75.07 Crisis Resolution _ Hospital at Night Presentation by liaoxiuli1


									   Update to Trust Board

  Crisis Resolution / Home
Treatment developments and
      Hospital at Night

  Clair Carson & Alison Kendall
April 2007
Reported to Trust Board that we had achieved the CSIP / DOH targets re:
  Crisis Resolution:

•   Current day-time Crisis Resolution / Home Treatment services
    extended to cover 8am-10pm in all boroughs – additional staff funded
    in some boroughs

•   CRHT teams gate keeping all inpatient admissions via the Trusts new
    gate keeping protocol, developed as part of this project.

•   Two divisional based night teams developed operating from 10pm-8am
    (one in the North and one in the South) – interim arrangement pending
    the development of the Hospital at Night team.

•   The teams consist of two qualified practitioners who will be mobile and
    able to respond to requests for home treatment out of hours and
    perform the gate keeping function in conjunction with the bleep holder
    and medic on-call.

•   Trust established a Hospital at Night sub-group chaired by Dr Harris to
    look at a longer-term solution, due to be implemented October 2007.
The longer term solution
Hospital at Night: Background
•   H@N initiative first developed by Acute Trusts – solution to WTD and need to
    meet 48 hr working for junior doctors
•   In acute medical and surgical specialties, the H@N approach has enabled
    Trusts to develop generic cross speciality multi-disciplinary teams to manage
    medical and surgical emergencies at night.
•   Focuses on competencies, team working and communication
•   Evidence from Acute Trusts – pronounced benefits for patients and staff –
    receive care from most appropriate person, delivered in timely manner and
    better co-ordinated. Improved job satisfaction and reductions in absenteeism.

    In Mental Health, cross speciality cover is not possible but the development of
    effective competency based teams with smart communication could support
    better patient care as well as provide a robust solution to WTD, the delivery of
    CRHT and access & liaison services out of hours

How can we apply it in a Mental Health setting?
Hospital at Night: Mental Health drivers
•High number of inpatient admissions – excessive bed occupancy levels. Junior doctors
often working in isolation at night with no identifiable team structure and this can result in
inappropriate admissions.

•In Aug 2007, ¼ of ST Year 1 to 3 posts in Psychiatry -allocated to General Practice leading
to a reduction in the overall clinical experience amongst the junior doctor body. In most
boroughs most doctors on the on-call rota will be in their first or second six months of

•Consultants responsible for medical training, concerned about impact of night shift working
on junior doctors training. The advent of full shifts in Aug 2004 has reduced trainees
exposure to daytime - impacting on quality and quantity of training (MMC).

•Need to meet WTD targets

•Limited A&E Liaison team cover out of hours – 4 hr targets for Acute trusts

•Difficulties in delivering home treatment services out-of-hours – limited capacity

•Gate keeping inpatient beds out of hours – often left to junior doctor and nurse bleep
holder to make clinical decision. Need to develop capacity for MDT clinical decision-making.
Pennine Care Hospital at Night
Pennine Care is part of the wider Greater Manchester Hospital at Night project
supported by Brian Jones, Project Manager.
The sub-group was formed in January 2007 chaired by Dr. Vic Harris and
supported by Alison Kendall (Project Management Lead) and Clair Carson
(Clinical Lead).
The Trust is one of the first mental Health Trusts nationally to be developing a
Hospital at Night initiative / model.
The proposal regarding the Hospital at Night team has recently been approved
by the SD Board and an implementation plan has been developed.
Phase 1 of the project will go-live in December 2007, with phase 2 changes
planned for August 2008.
Baseline Audit
Brian and his team undertook a detailed audit of out of hours activity including SHOs,
SpRs, Consultant Psychiatrists and nurse Liaison teams across all boroughs of the Trust
from 25 September 06 until 22 October 06.
Trust now in possession of wealth of data and information regarding out of hours activity
and demand.
The data confirmed the following:
•Poor handover arrangements – with junior doctors and nursing staff carrying out
separate handovers
•Junior doctors often working in isolation with no identifiable team structure
•Workload out of hours is not co-ordinated with no structured prioritisation of patients

Table 1: Mean Daily Activities by Borough & Division across SHO, Access & Crisis and Liaison staff groups
                                                    Liaison / Access
                                 SHOs               & Crisis
    Division     Borough         Mean activity      Mean Activity      Total by Division   Activity pre   Activity post
                                 17.00hrs to 9.00   17:00h to 09:00h                       00:00h         00:00h
                                 hrs                (hrs)

