Birmingham: A Framework for developing community based mental health services

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1 Birmingham: A Framework for developing community based mental health services November 2010 Kevin Heffernan Honorary Research Fellow Centre for Mental Health Birmingham City University

2 Kevin Heffernan Nurse (RMN) 11 years leading HT developments in Birmingham services, (National award winning beacon site) Consultant for the World Health Organisation National Institute Mental Health England (Regional Implementation 5.5 M pop.39 HTT, 27 AOT) Honorary Research fellow Birmingham City University West Midlands Strategic Health Authority (Programme Specialist service development, currently leading a mental health and learning disability peer review project across West Midlands)

3 Overview of Presentation Introduction to Birmingham Services Outline of Framework for Adult Mental Health Services that influenced national policy National/Regional Implementation of policy Discussion

4 Birmingham at the Heart of UK Mental Health Service reform NHS National Service Framework for Mental Health(1999) this document was heavily influenced by the Birmingham experience. A template for redesign of (failing) community mental health services. The document specifically recommended (and the National Plan, 2002 then funded) Home Treatment and Assertive Outreach teams, both pioneered as system-wide services in Birmingham. Policy implementation guides (PIG s) were issued to support putting the theoretical frameworks into practice. Each service had there own PIG to relate to

5 BIRMINGHAM AND SOLIHULL MENTAL HEALTH TRUST One of the largest mental health Trusts in the UK Serves population 1.2 million Mainly Inner City Single population is high Higher levels of deprivation against England average Area: 172 square miles Diversity initiatives

6 BSMHFT Delivery Total income - 207million per year Contact with 50,000 people a year Employ over 3,900 staff Operating out of 106 sites 130 Clinical teams 722 inpatient beds 50 wards/ units

7 3,500 STAFF 1,380 Registered Nurses, 500+ Non-professional care staff 240 Medical staff 140 Psychologists 110 Allied Health Professionals (Occupational Therapy) % staff employed in Specialist Services 445 staff employed in Older Adults Does not include Social Workers funded and employed by Birmingham Local Authority Social Services

8 Birmingham Beds (722) BED TYPE n Comments Acute sites across City and Solihull 17 units, beds per unit Includes 2 Intensive Care Units Separate Male and Female Longer Stay 112 Hospital type facilities Forensic 152 Speciality REGIONAL medium secure Older Adults years 30 REGIONAL Deaf (12), Eating Disorder (10) Mother and Baby (8)

9 Why Birmingham developed community based mental health services? De-institutionalisation New Models of Mental Health linked to new insights into mental illness Human Rights and Values National Mental Health Policy Consumer/ User/ Carer involvement

10 Developing a framework Why was Birmingham able to influence? Development of effective individual community TEAMS requires consideration of the impact on the whole system. In Birmingham community TEAMS development was part of total service re-design; re-organisation of services and re-allocation of resources. There was an intentional shift of the centre of the service away from hospital into the community. This has had a significant impact on the function of the hospital too. Success of the Birmingham model was dependant on the Implementation of a number of different teams at the same time. This supported each new team to maintain a commitment to individual team fidelity, thus maximising the potential for them to meet anticipated outcomes, to ensure a smooth functioning system The organisational commitment gave staff the opportunity to develop shared values on the future direction of services

11 Developing a framework Why was Birmingham able to influence? Shift focus from hospital to community: Functionalise community in same way that hospital was/is functionalised, i.e. separate specialised services or TEAMS. Early Mental Health teams reported being overloaded and unfocused Emphasis on multi-disciplinary TEAM WORKING with integrated social care provision. Identifying clear roles and boundaries between functions i.e. between TEAMS (what do I need to deliver on behalf on this whole system )

12 Developing a framework Some key concepts: A system of filters and gateways Fidelity for each part of the jigsaw Gatekeeping acute beds Staff training and team development

13 Once upon a time.. HOSPITAL Continuing needs: rehabilitation wards long stay wards Acute - admission wards Out-patients department COMMUNITY PRIMARY CARE & AFTERCARE SERVICE Counselling & Depot injections Psychotherapy Residential care support

14 Family doctors and other referring agencies Functional map of Birmingham PRIMARY CARE LIAISON teams CONTINUING NEEDS teams RECOVERY AND REHABILITATION Acute HOME TREATMENT teams ASSERTIVE OUTREACH Residential based care Hospital Beds, Crisis Homes

15 Primary Care Liaison/ CMHT Interface between primary care and specialist service Gateway to specialist services Manage all new referrals from Primary Care Multidisciplinary team Key workers with variable case load Clinics, groups, home based intervention Improving access to psychological therapies

16 Rehabilitation and Recovery Teams People predominantly with severe/ enduring illness experience Complex social and health care needs Long term service use Need for community based support Recovery and social integration Individual case management but access to team resources

17 Assertive Outreach Difficult to engage as defined by hospitalisation patterns and forced care Severe and enduring mental health problems Team based approach One team member is care coordinator Shared case load

18 Assertive Outreach Treatment is individualised Services provided out of office Assertive can do approach Team responsible for meeting all needs Assistance in obtaining basic needs Primary goal of improved client functioning Assistance with symptom management

