Sunderland and South of Tyne Initial Response Team

Feedback in relation to the Trust's Crisis response services in Sunderland and South Tyneside once users were accepted and being treated in the service was positive, but there were complaints from service users, carers and referrers, that the crisis service is often inaccessible; cases are “bounced” in and out; it takes a long time to get help; no one answers the phone. As a result of this NTW launched the Initial Response Team (IRT) in April 2012. The establishment of the IRT had anticipated benefits as follows: 1. Quick and efficient responses to requests for help

2. Effective routing to the correct services in and out of NTW

3. Flexible and collaborative working with newly configured UCT which will focus on the work for which it is commissioned

4. Reduction of clinician administration burden, and freeing time to care 5. Improving personal and clinical outcomes for people in crisis with mental ill

health by reducing harm and premature mortality, improving safety and service user experience.

Owing to the success of the pilot, IRT was then developed for the whole of South of Tyne including Gateshead and South Tyneside from December 2012, thus covering a population of 465,850. The Case for change Sunderland was chosen as the location for the development of a new access model following discussions with service users, carers, GPs and commissioners. A key issue was that the Crisis team, commissioned to deliver assessment and support for serious mental health problems, was not responsive, as it was saturated with responding to a wide variety of requests for help at the more moderate end. In addition each assessment, following the national service framework model, took 2 hours regardless of the presentation. It was obvious that there was a lack of alternative responsive services for urgent requests for help in non-crisis situations that was more fit for purpose. A scoping exercise identified that only 35% of all contacts needed the response of the Crisis Team. 43% of the inappropriate contacts were for advice or help and often these were people clearly in need of support and signposting, but considered to be at low risk of requiring hospital admission, often experiencing low mood as a result of social issues. A further 8% were referrals for assessments which were deemed inappropriate for the Crisis team. Through staff engagement workshops we articulated how IRT would help reduce clinician administration burden, improve outcomes and safety, and reduce harm. The subsequent engagement of staff allowed us to better overcome boundaries and solve problems.

The Model The aim of the service is to provide a responsive single point of access for urgent requests for help to NTW including signposting to relevant services within and without NTW. The key objectives of the IRT are to offer a 24/7 response to telephone requests for help for urgent mental health needs for people of all ages and conditions; to offer triage & routing to appropriate mental health services and to offer triage & signposting to other local services as appropriate, using the Sunderland Well Being Directory. A number of new staff were appointed to establish the Initial Response Team including seven Band 6 Nurses to provide clinical triage and lead the Rapid Response. Five Band 3 Nurses were appointed to support the access element of the service (call handling) and provide support to the rapid response nurse. A crucial part of the design was to enable the IRT to work alongside and co-exist with the crisis team. They were therefore able to share skills and experience and promote positive learning and development for all staff within their roles, offering flexibility to staff and the service. In addition, all staff have interchangeable roles across IRT and the Crisis team. An important aspect of the transformation was to make the Crisis service available to users of all ages and conditions. On the diagram ICTS (Initial Crisis and Treatment Service) for children, older people’s service (OPS) and learning disability (LD) teams work closely with working age adults crisis staff so the service is life span universal.

Staffing for 24/7 provision The Sunderland pilot IRT in addition to the Crisis Resolution and Home Based treatment teams, resulted in a staffing establishment of 45 WTE as comprised as follows.

The expansion to implement IRT in Gateshead and South Tyneside required some logistical changes. The telephone hub for the South of Tyne area remains in Sunderland, and for each shift Gateshead and South Tyneside are each required to locate one of their band 6 clinical triage staff within the Sunderland hub. Gateshead and South Tyneside teams continue to provide the functions of IRT and CRHT form their respective geographical bases on a 24/7 basis, and receive referrals direct from the triage workers in the Sunderland hub who triage calls for the whole of South of Tyne, serving a population of 465,850 over a land area of 133 miles sq. The resulting staffing for Gateshead and South Tyneside is as follows:

