How one area’s mental health teams are tackling the ‘scandal’ of out-of-area care

Today Community Care reveals England’s mental health services sent more than 5,000 acutely unwell adults away from their home areas for beds last year due to local wards being full. Some had to travel almost 300 miles for care.

It’s the fourth year in a row the problem has worsened. Experts say it’s a “scandal” that increases suicide risk. Ministers and NHS leaders have finally committed to ending the practice – albeit by 2021.

In Bradford, services are ahead of the game. The local mental health trust sent not a single adult out of area for a standard acute admission in 2015-16. The previous year they spent almost £2m sending 106 people to out-of-area beds, which often have to be purchased from private providers.

The turnaround marks the most striking outcome from a redesign of Bradford’s mental health crisis care system over the past 18 months.

The project was a partnership between the local NHS care trust, the local authority, police, other NHS trusts and voluntary sector agencies. It looked to rethink the way the entire system responded to mental health emergencies.

The redesign was born out of necessity. During 2013 and 2014 Bradford’s mental health services, like most in the country, were under severe strain.

Debra Gilderdale, deputy director for acute services at Bradford District Care NHS Foundation Trust, describes the pressures on the system at that time: “We had a large number of people presenting at A&E.

“Our inpatient wards were over occupancy. We regularly had people being placed out of area. We had a lot of people accessing our acute services because there were no alternatives for them. So the picture wasn’t looking good.”

System under pressure

Staff in health and social care were feeling the pressure too. The NHS trust’s mental health crisis team, which should provide intensive home-based support as an alternative to hospital, was finding itself overwhelmed by assessment requests and struggling to keep-up with demand.

Bradford council’s Approved Mental Health Professionals (AMHPs) – the group of mainly social workers who are responsible for carrying out Mental Health Act assessments – were also struggling.

Issues with bed availability meant their assessments were getting delayed. Stress on staff increased. AMHPs often worked late into the night, sitting with patients for hours anxiously waiting to hear if a bed could be found. If one was available, it might be anywhere in the country.

Tracy Loxam, social care manager for Bradford’s acute care mental health services, remembers how AMHP duty felt at that time: “It was very pressured. From the start of your shift you’d be anxious about beds. On assessments you’d sit with someone you knew needed to come into hospital then get told the only bed was on the other side of the country.

“You’d know their family saw them every day and might be key to their wellbeing. That was the hardest part for me. It was unacceptable for people.”

National beds shortage

This situation was not unique to Bradford. The mental health beds crisis was, and still is, a national problem.

The pressures come from a mix of factors. More than 2,100 mental health beds have closed since 2011. At the same time demand has risen for crisis care, partly driven by cuts to welfare, social care and the community support to keep people well and out of hospital. Meanwhile, services report delays in discharging people ready to leave hospital, often due to housing and accommodation problems.

Social worker Mark Trewin manages Bradford council’s mental health services, including the AMHP team. He remembers how his staff, aware that bed pressures were impacting teams all over the country, tried to keep going during 2013 and 2014. But eventually something had to give.

“It became clear this wasn’t a blip, it had become a permanent state of affairs across the country,” he says.

“Our AMHPs are fantastic. They’re not complainers. But it got to the point where people started saying things like ‘I can’t carry on like this much longer’. As a manager sensitive to what’s happening on the frontline, you just can’t ignore that.”

Impact on emergency services

There was pressure from GPs and the emergency services to act too. They felt they were being left to pick up the pieces when the local health and care system couldn’t cope.

GPs complained it was hard to access mental health services. The local ambulance service was also facing high demand. And the police were growing frustrated as a lack of staff at NHS ‘place of safety’ units meant people in crisis detained by police officers ended up having to go to cells rather than health facilities (again a national issue).

Facing their own pressures, the police wanted their officers freed-up again as soon as possible. Instead, despite the best efforts of services, they’d often accompany patients only to face long waits for an AMHP to assess them, particularly out of hours. Relationships were getting frayed.

