21St Century Mental Health Services for Older People in Edinburgh

“A sense of belonging” Lothian’s Joint Strategy for Mental Health and Wellbeing 2011-2016

Edinburgh Adult Mental Health Locality Partnership Model

The purpose of thisbriefing isto provide an update on theagreed future delivery model forEdinburgh’s Adult Mental Health Service. The implementation of the model will begin from 1 May 2015.

Background

NHS Lothian and partners developed a new mental health and wellbeing strategy for Lothian – “A Sense of Belonging”. This covers all life stages and sets out a clear vision of how we want to improve the mental health and wellbeing of all Lothian’s population.

A planning group with representation from senior management, clinicians and Partnership have been working on a redesign plan for community mental health services in Edinburgh, which includes services delivered by NHS Lothian and the City of Edinburgh Council. It also includes a number of commissioned third sector services which are funded by NHS Lothian and /or City of Edinburgh Council.

In recent months thedelivery modelhas been presented to and supported by the Edinburgh Joint Mental Health Forum and Lothian’s Joint Mental Health and Wellbeing Programme Board.

There are a number of drivers which informed this review:

• Improving the delivery of person centered services
• Addressing age discrimination
• Delivering outcome focused services
• Building community capacity to support people living in the place they call home
• Embeddinga living well ethos within service delivery
• Further shifting the balance of care from institutional settings to community
• Supporting carers
• Delivering on the Government’s national Mental Health strategy
• Increasing access to social prescribing initiatives
• Improving access to evidence based psychological therapies
• Meeting efficiency savings
• Sustaining and invigorating the workforce
• Establishing a model that will be sustainable in the face of increased demand expected in future years
• Increasing caseloads
• “New” groups of patients (diagnosis)
• Impact of Welfare Reform
• Increased national emphasis on locality and community planning

A number of synergies with other workstrands wereidentified. These include:

• Wayfinder – Rehabilitation Pathway
• Re-provisioning of Royal Edinburgh Phase One
• Acute Care Pathway redesign
• Programme budget to support delivery of the strategy – moving away from uni-professional LRP to releasing required efficiencies and creating a fund for reinvestment
• Matched care model of women with multiple and complex needs
• Early onset and first episode psychosis workstream

A number of opportunities and scope to build on good practice were also identified. These included:

•Integration – we have an agreed joint strategy and long history of joint working

•Development of psychological therapists

•Building on “The Works” –individual placement support model

•Roll out of psychosocial interventions and behaviour family therapy

•Working with substance misuse colleagues

•Peer support workers as part of teams

•Stronger links with Specialist Services

•Defining roles and responsibilities

•Meeting the needs of locality and communities within the locality

In addition to staff surveys and meetings, the Core Redesign Group organised two stakeholder events which took place in September 2013 and June 2014. At the September event the concept of creating locality hubs was introduced and debated and the key components that people felt should be part of the hub model were:

• Clear referral criteria
• Good quality, accessible accommodation for people using services and staff
• Flexibility
• Self referral
• Speed
• Clarity of staff/team/management roles and responsibilities
• Communication – of the redesign process and between people using services/teams/professions
• Carer involvement and support
• Administrative support
• Shared information and IT systems

What was important to stakeholders?

A number of issues and topics emerged in several or all of the table top discussion. These have been identified as key themes and are summarised below:

Self Referral, Open Access, Easier Access

•Keeping in touch – making it easier for people to ‘get back in’ when they need to

•Self referral to episodic support

•Not solely self referral – multiple routes to services

Single assessment/screening/point of referral

•A place where people can be referred or self refer to, to find out the best solution - a trial of screening assessments where people can be directed to the best service for them – which may, or may not, be community mental health services.

Peer support

•Peer support being more than just meeting for coffee - more than “just Starbucks’

•How peer support could enhance community mental health services

•Properly supporting peer support groups to ensure greater provision of ‘low level’ support

Where am I in the system?

•The importance of understanding where you are in a service/referral process

•Feeling like someone has an overview of the process

•Feeling informed

Older People

•Why do people get a different response when they turn 65?

