Trust in partnership redesigns services to help manage rising demand for mental health care, achieving better staffed teams and providing 24/7 treatment to patients

Synopsis

Service users, providers and commissioners working together to transform services for people severely affected by mental health problems, to improve:

• Patient outcomes and experience; through more person-centred care, improved inpatient facilities and through a wider range of out-of-hospital services;
• Productivity; through detailed needs analysis and shaping the workforce around people’s needs;
• Efficiency; using resources differently to meet national standards for care and, at the same time, improving the financial position across the health economy.

The redesign covers the populations of Cheshire East and Vale Royal (7000 people accessing specialist mental health services).

Ambition

What was the context in which a redesign necessary?

During listening events a service user said she “wanted to thrive not just survive”. This epitomised the problems, with limited resources to prevent ill-health and support people to live well.

Other factors included:

• Rising demand, with increased activity of 35% for people with moderate to severe needs and 60% for dementia since 2010;
• The existing model of care was not able to respond to new developments with national policy, best practice and emerging local transformation plans;
• Engagement with service users showed limited choice and access to care in crisis, with only A&E departments offering 24/7 support and an over-reliance on inpatient beds;
• The deteriorating financial position required action with local funding for mental health in the lower quartile nationally and the cost of services exceeding the funding available.

What was the ambition of the project including any targets?

The ambition of the project was to:

• Focus on early intervention and prevention;
• Improve outcomes for people with serious and complex mental health needs;
• Meet people’s health and well-being needs;
• Ensure people live longer, healthier lives;
• Support people at home or as close to home as possible in the most appropriate environment;
• Empower people who access services and their carers through choice and involvement;
• Ensure the greatest benefit for patients was achieved from the resources available.

How were those targets identified and what initial planning and research took place?

• Desktop review of national policy and best practice guidance;
• Site visits with service users to explore alternative models and services;
• Detailed needs analysis using public health, business intelligence data and NICE guidance;
• Extensive user engagement to co-produce both the clinical and service delivery model including mental health forum engagement.

What planning was put in place to work with stakeholders, colleagues, partners and patients?

• A communications and engagement plan included a range of listening events, engagement with mental health forums, healthwatch, local health scrutiny, local authority colleagues and with service users and carers within services and recovery colleges;
• The options appraisal was clinically led, with a strong focus on staff engagement throughout -including workshops, online hubs and links to the wider Trust People plan;
• A Building User Group has co-produced the design of the new inpatient facilities - with state of the art features such as communal hubs and touch down’ staff bases, including en-suite accommodation for all patients.

Outcome

What were the results of the redesign and what were the effects on patients and staff?

In real terms the redesign has delivered the following, within a smaller financial envelope and with funding taken out of running costs for inpatient services and put into community care:

• Enhanced community mental health teams;
• Enhanced 24/7 crisis home treatment teams;
• New dementia outreach staff to support people in their homes and care homes;
• Specialist inpatient beds for adults and older people with serious mental ill health;
• Specialist inpatient beds for people with dementia;
• Community-based crisis beds;
• Centralised centres of excellence for rehabilitation and ECT (electro-convulsive therapy).

Also see qualitative patient and staff feedback in the supporting information indicating improved patient experience and improved staff morale and enthusiasm for the new model of care.

How effective was any collaboration with key colleagues, stakeholders, partners and patients?

• The redesign process took place within the context of intense media and local political scrutiny with a strong resistance to change that would reduce local inpatient beds (see supporting information);
• Collaborative working was vital in order to make the case for change effectively;
• The case for change was supported. A system solution was found that responded to service user feedback, with the help of the district general hospital acute trust (who is the landlord for the inpatient site occupied by CWP) together with significant capital investment from CWP and new recurrent monies from the CCGs. This enabled a smaller specialist inpatient service to be retained in East Cheshire whilst releasing recurrent funds from the old inpatient unit to invest in community services.

All of this was achieved within the context of a healthy economy with a significant overspend against allocated budget.

What was the financial impact of the redesign?

• The redesign will deliver a net financial benefit of £1,2m within Adult and Older People’s Mental Health services, as the service was costing more than the allocated budget. This includes re-configuration of inpatient services saving £2.5m - of which £1.3m has been reinvested to enhanced community services;
• Joint working across the system, between providers and commissioners, has supported the achievement of improving the financial position whilst ensuring a clear focus on optimising patient care and outcomes;
• Good financial stewardship at CWP enabled the release of significant capital funding to support the new inpatient units to be refurbished and extended without any external funding being available to achieve this.