“The police were unhappy with health and social care services,” says Trewin. “We had to make a choice. We were either going to completely fall out with one another or we were going to take mutual responsibility for the situation and do something about it.”

A forum for joint working

In summer 2014 things started to move. The mental health trust received some funding from local NHS commissioning groups for a six-month pilot of redesigned services.

A few months later 23 agencies, from health, social care, the emergency services, and the voluntary sector, came together to form Bradford’s local mental health crisis care concordat group.

The concordat was a national policy introduced by the coalition government. It “challenged” local partnerships to create action plans to drive improvements in their areas.

The coalition drew criticism for attaching no funding to the scheme. Campaigners in Norfolk labelled it the “cashless concordat” – a cheap option that was no substitute for investment in services. It’s impact nationally has still to be evaluated.

Trewin, who co-chairs Bradford’s concordat group alongside the city’s NHS commissioner for mental health, says he understands why some people were cynical but feels locally the concordat has been “absolutely vital” in providing a forum for Bradford’s services to clear the air on difficult issues and find solutions together.

“We saw it as an opportunity. We were able to really listen to each other. We mapped everything out,” he says.

“It was clear we were all interlinked and there was no point in one part of the jigsaw setting out to fix this on its own. So we knew we all had to develop services that were weren’t just good for our own organisations but also helped the others with the pressures they faced.”

Reform plans

Those discussions set in a train a series of reforms to Bradford’s crisis care system that were funded by the local CCGs and NHS trust with some extra investment and support from the council and police and crime commissioner.

First up, the trust restructured its crisis and acute inpatient services. A new 24-hour ‘first response’ service was opened in February 2015. The team would handle all initial assessments of people in crisis. This in turn freed-up the crisis home treatment team to focus on delivering intensive home care.

The change meant the home treatment team staff had the capacity to visit people two or three times a day if needed, as well as working more closely with carers and families. Around the same time, the AMHP service moved so it was based alongside the first response and home treatment teams, a move both Trewin and Gilderdale say has strengthened joint working.

In planning the changes, the NHS trust asked for input from social care. This was helped by the fact Bradford’s council’s mental health social workers had been integrated with the trust’s teams since 2002. A decision was made to set up joint management arrangements across the pathway so that both health and social care had a presence.

Social workers, 11 in total, were used throughout the redesigned services. Most were in the first response or home treatment teams, backed up by staff in the community mental health teams coordinating non-crisis care.

A specialist housing worker, dedicated to resolving accommodation problems that stopped people leaving hospital, was also appointed. This was part of an improved bed management and discharge planning process that would kick in as soon as someone was admitted to hospital.

Another social worker was based in the local acute hospital’s A&E department as part of a redesigned liaison psychiatry service to support people attending with mental health crises.

Improved working with police

To improve work with the emergency services, a group of mental health professionals were stationed with police call handlers.

This meant police hub teams could now access health, social care and police systems. They could also get mental health first response assessors out to incidents quickly.

Meanwhile the NHS trust redeveloped their two NHS place of safety units. It meant if somebody in crisis was detained, police officers should no longer have to take them to police cells.

In an effort to expand alternatives to hospital for people in lower levels of distress, a small number of care homes and hostels developed services for people needing emergency accommodation or low level respite care. Patients placed in the homes would receive support from first response or home treatment team.

Meanwhile Bradford Mind, a local mental health charity, was funded by the NHS trust to set up the ‘Sanctuary’ project as part of the concordat developments. The community-based service offered support in a crisis, from 6pm and 2am every day.

It was a small service where people could receive intensive therapy and provided an additional option for the trust’s first response team to direct people to.

System-wide changes

Trewin says the “system-wide” changes have led to a far better response to crisis situations: “If someone’s at risk of their mental health deteriorating we can now send first response out to give them an immediate assessment and we have options other than hospital.

