrictive setting

There was some limited patient involvement in the NWL Urgent Care Reference Group which developed the standards, but there will be further testing of implementation by West London service users and carers as part of the mobilisation.

The Single Point of Access (SPA) will provide refers with ‘one route in’ supported by a single

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telephone number available 24/7 every day of the year, thus enabling patients to have access to services and to receive the most appropriate treatment when experiencing a mental health crisis. A key feature of the SPA is all patients will receive a face-to-face assessment and GP’s can be assured once a referral is made to the service the patient will be assessed and managed safely through their mental health crisis.

A number of case vignettes have been presented to CCG commissioners outlining the expected services improvements that will be in place once the SPA is fully operational and embedded into current service pathways.

Finance, resources and QIPP

The proposed model for Urgent Assessment and Care will cost an additional £2.193m (fye) across the three WLMHT facing CCGs, with an additional £0.369m should the proposal for Street Triage be included. It is recommended that the costs are split based on population which would result the costs for Ealing CCG as follows:

2015/16 2016/17

Urgent Assessment & Care Model £404,000 £987,000

Total £404,000 £987,000

The NHSE mandate requires measurable progress towards achieving Parity of Esteem. The Keogh Report and Crisis Concordat provide further detail. £510,000 has been identified within the CCG’s investment programme for 2015/16 for this development which will meet the requirements of the Concordat and the needs of local residents and should contribute to a reduction in demand from mental health clients on A&E and other emergency services. The service is not anticipated to deliver cash savings but will release capacity elsewhere in the system and improve the quality of response to patients.

Equality / Human Rights / Privacy impact analysis

The implementation of this service development is a significant part of the CCG’s response to developing parity of esteem for mental health services, delivering a comparable standard of crisis response to mental health needs as are currently expected for physical needs.

Risk Mitigating actions

The proposal assumes implementation across the Trust, and therefore requires all three CCGs to agree the investment.

The proposal secures high quality services and improved outcomes for people with mental health difficulties; and reduces inequalities.

The proposal will contribute to an effective

The new standards for urgent mental health care were developed across North West London so have commitment from all eight CCGs who are signed up to the Crisis Concordat.

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response to people in crisis and reduce pressure on A&E and other emergency services.

Supporting documents

Mental Health Urgent Care and Assessment Pathway Redesign – CCG Summary Paper

Governance and reporting (list committees, groups, other bodies in your CCG or other CCGs that have discussed the paper)

Committee name Date discussed Outcome

Clinical Executive 04/02/2015 Model agreed; more information requested.

Finance & Performance 01/04/2015 Direction of travel approved and funding signed off subject to assurance on the issues highlighted.

Finance & Performance 31/7/2015 Business case and funding approved. Subject to ratification by Governing Body

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MENTAL HEALTH URGENT CARE AND ASSESSMENT PATHWAY REDESIGN CCG Summary paper

1. Purpose of this paper

Over the past 2 years partners across North West London have been working to co-produce improvements to the secondary care urgent mental health assessment pathway, agreeing key principle, such as ease of access and speed of response. This paper brings together that work, including a proposal for additional investment in West London Mental HealthTrust (WLMHT) to deliver the required changes. It sets out the rationale for investment in new, more effective urgent care pathways for people in mental health crisis which will improve the quality of care and outcomes for patients and value for the local health and social care economy. It represents the first stage in transforming the way in which mental health services are delivered locally.

2. Context and background

National guidance and best practice

Nowhere is the ‘parity of esteem’ gap between physical and mental health services more obvious than for people experiencing a mental health crisis. People in physical health crisis have a clear path to care and support, with clear access standards, whilst those in a mental health crisis and GPs have to navigate multiple entry points and hand offs which delay the start of treatment and support.

When people experience, or are close to experiencing, a mental health crisis, there should be services available to provide urgent help and care at short notice. This includes advice from telephone help lines, assessment by a mental health professional, intensive support at home or urgent admission to hospital. The recent Care Quality Commission report ‘Right here Right now’i found that far too many people in crisis have poor experiences due to service responses that fail to meet their needs and lack basic respect, warmth and compassion. The CQC found that there was a clear need for better 24 hour support and access to ensure that people receive care straight away rather than go to A&E departments or police cells1.

