Outside‐In and Inside‐Out:Outreach as a Copernican moment

in psychiatry?

Prof. Mervyn Morris

Birmingham City University

presentation

17th March 2011

Where is Birmingham?

‘De-institutionalisation’:Birmingham Beds: 722 (pop.1.2 million)

BED TYPEBED TYPE nn CommentsComments

‘‘Acute’Acute’ 234234= 1:5000 = 1:5000

poppop

8 sites across City and 8 sites across City and SolihullSolihull

17 units, 6-16 beds per 17 units, 6-16 beds per unitunit

Includes 2 Intensive Care Includes 2 Intensive Care UnitsUnits

Separate Male and Separate Male and FemaleFemale

‘‘Longer Longer Stay’Stay’

112112= 1:10,000= 1:10,000

Hospital type facilitiesHospital type facilities

ForensicForensic 152152 REGIONAL REGIONAL

‘‘medium secure’medium secure’

SpecialitySpeciality 3030 REGIONAL Deaf (12), REGIONAL Deaf (12), Eating Disorder (10) Eating Disorder (10) Mother and Baby (8)Mother and Baby (8)

Older AdultsOlder Adults 194194 65+years65+years

Deprivation in Birmingham..

The ‘BIRMINGHAM MODEL’

• A defined set of ‘functional’ outreach

teams, providing a mobile/

ambulant community service, with

different ways of working that

reflect the different needs of people;

• Strong emphasis on multidisciplinary team-working;

• Different teams working in the same community..

COMMUNITY MENTAL HEALTH TEAMPrimary Care Continuing Need:Liaison Rehab and Recovery

CONTINUING NEED

ASSERTIVE OUTREACH TEAM

HOME TREATMENT

TEAM

Residential based care: Hospital Beds, Day services, Crisis Homes,

PRIMARY CARE SERVICES

Primary Care interface

Hospital interface

BIRMINGHAM MODEL..core teams

‘Functionalised’ Community Teams

KEY CHARACTERISTICS 1

• Same pattern of services found

across City;

• Each team suited to work with

different levels of need;

• Multi-disciplinary, integrated with social care;

• Depending on deprivation, serve smaller or larger populations..

COMMUNITY MENTAL HEALTH TEAMPrimary Care Continuing Need:Liaison Rehab and Recovery

CONTINUING NEED

ASSERTIVE OUTREACH TEAM

HOME TREATMENT

TEAM

Residential based care: Hospital Beds, Day services, Crisis Homes,

PRIMARY CARE SERVICES

Primary Care interface

Hospital interface

BIRMINGHAM MODEL

X 21 teams

X 5 teams

X 17 wards

X 7 teams

‘Functionalised’ Community Teams

KEY CHARACTERISTICS 2

Differences in:

• Caseload; staffing ratio/population

served/ working hours;

• Contact frequency/ location;

• Visiting patterns/ length of time on caseload;

CORE SERVICE TEAMS ACTIVITY

FUNCTION

CASELOAD•Staffing ratio to Pt.•Availability•Population (av.morb)

CONTACT•Frequency•Location

VISITING•Time on visit•Time on caseload

CMHT:

Primary Care Liaison

&

Rehabilitation/ Recovery

•≤ 1:30

•‘working week’•50,000

•Weekly – Monthly•Clinic or Home

•Therapeutic Session Up to 1 hour•Up to 6 months

•≤ 1:25‘

•Working week’•50,000

•Weekly – Fortnightly•Home or Community

•Activity based •Years (ALAN)

Assertive Outreach

•≤ 1:12

•0900-2100 6 days•150,000

•Daily-Weekly•Home or Community

•Minutes to Hours•Years (ALAN)

Crisis/ Home Treatment

•≤ 1:2

•24 hours, 7days•150,000

•Multiple visits daily – 3 times per week•Home or Community

•Minutes to hours, as required•Up to 3 months

‘Functionalised’ Community Teams

KEY CHARACTERISTICS 3

• Integrated into care pathways:

Acute and Continuing Care;

• Emphasis on avoiding hospital;

• Clearly defined boundaries and

interface with hospital and primary care;

• Some outreach teams more specifically target vulnerable populations, for example; early intervention; homeless team.