“If somebody turns up at A&E with a mental health or social care-related issue we can get them seen immediately at the Sanctuary. People detained by the police almost always get a place of safety, not custody suites. Our intensive home treatment teams are able to do the intensive work they were set up for and do best.

He acknowledges the redesigned system, while much improved, is still far from perfect.

With budgets in health and social care tight, and getting tighter, the new system inevitably involved an element of compromise (the use of care homes is one example – if full funding was available a more specialist service, such as accommodation to help people avoid a crisis, might have been commissioned).

“Don’t get me wrong. We’re still grappling with issues. There’s still plenty to do,” he says. “But it’s much improved from where we were and we now address problems together. Integrated and joint partnership working, even though it’s a lot of hard work, has helped us to redesign our services.”

Gilderdale agrees: “We’ve really gone for whole system change. It’s a shared vision. I’ve been involved in partnership working before but this feels different. We’ve got sign-up from senior staff here at the trust, at the CCGs, at the local authority – it’s that senior buy-in and mandate that makes all the difference.

“Relationships are key. If something’s not working, or we’re not happy about a system or process, it is about being honest and open around the challenges and work through them together.

“Health or social care cannot do this alone. Social workers are a key component to the whole system. For example, if the first response team was going out without any social work input, they wouldn’t find the same solutions. Another example is we have weekly bed management meetings. Having social care in those meetings, having that housing specialist there, makes such a difference.”

Outcomes

As well as the dramatic reduction in out-of-area placements, the number of people detained by police using their Mental Health Act powers has also dropped from an average of around 25 a month at the start of last year to fewer than 10 a month now, says Trewin.

Use of police cells as a place of safety has been eliminated for children, and reduced for adults, he adds. A survey of police officers revealed the changes have improved their opinion of health and social care services too.

While the official figures have yet to arrive, Trewin says early estimates from the local A&E department suggest the number of people waiting to be seen for mental health emergencies has dropped by around a third since the new system came into place.

He feels that improvement is in no small part thanks to the Sanctuary. The service has supported more than 600 people since it opened. Plans are now being discussed to open a day-time project along similar lines.

The Sanctuary’s comments book lists a series of good feedback (and one negative comment) from those who’ve used the service.

One said: “I have never felt judged here. I feel so at home here and leave feeling so, so much better. Thank you. I hope this service is around for a long time because it’s badly needed.”

A second wrote: “There aren’t many places in this world where I can be both myself and accepted without fear of a negative response.

“Perhaps the ‘big’ surprise is that this hasn’t happened in a clinical setting. It’s happening in this sanctuary where the staff are not trained doctors or nurses. They see visitors as a person, an individual, not a label. They have a little note in their mind of how I like my cuppa. Those seemingly small things make a big difference.”

Feedback from the frontline

Frontline staff say they’ve noticed a difference in the past 18 months too.

Dave Hawkins, Bradford’s AMHP service manager, says staff morale has improved and late working reduced. Things are “a lot better” on the beds front he says, although there can still be significant problems with children’s mental health bed availability.

Rosie, a community mental health team social worker and AMHP, says the intensive home treatment team’s extra capacity and the other community alternatives now available have been a huge help.

“I’m a relatively new AMHP but when I’m going out on assessment I always feel I’ve got options other than just hospital admission. That’s the main thing. I feel I’ve got support.”

Sara, a social worker in an early intervention psychosis team and an AMHP, says the 24-hour first response cover has made a big difference: “I think that’s one of the best things about this. People have the out-of-hours number they can call. And first response can then go out and see them. It really does help to reduce the amount of acute referrals we get.”

Tracy agrees, and says the speed of response offered is helping services intervene earlier in crisis situations. She’s also proud of the joint working between the different services in Bradford and says a recent meeting with teams from other areas really brought home its value.

“Everyone was talking about the nightmare with beds. They were still having to send people miles away. And I just thought, it’s been hard work, we’ve had to really work hard together to get where we are. But for the people in our communities, I’m just so glad we’re not in that position anymore.”