The Government’s Mental Health Crisis Care Concordat, signed by 22 national agencies and government departments who have a ‘stake’ in the mental health urgent care pathway, sets out the principles and conditions to consistently improve the entire acute mental health pathway, including access to support, advice and assessment services, through prevention and self help, to the role of primary and secondary care in providing a high quality, timely and effective crisis service across the whole system, including importantly criminal justice agencies. The Concordat describes exactly how local commissioners, working with partners, can make sure that people experiencing a mental health crisis get as good a response from an emergency service as people in need of urgent and emergency care for physical health conditions2. NWL CCGs and their partners across health, social care, the third sector and the police were amongst the first in the country to develop and submit a signed local crisis declaration and action plan. The new model of urgent care and assessment summarised in this paper is an important step forward in delivering the local crisis concordat action plan.

1 Care Quality Commission, Right here Right now, June 20152 HM Government, MIND, Mental Health Crisis Concordat, Feb 2014

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3. North West London Like Minded Mental Health and Wellbeing Strategy

NWL Collaboration of CCGs has a significant history of working together to deliver innovation and improvement in mental health. The Like Minded Strategy builds on this success and the lessons learned. People with episodes of severe mental illness tell us they want to be treated as equal partners in their care, that they prefer to be treated in their own home, with seven day care and support for them and their families. They want holistic care that addresses their social, mental and physical health needs. People with serious mental illnesses die up to 20 years earlier as a result of poorer physical health and wellbeing and social outcomes such as employment and housing which are also significantly worse than for the general population. For people who need access to specialist mental health treatments, there is major variation in rates of early identification, timely access to treatment and access to the evidence based treatments that deliver the best outcomes3. The Like Minded Strategy aims to develop partnerships to prevent mental ill health and promote mental wellbeing for people across North West London. When people have an emerging or existing mental illness we want to ensure earlier intervention and a reduction in the amount of time people spend in hospital through the co-production of integrated care and support in the community which focuses on people’s needs and not their diagnosis. It is a major programme of transformation. The urgent care and assessment model has been co-produced by people with lived experience of mental illness, clinicians, social care and the third sector and brings us a significant step closer to ensuring that everyone’s mental and physical health is equally valued. It is the first stage of transformation across the whole system of delivery of current mental health services. People with a lived experience of long term mental health problems want the same things from life as everyone else – friends, stable housing and a job and the ability to self-manage their illness. 4. Development of the local Urgent Care Model The NWL journey towards achieving better mental health crisis care began in April 2013 with a series of large-scale co-production events involving GPs, service users, carers, secondary health clinicians and managers, local authorities and third sector. This culminated in a clear set of standards for assessment, available to all referrers, 24/7/365, standardised processes and ‘paperwork’, a requirement to create a single point of referral and that when a crisis assessment in the community was requested it was provided within these standards. A clinically led Urgent Care Expert Reference Group was established, jointly chaired by the NWL Lead Urgent Care GP, Dr Beverley McDonald, and DCI Daniel Thorpe, Metropolitan Police. The ERG defined a model whole system pathway and agreed the data set to inform a NWL wide demand mapping exercise. This work would inform urgent care business case development by West London Mental Health Trust, to include clear plans to deliver:

• Implementation of a Single Point of Access to adult mental health services across CCG areas to provide a central point for referrals and assessment;

• Extension of operational hours in home crisis/urgent assessment and initial crisis resolution service, operating 24 hours per day, 7 days per week, 365 days per year;

• Achievement of agreed performance trajectories for crisis/emergency, urgent and routine. 3 Carnall Farrar. Mental Health Outcomes NWL. May 2015

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The 2014/15 contract included a CQUIN which was put in place to support the development of the business case. Following the submission on 26th June 2014 the NWL Collaborative provided feedback to WLMHT on 23rd August. They expressed satisfaction with the clinical model and appreciated the transparency relating to skill mix and costs. Concerns were raised regarding the capacity and productivity assumptions, the lack of agreement on how the transformation would be funded and how the redesign would release funds.

A revised version of the business case was submitted on 30th September 2014. Detailed feedback to the Trust highlighted the need for further modelling of the efficiencies related to the “to be” model of care. It was agreed that support in further developing the business case would be provided to WLMHT by Northumberland Tyne and Wear NHS Trust representatives; and this support was commissioned by NWL Strategy and Transformation Team.