COMMUNITY MENTAL HEALTH TEAMPrimary Care Continuing Need:Liaison Rehab and Recovery

CONTINUING NEED

ASSERTIVE OUTREACH TEAM

HOME TREATMENT

TEAM

Residential based care: Hospital Beds, Day services, Crisis Homes

PRIMARY CARE SERVICES

Acute Care pathway

COMMUNITY MENTAL HEALTH TEAMPrimary Care Continuing Need:Liaison Rehab and Recovery

CONTINUING NEED

ASSERTIVE OUTREACH TEAM

HOME TREATMENT

TEAM

Residential based care: Hospital Beds, Day services, Crisis Homes

PRIMARY CARE SERVICES

Continuing Care Pathway

COMMUNITY MENTAL HEALTH TEAMPrimary Care Continuing Need:Liaison Rehab and Recovery

CONTINUING NEED

ASSERTIVE OUTREACH TEAM

HOME TREATMENT

TEAM

Residential based care: Hospital Beds, Day services, Crisis Houses,

PRIMARY CARE SERVICES

Additional teams

EARLY INTERVENTION SERVICE

COMMUNITY MENTAL HEALTH TEAMPrimary Care Continuing Need:Liaison Rehab and Recovery

CONTINUING NEED

ASSERTIVE OUTREACH TEAM

HOME TREATMENT

TEAM

Residential based care: Hospital Beds, Day services, Crisis Houses,

PRIMARY CARE SERVICES

Additional teams

HOMELESS TEAM

The Copernican shift.. The service begins to revolve around the patient

The Birmingham Model is not enough!

There’s a difference between:

“DOING THE RIGHT THING”

and

“DOING THE THING RIGHT”

The Birmingham Model explains DOING THE THING

RIGHT, about organising a system; it is then down to

the teams to do the ‘right thing’..

The Copernican shift.. The service begins to revolve around the patient

INSIDE – OUT

• Reduces the stigmatisation of• Hospitalisation• Relate to the person and their

social network in a different way;

• Seeing mental illness in context:

understand content of symptoms;

The Copernican shift.. The service begins to revolve around the patient

OUTSIDE – IN

A new model of psychiatric practice emerges:

• More personalised intervention:- empowerment through choice and

negotiation of meaning;

- in vivo, and with social network;

- including not excluding people from each other.

• Recognise the social context of mental health problems; to be in a position to address directly vulnerability; exploitation, poverty, homelessness.

The Copernican shift.. The service begins to revolve around the patient

Outreach is necessary, but not sufficient..

This is the moment to pause:

We can take ‘psychiatry out of

the hospital’, but we must also

take the ‘hospital out of psychiatry’.

If we continue to think and practice community

outreach in the same way as we thought and

practiced in the hospital, then we are not

de-institutionalising, we are re-institutionalising..

Thank you for listening..

mervyn.morris@bcu.ac.uk

www.hcc.uce.ac.uk/ccmh

www.soterianetwork.org.uk

COMMUNITY MENTAL HEALTH TEAM Primary Care Continuing Need:Liaison Rehab and Recovery

CONTINUING NEED

ASSERTIVE OUTREACH TEAM

HOME TREATMENT

TEAM

Residential based care: Hospital Beds, Day services, Crisis Homes

PRIMARY CARE TEAM

OTHER ADULT SERVICES

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LC

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CIA

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What made community services work?

• An integrated service pathway• Effective boundary management between teams – ‘system of gateways and filters• Integration with social care – housing, employment, benefits and ‘3rd Sector’• Teams with competent team managers • Preparation and learning as we go• Data – targets and monitoring• Continue to innovate and adapt

Gaps/ issues/areas for development

• Transition from child to adult services

• Biological v Social models:

i.e. EVIDENCE!! (families, work)

• Fidelity (e.g. CRHT)

• CMHT’s – function

• Shifting/ diversifying provision

• Effective commissioning/ contracting

Pre-conditions for transformation

• A vision.. Being ready..

• Evidence of effective community models

• Service user and carer support

• Existing competence amongst staff in independent community practice

• An opportunity e.g. psychiatric hospital that needs to close

• Courage