Team Role # Staff

Band 7 Team Manager 1

Clinical Lead 1

Band 6 17

Band 5 3

Band 3 5

Total 27

CR

HT

& IR

T

Gateshead Locality

Team Role # Staff

Band 7 Team Manager 1

Clinical Lead 1

Band 6 12

Band 5 2

Band 3 4

Total 20

CR

HT

& IR

T

South Tyneside

Team Role # Staff

Band 7 Team Manager 1

Clinical Lead CRHT 1

Band 6 14

Band 5 4

Band 3 3

Clinical Lead IRT 1

Band 6 11

Band 3 10

Total 45

Sunderland Locality

IRT

CR

HT

Call Handler (Band 3) Historically a significant number of telephone calls to the Crisis team did not require a clinical response. In addition, a significant proportion of clinical time was spent on the telephone collecting demographic data and completing administrative tasks. As a result the telephone was regularly engaged for long periods. Consequently service users and referrers utilised emergency services (police and ambulance) and / or expressed their dissatisfaction with the service. The Initial response team have improved access by utilising band 3 call handlers to take initial calls, collect demographic information and complete administrative tasks. In turn this has allowed the band 6 nurse to focus on the clinical elements of the triage process. Access has also been improved by providing ten telephone lines into the service, enabling access for all of the teams South of Tyne (Sunderland, Gateshead and South Tyneside). Historically only one line was available in each area. At busy times it is a team priority to answer the phone. Clinical triage (Band 6) The Band 6 triage nurse ascertains the nature and degree of the concerns of the referrer by utilising an agreed standard to collect information and support the decision making process. There are a number of possible outcomes:

• Face to face Triage / Rapid response • Signposting to the correct service • Accessing the “scaffolding” available from other services (Older

Persons, Learning Disability and Children’s and Young Person’s Services)

• Providing the referrer with the correct advice to inform care and treatment

• Refer to Crisis team for Crisis Assessment The Clinical Nurse Triage gathers all relevant clinical information required to ensure that the referral is routed effectively to the correct team taking into account immediate needs and risks. They provide advice and information to referrers regarding clinical issues and route enquiries to the appropriate service, within or without NTW. Service users who are under the care of the local home treatment team continue to access this service as a point of contact should they require to speak to a member of the team or require clinical advice/support.

Evaluation Service user experience Evaluation questionnaires were written by service users and collected through Points of You (a service user organisation). Their responses were very positive and clearly showed service users feel that the IRT staff are polite, show kindness and empathy, and behave in a professional manner. Remarkably all service users were happy with the responsiveness and 100% would be happy to recommend the service to a friend. Quotation bubbles Carer Feedback South of Tyne Carers Liaison Group has been very positive. They particularly praised the initial contact and the very fast and appropriate response. GPs 100% of GPs surveyed said their calls were answered quickly and the IRT met their needs. Staff feedback The feedback from staff has been extremely positive. Staff report they are able to spend more time with the service users especially those who are perhaps more unwell or are perceived to be higher risk and the documentation which is completed is appropriate.

Thank you so much for your help and support over the past 6-8

weeks. I am well on the mend and couldn’t have got this far without

your help.

You saved my life! I know I’ve still got a far way to go but I have the determination to fight and

get there, so please accept my appreciation and thanks. You do an amazing job!

Wonderful support and understanding during a very difficult time. Make sure there is enough funding to

keep this very valuable service going.

Prompt and adequate response

Fantastic – a huge improvement!!

You should have done it before

As a band 3 I feel as if my skills and abilities to relate to others are finally being valued. I am

people’s first point of contact when they ring the number for the IRT and I am sure that service

users find us professional but also sensitive and personable.