Ongoing review has been undertaken with the oversight of West London Mental Health Transformation Board, and the Urgent Care Sub-group, co-chaired by the Trust Clinical Director for Urgent Care, Dr Murray Morrison, and Dr Beverley McDonald, NWL Clinical Lead for Urgent Care and GP Mental Health lead for Hammersmith and Fulham CCG.

A revised business case was produced and presented to commissioners on 22nd June 2015 by the Trust. The new model of care is summarised in the diagram below. This is in line with the pathway co-produced with partners across NWL during 2013.

New Urgent Care Pathway

The table below outlines the key differences between the current model and the future model described above. One element which has been added in the revised business case is the proposal for Street Triage – the introduction of a multi-agency street triage team providing an assessment, diversion, liaison and referral service across the three boroughs. The approach suggested is a service in which a mental health nurse accompanies a police officer and paramedic in an allocated vehicle to emergency response with individuals who may be experiencing difficulties with their mental health, learning disability, personality disorder or substance misuse. The team is then able

Rapid Response Nurses

Hub

Who? SUTS Assessment Team CRHBT Call Handlers Clinical Experts

What? Advice Line Receipt Review Triage Signpost Assessment Allocation Initial Response Initial Full Assessment (MH Act)

Urgent Access Pathway Initial

Assessment

Street Triage

Full Assessment

(MH Act)

Home Based Treatment

Bed Based Provision

24/77

Routine Access Pathway

Primary Care Mental Health

Treatment Teams

eg IAPT, EIP, Recovery Teams etc

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to help officers decide on the best options for individuals in crisis, reducing the use of s136 and avoiding inappropriate detentions. This service proposal was discussed at NWL Mental Health Strategic Implementation and Evaluation Board who are proposing to review best practice across the country and recommend a common approach across North West London, in discussion with the Metropolitan Police and other stakeholders. Street Triage is a feature of the longer term plan for Urgent Care services and it is proposed to adopt a phased approach to the redesign of Urgent Care services with further consideration of introducing Street Triage later in 2016/17, if research shows it to be appropriate for West London. Current model Future model Trust defines whether or not the person is in crisis

If you say it is a crisis the Trust treat it as a crisis

Multiple access points Single point of access which will deal with your call and not tell you to contact a different service. A ‘handshake’ not a ‘hand off’.

Various access points to service, not all of which operate on 24/7 basis

24/7/365 Single point of access

Limited capacity to provide rapid response to crisis out of hours and at weekends

24/7/365 response to crisis with the following standards: Emergency < 4hours Urgent < 24 hours Routine plus < 7 days Routine < 28 days Provided by a newly formed Rapid Response Team

Home treatment team only available for patients already known to the service

Home treatment rapid response available to all referrals that require it.

Urgent advice line unable to book or change appointments

Single point of access can book and change appointments

Onward referral from Assessment Teams can be lengthy or delayed

Standardised triage and trusted assessments improves continuity of care and access to the right service

5. Local Context Ealing, Hammersmith & Hounslow CCGs invest approximately £84m pa in WLMHT in secondary functional and organic mental health services and also the primary care mental health services. Prevalence of mental health conditions in the three boroughs is estimated at around 105,000 of whom 8940 have a serious and enduring mental illness such as schizophrenia and bi-polar. Over the last year, through wide engagement, we have been laying the foundations for a simplified mental health referral, assessment and treatment pathway for all, covering routine (lower risk) as well as urgent/crisis (higher risk) referrals, for getting the expert advice that GPs need, when and where they need it, and for improving the interface with providers for those already in treatment.

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‘As is’ Currently there are multiple points of referral for MH assessment and support:

• Multiple points of referral and response for Primary Care Mental Health Services (PCMHS) for people with common mental illness (CMI) and complex/stable Serious and Enduring Mental Illness (SEMI)

• Multiple points for complex/high risk cases to secondary services, depending on the time of day and whether the service user is already on the WLMHT caseload, and varying responses.

The secondary referral point and initial response requires redesign into the pathway model and standards set out at 4, above. This engagement has also set out a requirement for absolute clarity on the relationship between the two points of referral and the nature of the services behind each. ‘To Be’ The plan is to have a single access to Mental Health and Services for those aged 18+ with simpler criteria:

• Primary Care Mental Health Services: PCMHS linked to GP networks in each borough to work with GPs to support people with common mental illness or stable serious and enduring mental illness

• Mental Health Urgent Care: Single referral, response and treatment service for complex and higher risk patients who need an intensive or highly specialist service, 24/7/365.