Clear Roles, Responsibilities and Criteria

The importance of clearly defined:

•Professional roles

•Service remits

•Criteria and definitions

Information within services

•Shared assessments

•Shared Notes

•A front page of key information in notes

“Going where people are”

•Looking at delivering services and supporting people in non traditional spaces.

Information for people

•Clear information on what’s available – for people referring and people being referred.

•People feeling overwhelmed by wide range of current options

The new delivery model

The hub model discussed back in September 2013 through further stakeholder engagement and regular meetings of the Core Redesign Group has resulted in the proposed Locality Partnership Model.

There will be four Locality Partnerships in Edinburgh.

*This includes Intensive Home Treatment Team, Mental Health Assessment Service, the Rivers Centre, the Cullen Centre, Psychodynamic Psychotherapy, Veterans First Point, The Works

Each Locality Partnership and the City Wide Reablement and RehabilitationTeam will have a senior practitioner team comprising Allied Health Professionals, Nursing, Psychiatry, Social Work and Psychology, with the aspiration that key 3rd sector colleagues that are key service providers within that locality join the senior team

The Service will be working with preventive approaches which promote health, wellbeing and independence for people, using a broader conception of prevention encompassing different levels; primary, secondary, tertiary – targeted at different individuals.

The holistic LP will be multi-faceted, offering a range of interventions designed to enhance resilience across a number of related domains – physical health, engagement in social networks and relationships, access to and participation in social and community life, individual coping strategies and mental health.

The Locality Partnership for Mental Health and wellbeing will work with people with all mental health problems, illness and disorders

NHS Lothian and partners are committed to achieve sustainable culture change both in how we view mental health and wellbeing and in how mental health services are planned and provided. Key to cultural change is a commitment to a recovery ethos, values based practice and partnership working with people with lived experience, carers and people who provideservices, both in statutory services and the 3rd sector.

Our ethos

The Locality Partnerships for Mental Health and Wellbeing will:

• Promote Recovery (Life) as a journey
• Promote hope and optimism
• Build on peoples’ strengths and assets
• Increase control, choice and inclusion
• Support positive risk taking
• Increase opportunities for self management and anticipatory care planning
• View positive relationships between staff and clients as an essential part of delivery

A key role of the LP is to establish and maintain therapeutic relationships and to deliver a wide range of evidence based treatment in line with the Integrated Care Pathway Standards (generic and condition specific) and the Matrix for Psychological Therapies. The LPs will provide timely and specialist assessment of individuals resulting in agreed treatment plan, this may involve collaboration with other agencies and providers.

There may be times that an individual under the care of LPs requires increased intensity of input and support. This may be to prevent admission, facilitate early discharge or provide additional support in terms of reablement and rehabilitation. This will be provided by Edinburgh Adult Mental Health Intensive Home treatment Team and the Reablement and Rehabilitation Team.

Our relationships

Locality working gives a great opportunity to work with the 3rd sector and community groups both within the geographical locality and with those that provide city wide services. The LP will actively collaborate with key 3rd sector partners, registered social landlords and housingproviders and with other statutory service provision including housing and local police and fire services, .

Each Specialist Service is currently or has identified a link worker for each LP. The will enable enhance working relationships facilitating consultation and liaison with a number of specialist teams which will either enable the person to continue to be cared and treated by the LP or enable a smooth transition to a specialist service practitioner due to the individual’s needs. This is also being explored with the Substance Misuse Recovery Hubs with a particular focus on North East Edinburgh.

The LPM also gives us a great opportunity to try out different ways of working and developments will reflect the needs of that community. Examples of this include a housing pilot in south west of the city; looking at resilience in the north east of the city.

Locality Partnership Workforce

New Roles

An early part of the Core Redesign Work was to clearlyindentify role definition and input by the range of different professional groups who currently deliver community mental health services:

• Healthcare Support Workers
• Social Care Support Workers
• Social Workers and Mental Health Officers
• Occupational Therapists
• Consultant Psychiatrists
• Speciality Doctors
• Commuity Psychaitric Nurses
• Clinical Psychologists
• Arts Therapists

This clarity of role work was important as it not only clarified key inputs of different professional groups currently in turn helped to identify a number of new roles which needed to be par to the developing LP model. Three new roles were indentified as core LP members. These are:

• Advanced Nurse Practitioner
• Psychological Therapist
• Peer Worker

Advanced Nurse Practitioners

The role of the Advanced Nurse Practitioner will be a welcome addition to the nursing skill mix. The ANP will be able toprescribe and administer drugs in accordance with NMC guidelines as a non-medical prescriber/and or agreed Patient Group Directives (PGDs). This will provide invaluable support of psychiatrists enabling them to focus on people withthe most complex needs who are subject to the Mental Health Act.