19 Home Treatment and Crisis Resolution Acute psychiatric care at home Choice and alternative to hospitalisation Mobile, 24 hour 7 days a week service Gatekeepers to all potential admissions In-reach to hospital for early discharge Multidisciplinary team Corporate caseload

20 Crisis Resolution/ Home Treatment (CRHT) Rapid response following referral Intensive intervention and support in the early stages of the crisis Active involvement of family and other supports Time-limited intervention that has sufficient flexibility to respond to differing service user needs Learning from the crisis

21 ACTIVITY TEAM CMHT/ Primary Care Liaison Rehabilitation/ Recovery CASELOAD/ Size/ Time 1:30 Up to 18 months 1:25 Years VISITING Availability/ Frequency 9am 5pm 5 days Weekly Monthly 9am 5pm 5 days Weekly - Fortnightly INTENSITY How long/where Clinic or Home Therapeutic Session Up to 1 hour Activity based Home or community Assertive Outreach Crisis/ Home Treatment 1:12 Years 1:2 Up to 3 months days Daily-Weekly 24 hours, 7days Multiple Daily 3 times per week Minutes to Hours Home or Minutes to hours, as required Home or

22 Functional map PRIMARY CARE LIAISON teams CONTINUING NEEDS teams RECOVERY AND REHABILITATION Acute HOME TREATMENT teams ASSERTIVE OUTREACH Residential based care Hospital Beds, Crisis Homes

23 NOT the whole picture.. PRIMARY CARE LIAISON teams CONTINUING NEEDS teams EARLY INTERVENTION SERVICE RECOVERY AND REHABILITATION Acute HOME TREATMENT teams ASSERTIVE OUTREACH Residential based care Hospital Beds, Crisis Homes

24 NOT the whole picture.. PRIMARY CARE LIAISON teams CONTINUING NEEDS teams Acute HOME TREATMENT teams EARLY RECOVERY AND INTERVENTION REHABILITATION SERVICE SPECIALIST SERVICES ASSERTIVE OUTREACH Residential based care Hospital Beds, Crisis Homes

25 NOT the whole picture.. PRIMARY CARE LIAISON teams CONTINUING NEEDS teams Acute HOME TREATMENT teams PSYCHIATRIC RECOVERY AND LIASION EARLY REHABILITATION SERVICE INTERVENTION SERVICE Residential based care Hospital Beds, Crisis Homes ASSERTIVE OUTREACH SPECIALIST SERVICES

26 NOT the whole picture.. PRIMARY CARE LIAISON teams CONTINUING NEEDS teams Acute HOME TREATMENT teams Personality Disorder EARLY INTERVENTION service SERVICE Residential based care Hospital Beds, Crisis Homes RECOVERY AND REHABILITATION ASSERTIVE OUTREACH SPECIALIST SERVICES

27 NOT the whole picture.. PRIMARY CARE LIAISON teams CONTINUING NEEDS teams Acute HOME TREATMENT teams Dual Diagnosis EARLY service INTERVENTION SERVICE Residential based care Hospital Beds, Crisis Homes RECOVERY AND REHABILITATION ASSERTIVE OUTREACH SPECIALIST SERVICES

28 NOT the whole picture.. PRIMARY CARE LIAISON teams CONTINUING NEEDS teams OLDER ADULT SERVICES Acute HOME TREATMENT teams Dual Diagnosis EARLY service INTERVENTION SERVICE Residential based care Hospital Beds, Crisis Homes RECOVERY AND REHABILITATION ASSERTIVE OUTREACH SPECIALIST SERVICES

29 NOT the whole picture.. PRIMARY CARE LIAISON teams CHILDRENS OLDER SERVICES Dual ADULT Diagnosis EARLY service SERVICES INTERVENTION SERVICE Acute HOME TREATMENT teams Residential based care Hospital Beds, Crisis Homes CONTINUING NEEDS teams RECOVERY AND REHABILITATION ASSERTIVE OUTREACH SPECIALIST SERVICES

30 NOT the whole picture.. PRIMARY CARE LIAISON teams CHILDRENS SERVICES OLDER ADULT SERVICES Acute HOME TREATMENT teams Dual Diagnosis EARLY service INTERVENTION SERVICE Social Services Residential based care Hospital Beds, Crisis Homes CONTINUING NEEDS teams RECOVERY AND REHABILITATION ASSERTIVE OUTREACH SPECIALIST SERVICES

31 NOT the whole picture.. PRIMARY CARE LIAISON teams CHILDRENS SERVICES OLDER ADULT SERVICES Acute HOME TREATMENT teams Dual Diagnosis ETCETERA! EARLY service INTERVENTION SERVICE Social Services Residential based care Hospital Beds, Crisis Homes CONTINUING NEEDS teams RECOVERY AND REHABILITATION ASSERTIVE OUTREACH SPECIALIST SERVICES

32 teams in Birmingham Caseload size and distribution in a locality of 150,000 population