The Urgent Care Pathway Business Case is a key step towards realising this ‘To Be’ vision locally. Agreement to fund this transformation will enable us to take forward local discussion September – October 2015 to agree exactly how this model will be implemented. The Vignettes set out in Annex C give some examples of how the service will be different for patients. 6. Benefits realisation This plan provides an outline of the key benefits that we expect to be realised as part of the implementation of the Urgent Access and Care business case. WLMHT are working with Northumberland Tyne and Wear (NTW) to ensure that we establish from the outset the benefits we expect as a result of this change. They are mindful that they need to address the service user/patient expected outcomes as outlined in the Mental Health Crisis Care Concordat and are keen to continue to engage service users/patients in the development and monitoring of the benefits to the new model of care. The table below summarises the anticipated key benefits which would be realised from implementation of the new model of care. Further work to confirm the benefits to be delivered and the timescale for delivery would be undertaken as part of the service mobilisation.

Benefit Benefit to patients Expected range of improvement Improved patient outcomes

Referrals will be consistently triaged and people will be given consistent advice; and where required be given a timely appointment

• In 2014/15 15428 referrals were accepted from the 16837 referrals received across the three boroughs. Acceptance rates ranged from 88 -95%

• With the future model there will be greater consistency in applying thresholds for care

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Benefit Benefit to patients Expected range of improvement and assessment and support from secondary care.

• All calls to the SPA will be dealt with and patients will not be bounced around the system

Improved patient reported outcomes

Patient reported outcomes are expected to improve for this client population

• Improvement in patient experience will be reflected in patient reported outcomes such as the family and friends.

Improved patient assessments

People will have timely specialist assessment that meets new standards

• Urgent and emergency assessments improve from 60% of people seen in < 4 and 24 hours to over 95% of people seen < 4 and 24 hours.

• Over 800 more people have timely urgent assessment.

• Specialist routine assessments could improve from 75% of people seen in < 4 weeks to over 95% of people seen in < 4 weeks.

• Over 600 more people have timely routine assessment.

Improved continuity of care

Continuity of care will be improved

• All routine assessments will take place in primary care as appropriate.

• There will be no handoff and delay following assessment and initial treatment.

• Trusted assessments will reduce bureaucracy and delays in accessing treatment.

• Face to face contact time of staff will be increased from 25% to 50%.

Improved patient experience

People will be cared for in the least restrictive setting.

• Timely face to face assessment for people in crisis will reduce the depth and breadth of the problems that ensue.

Reduction in A&E attendance

There will be a reduction in people presenting to A&E in mental health crisis

• Reduction in A&E attendances for an urgent assessment for around ~ 550 patients will no longer be necessary with savings to the health system.

Increased GP Satisfaction

Reduced waiting times and increased responsiveness

• Waiting times throughout the pathway should be minimal if services are operating efficiently. Including waiting times from referral to first assessment and GP notification.

Improved Efficiency

Reduction in DNA rate • The number of DNAs is expected to reduce this will result in reduced duplication and better use of resources leading to improved efficiency

Reduced Reliance on beds

Re-admission rates • Re-admission should reduce as the skills of community teams will be enhanced to keep service users well.

Improved efficient workforce

Engaged workforce • Staff survey results are expected to improve • Sickness levels will reduce • Staff turnover will reduce with a motivated

workforce

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Benefit Benefit to patients Expected range of improvement Improved Organisational capacity and capability

Optimised staffing levels • Use of bank and agency staffing will reduce • Vacancy rates will reduce with a motivated

workforce and optimal staffing levels maintained.

7. Financial Implications Investment The Trust has identified the need for an additional investment across the three boroughs of £2,193,000 for the Urgent Assessment and Care Model. This investment would enhance and develop the Home Treatment Teams into Rapid Response Teams to provide a 24/7 response to people in crisis within 4/24 hours. The Trust has also provided CCGs with an estimate of the additional costs for Street Triage, should further investigation indicate a willingness to invest in this service. Given confirmation from the commissioners in July/August, the Trust has indicated that the Single Point of Access and Rapid Response Teams would be fully operational from 1st April 2016. The table below outlines the new investment based on share of registered population across Ealing, Hounslow and Hammersmith and Fulham CCGs, showing the Full Year Effect from 2016/17 and the part year costs for 2015/16.

