The Pointless Separation of Care

1. The Pointless Separation of Care

2. Health Perspective • 1 in 4 people will experience a Mental health problem at some time in their life • We have introduced open access psychological therapy services In primary care. • In a year about 29,OOO Derbyshire people will be open to NHS MH adult teams . • Integrated services is a fundamental driver for the future • Derbyshire CCG have invested more in MH services but… • Non Service Solutions, community asset building and resilience is needed .

3. Crisis Concordat A Health Perspective • Casualty 1500 people a year coming to casualty following self harm (approx.) • Used to be seen 9-5 7 days week. • Now 24 hours 365 days per week through RAID investment-Liaison team in DRH and CRH

4. Liaison team

5. The view for AMP • Increasing use of MH Act powers • 5 % increase year on year in compulsory admissions • Before the street triage pilot of those that come to hospital on a section 136 only 30% are admitted. • Disjointed connections between agencies and expectations of roles and of what a person wishes and what is offered –see the vignettes • Reforming 136 Group and multi professional forum to link into the Crisis concordat

6. 136 to Hospital

7. Out of hours • High priority and area of concern for People who use services • How to extend hours so a problem doesn't become a crisis • Help line Rethink Focus Line and Samaritans • Trialling a nurse in 111 over weekend

8. Children and Young People Note: Patients may be included more than once if multiple categories have been identified.

9. Young People referrals For Southern Derbyshire and Erewash CCG s only data for DHcFT

10. Adult Crisis Team • 43,617 contacts • 1090 people • Total MH contacts by Crisis team and by CCG • Average length of treatment spell is 39 days

11. Crisis Team By cluster cluster Percentage %

12. Clusters • Care Cluster 4: Non-Psychotic (Severe) - This group of PATIENTS is characterised by severe depression and/or anxiety and/or other disorders, and increasing complexity of needs. They may experience disruption to function in everyday life and there is an increasing likelihood of significant risks. • Care Cluster 5: Non-Psychotic Disorders (Very Severe) - This group of PATIENTS will be severely depressed and/or anxious and/or other. They will not present with hallucinations or delusions but may have some unreasonable beliefs. They may often be at high risk for suicide and they may present safeguarding issues and have severe disruption to everyday living. • Care Cluster 6: Non-Psychotic Disorder of Over-Valued Ideas - This group of PATIENTS suffer from moderate to very severe disorders that are difficult to treat. This may include treatment resistant eating disorders, Obsessive Compulsive Disorder etc, where extreme beliefs are strongly held, some personality disorders, and enduring depression. • Care Cluster 7: Enduring Non-Psychotic Disorders (High Disability) - This group of PATIENTS suffer from moderate to severe disorders that are very disabling. They will have received treatment for a number of years and although they may have an improvement in positive symptoms, considerable disability remains that is likely to affect role functioning in many ways. • Care Cluster 8: Non-Psychotic Chaotic and Challenging Disorders - This group of PATIENTS will have a wide range of symptoms and chaotic and challenging lifestyles. They are characterised by moderate to very severe repeat deliberate self-harm and/or other impulsive behaviour and chaotic, over-dependant engagement, and are often hostile with services. http://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/m/mental_health_care_cluster_de.asp?shownav=1

13. Clusters • Care Cluster 10: First Episode Psychosis - This group of PATIENTS will be presenting to the Mental Health service for the first time with mild to severe psychotic phenomena. They may also have depressed mood and/or anxiety and/or other behaviours. Drinking or drug taking may be present but will not be the only problem. • Care Cluster 11: Ongoing Recurrent Psychosis (Low Symptoms) - This group of PATIENTS have a history of psychotic symptoms that are currently controlled and causing minor problems if any at all. They are currently experiencing a period of recovery where they are capable of full or near functioning. However, there may be impairment in self-esteem and efficacy and vulnerability to life. • Care Cluster 12: Ongoing or Recurrent Psychosis (High Disability) - This group of PATIENTS have a history of psychotic symptoms with a significant disability with major impact on role functioning. They are likely to be vulnerable to abuse or exploitation. • Care Cluster 13: Ongoing or Recurrent Psychosis (High Symptoms and Disability) - This group of PATIENTS will have a history of psychotic symptoms which are not controlled. They will present with moderate to severe psychotic symptoms and some anxiety or depression. They have a significant disability with major impact on role functioning. • Care Cluster 14: Psychotic Crisis - This group of PATIENTS will be experiencing an acute psychotic episode with severe symptoms that cause severe disruption to role functioning. They may present as vulnerable and a risk to others or themselves.

14. Crisis Team

15. Is a bed available ? • Last 3 years build up of demand leading to in 1April 2013-14 March31 125 People sent outside Derbyshire for an Acute ie urgent MH bed • Invested in crisis house -5 beds • Invested in new ward in Derby and home treatment staff • Now no one sent outside Derbyshire (but its very tight)

16. East Midlands Ambulance service April 2014 we attended 172 calls for psychiatric/suicide in Derbyshire alone; this does not include many other call categories for this patient type We do our best!!! But is it good enough for these patients? We want to work with you to help these people but we can’t do it without you

17. Workforce at EMAS Clinicians • Emergency care assistants and Technicians • Paramedics and ECPs • Registered Nurses • Recruiting GPs Emergency Control room • Call takers and dispatchers • Clinical assessment team

18. Issues we face • Limited care pathways for patients with mental health problems/ in crisis • Limited referral routes especially out of hours • Frontline staff with limited MH training expected to treat this patient group • No access to patients notes so unaware of the patients background (especially when violent) • No where to take the patient except ED ????

19. The question from EMAS • “Where do we refer these patients to?? There are very few pathways open to them and we do not have the skills to adequately assess them correctly.”

20. The NHS Questions • What can we do differently to divert before a crisis? • Once a crisis has occurred what could we do differently? • Should we all aim to reduce compulsory admissions by 2017 is that a sensible target for us all?