                 Bury            2.2                1.9
                 Oldham          7.4
    NORTH                                                                    16.7                69.8%          30.2%
                 Rochdale        5.2

                 Tameside        7.0                3.9
    SOUTH        Stockport       4.5                                         15.4                75.0%          25.0%
Solution: Outline model
•Development of a multi-disciplinary team to operate out of hours

•Support CRHT targets through providing capacity for home treatment out of hours if
•Provide a rapid response to A&E out of hours that does not solely rely on the junior
•Ability to respond to the inpatient wards out of hours
•Provide out of hours function re: gate-keeping to inpatient services

•Two divisional teams – 1 x North (hub based in Oldham) / 1 x South (hub based in
•Mobile practitioners to cover the divisions

•Twilight shift operating from 4.00pm – 12midnight
•Night shift operating from 10pm – 8am
•Supported by development of a new role – Team Co-ordinator working 4.00pm -
Crisis Resolution / Home Treatment component:
Borough based CRHT team continue until 10pm
This is due to a higher demand for home treatment between hours of 5pm-10pm
However practitioners working post 5pm become part of the Hospital at Night team and
report to the Team Co-ordinator
CRHT is delivered on a divisional basis post 10pm through the H@N night shift
Access & Liaison component
Borough based Access & Liaison teams finish at 5pm
A&E assessments post 5pm fall under the remit of H@N team, with requests for
assessments and the allocation of practitioners done through the Team Co-ordinator
Gate keeping of inpatient resource
Post 5pm this become the remit of the H@N team, managed via the Team Co-ordinator
Emergency response to the wards
Bleep holders on inpatient wards will be able to contact the Team Co-ordinator in the
event of any emergencies out of hours and appropriate support administered.
The Team Co-ordinator will support robust handover at 4.00pm (from those team
finishing at 5pm) and again at 10pm (from borough based CRHT teams finishing and the
H@N night shift commencing)
Incremental approach
Phase 1 of the Hospital at Night approach retains 1 x SHO in each borough on-call, in
conjunction with the development of the Team Co-ordinator role the administrator role
and the support worker.
Phase 2: However it is proposed that in August 2008 the Trust moves to phase 2 of the
approach (to coincide with the junior doctor rotation) moving to one SHO on-call per
division - and removing some of the SHOs from the on-call rota (which will see some
financial benefits for the Trust).

Reduction in SHOs working nights – potential savings
The reduction in number of junior doctors on the on-call rota will enable the Trust to
reinvest this monetary saving into the H@N team.
This approach also supports the need to modernise the medical workforce and allows
junior doctors to be exposed to more training opportunities in the day light hours.
Incremental approach
This approach is being adopted to:

•Provide a 6-month period in which to train new staff, including the Team Co-ordinator
and the future band 6 role, develop the team, and change the culture away from relying
on the on-call SHO, in preparation for moving to 1 SHO per division from August 2008.
•Allow for ongoing audit of activity levels (both out of hours and during weekends) to
ensure appropriate staffing is being put in place from August 08, and demonstrate that it
will be ‘safe’ to move away from having one SHO in every borough.
•Take account of the unknown impact of external developments such as the changes to
Acute Trusts A&E services and the potential impact on mental health services
•Allow for time required to have the appropriate negotiations with the BMA, Deanery and
the Royal College with regards to the proposed radical changes to junior doctors terms
and conditions, rotas and pay banding.
•Audit the possibility that this development is self-financing in terms of the potential
impact on occupancy levels and the demand on the inpatient resource.
•Support the training of Advanced Practitioners - we will be able to support a move away
from having an SHO in each borough and see an increase in Advanced Practitioners
(2009). In the interim, however the move to one SHO will need to be supported by band
6 practitioners until sufficient numbers of Advanced Practitioners have been trained.
Staffing the model
•A skills & competency based approach has been taken to staffing the model
•Activity data collected during the audit work was used to look at the skills and
competencies required out of hours
•The group also tried to factor in certain ‘unknown’ quantities such as the potential
increase in demand for home treatment out of hours

•A Population Centric Workforce Planning tool was utilised in marrying demand to
competencies and ultimately whole time equivalents.

•A series of workshops were facilitated to populate the model. A broad section of Trust
staff attended, including junior doctors, SpRs and Consultants, managers with a
modernisation remit and members of the crisis resolution and A&E liaison teams. The
workshop began to map the level of competency required for a Hospital at Night team by
‘weighting’ each work activity as basic, intermediate and expert.