By Population Urgent Assessment & Care Model

Current Service

Cost

Cost of proposed

model

New Investment

registered population % shares

Share of investment based on registered population

shares 2015/16

Share of investment based on registered population

shares 2016/17

CCG: £'000 £'000 £'000 £'000 £'000 H&F 1,676 2,419 743 23% 206 504 Hounslow 1,534 2,259 725 32% 287 702 Ealing 1,844 2,569 725 45% 404 987 sub total 5,054 7,247 2,193 100% 897 2,193

Cost Breakdown

The Trust figures below show where the 15/16 figures are derived from and the full year amount. They have indicated that at a high level the implementation plan is to front load where possible around ICT and also infrastructure, with new staff recruitment from Jan 2016. Assuming the Trust didn’t have issues on recruitment they would assume to be fully staffed and resourced by the end of 2015/16.

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The additional costs of a Street Triage service have been indicated below, although this is not recommended for investment at this time, until further research has been done on the impact of such a service and its appropriateness for West London.

Street Triage

Current Service

Cost

Cost of proposed

model

New Investment

registered population % shares

Share of investment based on registered population shares

CCG: £'000 £'000 £'000 £'000 H&F 0 123 123 23% 85 Hounslow 0 123 123 32% 118 Ealing 0 123 123 45% 166 Total for Street Triage 0 369 369 1.00 369

Potential Savings

The Trust business case does not offer cash releasing savings to the CCGs, nor to the Trust. The driver for the business case is improving the quality and effectiveness of the urgent care pathway and the benefit criteria against which the various options have been tested are as follows, with finance weighted accordingly. Benefit Criteria Weighting Option 3a (Preferred Option) Effective Care 15% 12% Safe Services (including Transitions) 20% 16% Patient Experience (and Carers) 15% 12% Effective Use of Staff 15% 12% Sustainability and Resilience 15% 12% Acceptability 10% 8% Finance 10% 4%

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In the short term, however, further efficiencies would be realised to the health care system as a whole through the implementation of the new pathway in itself. For example, the proposed extension of the operating hours for Crisis Resolution and Home Treatment to 24/7 could have a significant impact on A and E attendances, in addition to reducing the demands upon the current Liaison Psychiatry services based within the acute hospitals. Between 26%and 39% of all work undertaken by LPS in A&E is assessing patients already on the caseload of WLMHT. Eliminating all avoidable duplication of assessment from LPS, as well as internal referral between services, could liberate significant capacity and potentially resource for use elsewhere, and will also represent a better experience for users, carers and clinicians. The development and implementation of the Single Point of Access and Response Teams constitutes the ‘Front End’ of the wider transformation opportunities that will be achieved through community redesign and rationalising the acute capacity. Better expert tele-triage at this stage will ensure that resources are targeted to greatest areas of need and reduce unnecessary ‘call outs’. The Trust is currently running a pilot on police liaison and diversion services with three local police stations in Acton, Hounslow and Hammersmith, aiming to reduce numbers of local people spending time in custody suites and enabling faster mental health assessment and access to treatment where clinically appropriate. Implementation of the proposed Street Triage service would have a positive impact not only for service users but also on the Police and Criminal Justice Services and potentially on AMHP and S12 assessments. 8. Implementation Plan The Trust’s Implementation for the Business Case is attached at Annex A. 9. Risk Log: Urgent Access and Care Business Case The Trust has prepared the Risk Log attached at Annex B for the implementation of this business case.

Annex A – Urgent Access and Care Implementation Plan – West London Mental Health NHS Trust

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Urgent Access and Care Implementation Plan

Staff consultation ends

2014 2015 2016SEP OCT NOV DEC

KEY

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT Nov DEC JAN FEB MAR APR MAY JUN

High level Timeline and Governance

Task /Activity TaskMilestone

Interdependency flow Key Meetings Transition Hotspot – Key risk to successful Implementation

Dependency

Full Business Case re- submitted 30th SEP

Deadline

Reconfigure Services

Demand and Capacity

Communication and

Engagement

External Dependency

3 CCGs Review Business Case

Trust 90 day Staff consultation

Approval of finance in Business case will determine if proposed re-design can continue