Spread

Outline examples where this project was embedded and spread to other departments, settings or organisations

• Early on in the redesign process there was a detailed needs analysis undertaken which utilised both public health and local activity data benchmarked, to ensure demand for services was accurately captured. This needs analysis was then mapped to evidence based pathways to identify the workforce required and informed both the workforce plan and the financial modelling for the business case.
• The consultation process was considered to be a highly effective and authentic process, satisfying both internal statutory committees and providing assurance to external regulators regarding process; with the local Health Scrutiny Committee commending the approach.
• The co-production with the local mental health forums and other local community groups is now embedded in future system working via the new Cheshire East Mental Health Partnership Board.
• The Pre-Consultation Business Case process and associated consultation plan is being used as a framework for an upcoming Cheshire and Wirral-wide consultation on learning disabilities.
• The learning from the communications and engagement process has been shared nationally at a session led by the joint comms and engagement lead for this project, at the NHS Providers Communications and Engagement Network World Cafe event and widely via NHScomms.org and social media channels; on the NHS England/improvement Healthcare Communications Postgraduate course (where the project is the featured consultation case study) and in a CCG best practice webinar for the use of animation - see supporting information.

Value

Describe the impact of the redesign on staff and patient experiences the increased capacity enabled by the redesign includes:

• Local crisis beds, drop-in centres and cafes to enable us to support an additional 30 people at any one time to remain out of hospital;
• A better staffed home treatment team to care for more people in their own home and oversee crisis beds/centres on a 24/7 basis;
• Better staffed specialist community mental health teams with peer support and more joined-up working for our 7,000 people currently on caseload with a clear focus on prevention, early help and providing further intensive support for up to 630 people per year;
• A new service to help up to 12 people at any one time with dementia who have complex needs to remain in their own homes rather than being admitted to hospital;
• Closer working across physical and mental health services and social care so care is balanced and tailored to the individual;
• Modern inpatient services meeting Care Quality Commission standards, as close to home as possible for those that still need them.

The reduced variation enabled by the redesign includes:

• Creating a consistent model for home treatment teams in terms of availability and a consistent service offer/range of interventions;
• Meeting privacy and dignity standards throughout the inpatient environments and a general improvement in building optimisation to support the delivery of high quality and safe care;
• Reduced variation in the clinical pathway within our rehabilitation services by centralising them in a centre of excellence;
• Standardised the pathway for ECT (electro-convulsive therapy) within a centre of excellence achieving ECTAS accreditation (ECT accreditation service).

Within the funding available we have used resources differently to achieve more efficient services by:

• Driving greatest value for the commissioned spend by reducing reliance on inpatient services. The increased community staffing has not only delivered a preferred model of care, but also supported increased access to mental health services and brought the services in line with national policy;
• Increased staffing in home treatment teams has enabled them to operate 24/7;
• Some funds released from the inpatient redesign are enabling the provision of six community crisis beds which provide less-restricted and more suitable support for those who don’t need an inpatient stay - enabling a reduction in more costly inpatient beds;
• The redesign has also reduced excess staffing spend due to poor design of buildings and environment.

Involvement

Evidence of consistently strong team and/or organisation engagement in the redesign

• Providers and commissioners appointed a joint project lead and a joint comms and engagement lead. A project team including representatives from all organisations, including people with lived experience, worked together as one team and this collaborative working has enabled a truly co-produced solution to be found;
• The business plan was overseen by a system leaders group where weekly teleconferences with CEOs from health and care were involved, who monitored progress and managed risks; providing an exemplar for how to get complex redesign projects over the line;
• Staff engagement at CWP was an essential factor in ensuring a 2-year project maintained staff buy-in. A staff engagement programme with strong clinical leadership, face to face briefings, dedicated briefings and workshops to involve staff in decision making (see supporting information).

Evidence of strong partnerships and engagement with all those impacted by the redesign - including those in other organisations

• The engagement exercise involved all those people accessing services, representative organisations, Healthwatch and the local mental health forums together with all emergency services (police and ambulance), local authority colleagues and third sector partners.
• The NHSE Assurance process for major redesign was a very supportive process and the project team found NHSE colleagues to be critical friends throughout the process, and the advice to bring in an independent clinical senate to review the proposals was a helpful contributor to discussions with health scrutiny committees.

What patient involvement was there in the redesign?

• In line with best practice, patient feedback from the listening events directly influenced the options that went forward to consultation;
• The views of people with lived experience were heavily referenced in the Pre-Consultation Business Case and in the consultation document;
• People with lived experience sat on the project group, and regular engagement with mental health forums, Healthwatch, PPGs, and CWP’s governors, volunteers and members took place;
• Significant efforts were made to respond to the Equality Impact Assessment to promote service user involvement, via recovery colleges, outpatient appointments, easy read copies of consultation document etc - see supporting information;
• Service user feedback provided rich quantitative and qualitative data that was reflected upon during a period of conscientious consideration (in line with the Gunning Principles) and, as a result, an amended preferred option was taken forwards;
• During implementation the voice of service users has continued to be a key feature of the project.