•From this information, the Trust was able to determine the shape of the team.
   Team staffing

                              Hospital at Night Team (1st December 2007 - 31st July 2008)

                                                                                                                                      Weekdays, Weekends & BH

                                    CRHT Unqual. (Band 3-4)   16:30h to 22:00h                                                                         22.00h to 00.00h                                      00:00h to 09:00h

                                                                                                       Team Co-Ord (Band 7)
                                                                                 CRHT Qual. (Band 6)
                                                              Access & Liaison

                                                                                                                                                       Band 6 Nurse

                                                                                                                                                                                                                 Band 6 Nurse
                                                                                                                                                                      Team Co-Ord

                                                                                                                                                                                    Supp Wkr

                                                                                                                                                                                                                                Supp Wkr




       Division   Borough

                  Bury        1.0   1.0                                          1.0                                                             1.0                                                   1.0

       North                                                                                           1.0                    1.0       15.0           2.0            1.0           1.0        7.0              2.0             1.0        6.0
                  Rochdale    1.0                                                2.0                                                             1.0                                                   1.0

                  Oldham      1.0   1.0                       1.0                2.0                                                             1.0                                                   1.0

                  Stockport   1.0                             1.0*               2.0                                                             1.0                                                   1.0
       South                                                                                           1.0                    1.0       10.5           2.0            1.0           1.0        6.0              2.0             1.0        5.0
                  Tameside    1.0                             1.0                3.5                                                             1.0                                                   1.0

*NOTE* From December 2007, there will be 6 Advanced Practitioners in training, 3 per division, who will be able to offer
3 shifts per practitioner on average per week to supplement the required numbers in the team (covering all hours)
                         Hospital at Night Team (From 1st August 2008)

                                                                                                                                                  Weekdays, Weekends & BH

                                                                   16:30h to 22:00h                                                                               22.00h to 00.00h                                      00:00h to 09:00h

                                 Band 6 nurse (Access & Liaison)

                                                                   CRHT Unqual. (Band 3-4)

                                                                                                                   Team Co-Ord (Band 7)
                                                                                             CRHT Qual. (Band 6)

                                                                                                                                                                  Band 6 Nurse

                                                                                                                                                                                                                            Band 6 Nurse
                                                                                                                                                                                 Team Co-Ord

                                                                                                                                                                                               Supp Wkr

                                                                                                                                                                                                                                           Supp Wkr




Division   Borough

           Bury                                                    1.0                       1.0

North      Rochdale      1.0    1.0                                                          2.0                   1.0                    1.0      11.0     1.0   2.0            1.0           1.0        5.0     1.0      2.0             1.0        4.0

           Oldham                                                  1.0                       2.0

           Stockport                                                                         2.0                                                                                                          5.0     1.0
South                    1.0    1.0                                                                                1.0                    1.0       9.5     1.0   2.0            1.0           1.0                         2.0             1.0        4.0
           Tameside                                                                          3.5

Note 1     It is planned to take a proportion of junior doctors off out-of-hours on-call altogether from August 08
Note 2     There is an aspiration to replace SHOs after 22:00h with qualified Advanced Practitioners in September 2009.
           New roles / additional resources
It is envisaged that the creation of these teams will bring positive outcomes for the Trust.
These can be summarised as follows:

•Robust out of hours provision (multi-disciplinary) across all boroughs of the Trust
•Achievement of WTD targets by 2009
•Increased quality in medical training / experience as the SHO becomes a key member
of an out of hours team, and a lower proportion of their time is spent covering out-of-
hours alone.
•Supports New Ways of Working.
•Ongoing compliance with the CSIP / DOH guidance concerning provision of CRHT out
of hours.
•Potential reduction in inpatient admissions out-of-hours due to less reliance on junior
medical staff, improved assessments, and more robust provision re: alternatives to
•Robust gate keeping out of hours - ensuring that only those service users in crisis and
requiring an inpatient bed access the inpatient resource.
•Supported and robust, multi-disciplinary decision-making out of hours
      For more information
                      Alison Kendall
Service Improvement Manager / Project Management Lead H@N
         Email: alison.kendall@penninecare.nhs.uk

                       Clair Carson
    Acute Services Manager Oldham / Clinical Lead H@N
                Email: clair.carson@nhs.net

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