Staff consultation may extend timeline

3 months implementation

Official launch

Review and Evaluation

Mobilization work stream to over see project cycle form Sep 2015 to May 2016 (reconfigure CRHT and Assessment Teams)

Single point of Access

Design Liaison Psychiatry Services (LPS) Trusted Assessment Model to improve access to secondary MH

Task and Finish groups to review capacity and Demand across 3 CCGs Acute Trust, GP’s for 6 months

Identified external modeling support required

Trusted Assessment model implemented across all 3 boroughs

Estates and IT in place

Trains/Shadow LPS staff on HONOS/PBR/CRHT Policy

3 CCGs to review commission of AMPH and EDT services to develop interfaces with the new model from April 2016

Staff recruitment

Staff and Stakeholder Engagement for 6 months. This will have an impact on all our services to reconfigure

NWL Urgent Care Access Standards Achieved

HR support with transformation in line with Organization Development Policy

Consultation with Local Authority employees in line with their Organizational Development Policy

3 CCGS Governance Review Full Business Case SEP

Identify suitable estates

Identify IT requirements

5 Work streams across the Pathways established.

Launch Transformation

Presentation to CCG Urgent Care BC in wider

Transformation Context

Start development of Service Specification and

policies and procedure's. End JAN 2016

Demand and capacity complete

External Communication , Carers/SU/GP’s/Police/Ambulance

Annex A – Urgent Access and Care Implementation Plan – West London Mental Health NHS Trust

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Urgent Access and Care Implementation Plan

Action Lead Timescale Business Plan submitted to CCGs

Paul Meechan WLMHT AD Local Services

August 2015

WLMHT begin consultation with all Service Users and Staff on proposal

Helene Fager Director WLMHT Communications HR WLMHT

Staff and Service user - August 2015Formal Staff WLMHT and LA -September 2015

Mobilisation of reconfiguration

Dr Murray Morrison WLMHT Clinical Director Local Services and Sonya Clinch Service Manager

September 2015through to April 2016

Demand and capacity modelling

Farinaz Mazhari appoint -SpecialistInformatics Lead

September 2015 to January 2016

Staff Recruitment HR WLMHTHR Local Authority

January 2016 for 3 months

Official Launch Murray Morrison Clinical Director Urgent Care

April 2016

Review and Evaluation Sonya Clinch Service Manager

October 2016

Timescales

See Urgent Care Implementation Plan for a more detailed Timeline of key milestones and decision points. Please note any delay in decision or key milestones achieved will alter the timeline of the projects.

Annex B – Risk Log - Urgent Access and Care Business Case

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Risk Log: Urgent Access and Care Business Case

Risk No

Risk Likelihood (1-5)

Impact (1-5)

Score Owner Mitigation Live Y/N?

RK 1 All parts of the system need to be able to collaborate effectively to ensure that patients can flow through the system; the consequences of poor relationships are likely to result in reduced performance.

3 4 12 WLMHT • Implementation of the new model of care will be monitored at local partnership groups and learning will be shared across all CCG areas at the Like Minded Strategic Implementation and Evaluation Board

• The model of commissioning should be less transactional and focus more on outcomes and challenging providers to develop solutions.

• There is a Transformation board that meets monthly, where partners across the system meet to continue to discuss these issues. The Board has reformed and now has Executive Director Leadership from the Trust and CCGs.

Y

RK 2 There is a need for integrated development of the work streams that will need involvement from GP’s and the Local authority the consequences of this is that we develop a SPA that do not meet the Expected or agreed outcomes

4 4 16 CCG • The GP leads for the CCG have agreed to sign up to a communication plan, in addition they are updated through the transformation board.

Annex B – Risk Log - Urgent Access and Care Business Case

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Risk No

Risk Likelihood (1-5)

Impact (1-5)

Score Owner Mitigation Live Y/N?

RK 3 Improving performance requires a whole system approach to patient flow, matching capacity and demand and removing some of the visible and hidden backlogs along the patient system

3 4 12 WLMHT • Implementation of the urgent care model is the first step in a wider service redesign of the whole system of care including community services currently managing routine care and specialist services

Y

RK 4 Provider fails to deliver the new model of care effectively

3 5 15 WLMHT • The project will be managed as a joint project collaboratively between the CCG and the Trust with issues and delays flagged early and monitored through existing contract monitoring arrangements

Y

RK 5 There will be a need for the Social Workers employed by the local authority including the AHMPs to work within the new model of for the SPA, there is a risk that the Local Authority may not buy in to the new model of care and withdraw their teams

3 5 15 CCG • Local Authority Representatives and Joint Commissioners attend the Transformation board. They will also be a requirement to communicate more broadly with the over view and scrutiny committees across the 3 boroughs so that the impact of the changes is fully understood by council members and their constituents.

