Mental health - a joint approach

The intensive case review practitioner team based at NHS North of Tyne is a non-statutory body, working on behalf of three primary care organisations: Newcastle and North Tyneside primary care trusts and Northumberland Care Trust.

With the new commissioning arrangements taking shape across the country, the team felt it was important to explore better ways of working to support mental health patients, particularly how joint working can bring about improvements for people with highly complex needs.

The team sits in the patient safety department of NHS North of Tyne, which commissions local health services for around 780,000 people across urban and rural communities. It is led by a senior nurse, supported by two experienced nurse practitioners.

Although the local NHS providers deliver services that generally meet the needs of the population, a number of patients with highly complex needs require services that can only be met through an out of area placement.

A 2010 report by the King’s Fund advises commissioners to take “urgent action to cut back on clinically unjustified out of area treatments”. The use of this type of treatment is an expensive way to support people with mental health problems, learning disabilities or neurological disorders. The average cost of an out of area hospital placement is around £3,000 per week for someone with complex needs.

The report also recommended that “commissioners need to put in place robust systems for reviewing people who have been placed outside their areas”.

One of the tasks of the intensive case review team has been to clinically review existing out of area placements to ensure they are safe, clinically therapeutic, part of a pathway working towards maximising independent living, encouraging social inclusion, and working to a recovery model.

As a result, 11 patients have returned to services in the area over the past year. Other people have moved to new providers who are better able to work within this model.

Neutral ground

An example of this is when the mental health trust asks the organisation to fund a new placement. A nurse practitioner from the team ensures the proposed out of area placement is necessary, that there is clinical evidence to support it, and that there are no alternatives that are less restrictive.

In some cases, the team works with clinicians to develop a bespoke “alternative to a hospital placement” package, partnering independent social care providers with commissioned mental health service providers to support individual patients.

In light of the new commissioning structures the team felt it was important to create an opportunity to bring providers together in one room on neutral ground to encourage collaborative developments for future care pathways.

The forum sought to offer an equal platform of opportunity for all providers. It would develop discussion and provide commissioners involved in out of area placements with the opportunity for feedback. Consequently, an open morning was developed to which national and local providers were invited.

Providers attended from the independent sector and NHS, from mental health to learning disabilities to neurological specialist providers to autism, from hospital settings to independent supported living providers, making for a rich and varied discussion and exchange of views.

The open morning included a presentation setting the scene of what commissioners expected from providers of out of area specialist funded placements, detailing our expectations prior to contracting, which included:

• clear contracts, transparent costs;
• a clean, safe and attractive care environment;
• focus of recovery, social inclusion and service user involvement;
• high standards of record keeping;
• regular CPA reviews and clear details of progress and outcome measurement;
• proactive discharge planning.

The table-top exercise included asking providers what they wanted from commissioners. Their comments include:

• To give reassurances that independent providers are on a level playing field with NHS providers.
• Assurance that if a pathway has been set out by a provider, the patient is not “pulled back” into an NHS bed halfway through their pathway if it is not in their best interest.
• To proactively engage with care co-ordinators to promote their engagement with the providers.
• A need for increased step-down facilities.
• They would like more events like the open morning.
• They would like commissioners to share processes and protocols so that providers can follow correct processes for referrals and admissions.

A further exercise involved asking providers to write down what they thought made their service special. The responses help identify whether what is being offered is suitable and appropriate to the service users’ needs before an assessment is requested.

The final element of the event involved providing the participants with some thoughts on future developments and needs in the NHS North of Tyne region.

During the course of the morning opportunities were provided to network and discuss how future pathways may be progressed.

The feedback from the experience has helped demonstrate that competing providers are prepared to develop ways in which they can explore collaborative working relationships that can only improve the spectrum and pathways of mental healthcare provision for service users in the north of Tyne area.

Faye Spedding and Austin Wilcock are practitioners, and Siobhan Armstrong is lead nurse for the intensive case review team NHS North of Tyne.