33 Days High Caseload Low Intensity Primary Care MH team 1:30 20 staff 600 Cases Weekly - Monthly Rehabilitation/Recovery 1:25 15 staff 370 Cases Weekly - Fortnightly Years Assertive Outreach 1:10 Home Treatment 12 staff 1:2 123 Cases 14 staff Daily - Weekly 25 Cases Multiple daily - decreasing Low Caseload High Intensity

34 Distribution of Cases Serious Mental Illness Assertive Outreach 12 staff Rehab & recovery 15 staff CMHT s 20 staff ************ *********** *********** 123 cases ************ *********************** ***************************** ***************************** ************** 370 Cases ***************** ************** ***************** **************************** ***************** ***************** 600 Cases ************ ***************** Days Years Intensity of support & Length of stay in the service

35 Serious Mental Illness Assertive Outreach 12 staff Rehab & recovery 15 staff CMHT s 20 staff Distribution of Cases Crisis Resolution/Home Treatment 14 staff ************ 20 cases *********** *********** ************************ 123 cases ************ ************************ ****************************** *************************** ************** 370 Cases ***************** ********************* ************************* ***************** ******************* ************************* ***************** ****************** ***************** 600 Cases *** ***************** ** ************ ***************** Days Years Intensity of support & Length of stay in the service

36 Serious Mental Illness Assertive Outreach 12 staff Rehab & recovery 15 staff CMHT s 20 staff Distribution of Cases Crisis Resolution/Home Treatment Most Impact on diverting cases 14 staff From Hospital admission *********** 20 cases *********** ************************ ************ 123 cases ************************ ************************* ****************************** *************************** ************** 370 Cases ***************** ********************* ************************* ***************** ******************* ************************* ***************** ****************** ***************** 600 Cases ***************** ************ ***************** Days Years Intensity of support & Length of stay in the service

37 Distribution of Cases Serious Mental Illness Assertive Outreach 12 staff Rehab & recovery 15 staff CMHT s 20 staff Most Impact on diverting cases From Hospital admission *********** *********** ************ 123 cases ************** *********************** ************** ************** ************** 370 Cases ***************** ************** ***************** ***************** ***************** 600 Cases ************** ***************** Norway ACUTE Days Teams Years Intensity of support & Length of stay in the service

38 How did the Department of Health support a national roll out of policy based on some of the Birmingham success story? From Policy to Implementation The role of regional development centre s.

39 National Institute of Mental Health in England (NIMHE) was formed by the Department of Health in 2002 to help the mental health system implement the National Service Framework for Mental Health and the NHS Plan. 8 regional development centres were set up One in the West Midlands covering a population of 5.5 million Also regional centres in East Midlands London South East South West Eastern region North East North West

40 The main aim of NIMHE was to help improve the quality of life of o people of all ages who experience mental distress. Working beyond the NHS, it helped all those involved in mental health to implement positive change, providing a gateway to learning and development, offering new opportunities to share experiences and one place to find information. Through NIMHE's local development centre s s and national programmes of work, it supported staff to put policy into practice and to resolve local challenges in developing and sustaining new mental health services.

41 Workstream examples within the Regional Development Centre's Specialist mental health services Acute Inpatient teams (Crisis Resolution/Home Treatment, Assertive Outreach teams) Child & Adolescent Mental Health Dual Diagnosis Early Intervention Personality Disorder Improving access to Psychological therapies Improving access to psychological therapies for people with common on mental health problems. Equalities Race, Gender & Age Delivering Race Equality Gender, Equality and Women's Mental Health Programme Mental Health in Later Life Well being and Inclusion Social Inclusion Programme, mental health first aid training programme Legislation The Mental Health Legislation programme supported the implementation tion of service changes and changes in roles that are required to meet any changes set out in the Mental Health Act

42 Day in the life of a staff member Not official performance management/monitoring, but focus on service Improvement and development, therefore viewed as honest brokers Identify good practice areas Link areas together Protect and champion fidelity and values Develop regional network s s (e.g. CRHT, AO and EI) Influence policy review and refinement Strength in having a national profile (sharing across RDC s) Challenge with kindness!! (e.g. not if, but how!, rural v inner city)

43 Context Part of my role was to offer support & guidance across the West Midlands to 25 Assertive Outreach teams 39 Crisis Resolution/Home Treatment teams Regional forums (organise & chair) Specific developmental in vivo programmes to address local issues s (not off the shelf ) Coaching & mentoring of managers/leaders Ensure fidelity to the model All staff were recruited based on their experience and/or commitment ment to the new vision of services. The values of staff were a critical factor, to embrace the complex and unique issues of different areas who were at different stages of evolution was an essential skill

44 Systems are systems the world over, getting the right people in the right place at the right time is what makes it work! You are the catalysts for change. Your role will be to inspire and a give people hope that things can change. How you get support will be important I hope you are the right people with all the commitment, energy, passion, empathy, humour and perseverance required to move your mental health system forward. This ultimately will lead to the improvement in the quality of experience for Users and families that access your services

45 Characters represent CRISIS Danger/risk and Adversity Opportunity for Personal Growth

46 Let today's collaboration be your first step to inspiring and giving each other hope for the future development of local community based mental health services This is your opportunity! And not a danger or risk

47 Happy to take questions or to be contacted on