Y

Annex C Examples of how the new pathway might look for patients

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Scenario Pathway via new SPA Improvement on current pathway A 25year old male attends a GP surgery at 10am on Monday morning. He is new to the area and states that he is hearing voices. He also appears intoxicated and admits to drinking a litre bottle of vodka prior to attending the appointment. .

• GP can call SPA and speak to clinician or consultant. SPA may request details of last address and how long patient had lived in the area.

• SPA team staff will then try to find out more information if he was known to services previously.

• Based on the information provided referral will be sent to the appropriate Crisis & Response team who would arrange for assessment to be completed that day

• GP makes single call to SPA and provides patient history for SPA assessment team to process referral

• CRHT undertake assessment and will either manage within CRHT refer to D&A services

• GP receives details of assessment and treatment plan via contractually agreed discharge process

A request is received from a GP for a Mental Health Act assessment on Wednesday at 11am

• Referral will be received by SPA • If patient not known to services SPA will contact GP for further

information/history. • AMHP from the Crisis & response team will organize MHAA

assessment with staff from the Crisis & Response team and appropriate medical attendance.

• AMPH will liaise with ambulance/police (as appropriate) if they are required to support an admission.

• If warrant required the process could be delayed whilst obtaining warrant

• In-patient bed found and secured if assessment results in admission

• Ensure bed is available in MHU

• GP is contacted to fully understand the request for MHA.

• AMPH takes responsibility for co-ordinating the MHA.

• GP is not involved with discussions with emergency services.

• GP does not experience ‘hand offs’

A 28year old female visits her GP surgery at 10am on Tuesday morning. She has a history of depression and is known to Mental Health services. She is expressing suicidal ideation

• GP can directly contact SPA team and assessment can be arranged on the day.

• SPA Team will organize involvement of the appropriate Crisis & Response team.

• GP makes single call to SPA and provides patient history for SPA assessment team to process referral

• Patient assessed and allocated to appropriate team for management of suicidal risk.

• Once risk is minimised patient will be supported to community and voluntary support services.

Annex C Examples of how the new pathway might look for patients

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Scenario Pathway via new SPA Improvement on current pathway A 25year old male attends Accident & Emergency at 3am. He is new to the area and states that he is hearing voices

• A&E will contact SPA- referral directed to appropriate Crisis & Response Team. Assessment completed within the hour.

• SPA will ascertain registered GP • If patient requires admission the unit coordinator will need to

be contacted from the Mental health unit and bed secured. • If patient is not from the area then the Unit coordinator will

need to discuss transfer with bed manager from where patient is from. The transfer of this patient could take up to several hours especially as it is 3 am and we would not have transport available on site either even if out of area agreed to accept. If patient is deemed appropriate for admission but not from local area and remains in A&E for longer than 4 hours then we will admit to local bed as per policy.

• If patient does not require admission then treatment plan can be made at point of assessment.

• Referral on to appropriate service can be made from there. • Timescale for admission should be from 1-2 hours, patient only

experiencing one assessment. Only delay maybe if patient was not from the area.

• Pathway from A&E to SPA is straightforward

• SPA will identify registered GP and arrange assessment.

• If admission required and patient in area –admission takes place.

• If patient from out of area, the team will liaise with responsible area and arrange transfer ( if safe to transfer, if not the patient will be kept within local MH services until it is safe to transfer )

• Patient assessed and treated , risk of harm to self and others managed.

A request is received from a GP for a Mental Health Act assessment on Saturday at 3pm

• If referral is received on the Saturday this will be received into the SPA.

• SPA, will the send referral to appropriate Crisis & Response Team. The AMHP in Crisis & response team will organize relevant services including section 12 doctors, police and ambulance.

• Admission arranged if appropriate • Timescale for assessment should only be 1-2 hours.

• SPA accept referral and refer to CRHT for MHA

• AMPH co-ordinates MHA • Patient admitted if MHA deems

appropriate

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