They will provide clinical expertise to the Locality Partnership on the care of mentally ill patients contributing to the development, implementation and evaluation of independent integrated pathways and treatment modalities in keeping with Recovery principles. This will include a focus on physical health care. The ANP role is currently being piloted in the South East of the city.

Psychological Therapists

This new role has been introduced as part of the workforce who are delivering formal evidenced based therapies. Non recurring funding was allocated in June 2014 which enabled a number Psychological Therapists (band 6 and 7) to be recruited into current Edinburgh Teams.

The Psychological Therapies Training and Supervision Delivery Plan recommends all general mental health services should be deliveringfive core evidenced based therapies. These are:

• Cognitive Behavioural Therapy (CBT)
• Interpersonal Psychotherapy (IPT)
• Eye Movement Desensitisation & Reprocessing (EMDR)
• Dialectical Behaviour Therapy (DBT)
• Behavioural Family Therapy (BFT)

Training and supervision will be prioritised to enable the Partnerships to deliver these five evidence-based mainstream therapies for clients with common mental health conditions: depression, anxiety, post traumatic disorders, eating disorders and bipolar disorder, psychosis and personality disorder: Each LP will be able to offer one primary psychological therapy modality and an alternative based on an “A” rated evidence base from the Matrix.

In addition NHS Lothian there are fourteen frontier psychological therapy modalities. A number of these modalities will be delivered in as part of a Lothian-Wide Group Psychological Therapies Programmes. This will increase access and choice for people in terms of individual or group work. Group work has additional benefits of informal peer support.

Peer Workers

NHS Lothian with partners was one of the first areas in Scotland to introduce paid peer workers. In Edinburgh paid peer workers were funded by NHS Lothian and employed by Penumbra – “Plan to Change” project. In addition two peer workers were funded as part of the Rehabilitation service at the RoyalEdinburghHospital. The City Of Edinburgh Health and Social Care Partnership have recently introduced peer worker role to their social work teams. From our consultation with stakeholders it is clear that the role is highly valued and one that should be further developed. Each LP will have peer workers as part of their service.

ArtsTherapies

A brief staff questionnaire was designed to look at support for the development and increase in current arts therapies provision. The results of the survey show strong support for arts therapies provision to be made available to mental health services in south Edinburgh; and increased resources to enable access to a wider range of arts therapies interventions (art, dance movement, drama and music). It is recommended that there is equitable access to Art Therapists. An early meeting is being arranged with thenewlyappointedLothian leadfor ArtsTherapies.

The skill mix and identification of new roles as part of the overall workforce planning for the LP needs to take cognisance of different skill mix reviews and job planning which are taking pace in professions such as Applied Psychology and Psychiatry

What now?

An Implementation Group has been convened to take the LPM model. This will commence in May 2015. The Core Redesign Group will continue to oversee the implementation.

How will we know we are making a difference?

We are agreeing a number of key performance indicators which will help us to measure this including:

• Reduction in waiting times for mental health services
• Reduction in levels of emotional distress as assessed by a core set of outcome measures to be used at least at pre- and post-treatment intervals.
• Reduction in the number of unplanned transitions in care
• Reduction on length of stay in acute, rehabilitation and continuing care wards
• Reduction in the number of delayed discharges and delayed discharge bed days
• Reduction in staff sickness / absence rates
• Increase in number of people accessing psychological therapies within 18 weeks

We will also be introducing the routine use of Service and Carer defined outcome measures.

Keeping in touch

A further update will be circulated by the end of May.

Please share this briefing with your teams, services and networks.

Linda Irvine

9 April 2015
Appendix One:Members of the Core Redesign Group

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