Clinical Effectiveness The introduction of the IRT has resulted in an increase in the number of service users with urgent mental health needs receiving an intervention from NTW. The key clinical interventions include:

• Triage through telephone consultation with band 6 nurse to gather information regarding presentation. This results in a clinical decision as to the most appropriate intervention for the individual

• Rapid response (within 1 hour) home visit for face to face triage, risk/mental health monitoring, signposting, brief therapeutic interventions, managing distress

• Medication – we can access to PrimeCare (out of hours) GP service to manage presenting symptoms, or signpost to service user’s own GP

• De-escalating distress • Provision of advice in relation to benefits and other social issues • Depression mood management, relieving anxiety • Provision of advice and signposting in relation to substance use

Screening information is recorded in a standard format to collect a minimum dataset, and includes reason for referral, presentation including mental state, risk statement and formulation including exacerbating factors and protective factors, a plan and the outcome. Further interventions in relation to management of risk, distress and symptoms of mental ill health are then accessible, through the existing Crisis Resolution and Home Treatment teams, via various treatment models including Cognitive Behavioural Therapy, Solution focussed therapy, family interventions, bio -psycho social interventions and Dialectical behaviour therapy. A&E staff have reported a reduction in breaches of their 4 hour wait target related to service users presenting with mental health problems. Furthermore, the improved response times of the Crisis team has reduced the number of incidences when emergency services have had to be contacted in relation to service users with urgent mental health needs. Ambulance staff also report that the improved response times from the crisis team and the IRT has reduced the amount of time they are spending with service users presenting with mental health problems.

This feedback is now being evaluated quantitatively.

Benefits These are wide ranging and include: • Improved response times (average 30 minutes from call to door) • Improved telephone access (average 9 second pick-up) • Equality of access to urgent mental health services • Improved service user, carer and referrer experiences • Reduced avoidable harm - no “bounced referrals” (these are now routed to the most appropriate service) • Reduced assistance required from emergency services • Positive staff feedback

Supported by Technology, reducing clinician administration burden Support services played a pivotal role in the success of the IRT. The use of digital dictation (a system where staff use an application on a BlackBerry, and are able to dictate all clinical notes including triage and assessments), saves hours of time at a keyboard! Transcribing typists are employed 24/7 to ensure dictated notes, which are securely emailed to them, are recorded in a timely manner, which staff are then able to access and validate. Digital dictation has increased the efficiency of the team, and some staff report improvement in the quality of their working life as they are able to spend more time with service users and carers, the primary aim of clinical staff. Staff also have tablet computers with 3G technology enabling them to access records when out in the community, negating the need to return to base to do so, ensuring time is well spent.

Commissioner Support The need to improve access to mental health services where there was an urgent request for help became clear through extensive engagement with service users, families and referrers across Sunderland, South Tyneside & Gateshead through 2010/12. This work was the result of a whole system engagement & service transformation about mental health care, led by the PCT, which provided the means to develop a wide range of improvements, one of which is the Initial Response Team. Working collaboratively with Commissioners and other partners the transformation of access to NTW for urgent referrals was implemented and tested as a pilot in Sunderland, developing telephone triage and a rapid response function as a first point of access for the public, service users, carers and referrers, supported in its first year through the imaginative use of the CQUIN attached to the contract. The support (and ultimately funding) from Commissioners facilitated the roll out of the system to cover the whole of the South of Tyne services for NTW. Through the development of this model there has been a full health economy benefit (Qualitative and Financial) and thus commissioners fully supported the roll out.

Sunderland CCG & South Tyneside CCG have continued the collaborative support for this development and secured on-going funding for the service transformation to further evaluate its relationship to 111, the impact on other community pathways and further development of the call centre technology. Neighbouring CCGs are now also in discussion about commissioning the IRT. Building on this, we are now working on a single point of access for both urgent and non-urgent requests for help across the whole of the organisation, providing a single “front door” to NTW.

Conclusion The need to increase efficiency in the NHS whilst simultaneously improving quality is a tremendous challenge which we believe the implementation of the access system has gone a long way to achieve. There is no possibility of achieving and maintaining this without close working with all our partners and an important aspect is that if we do not improve the pathways that service users follow, including their discharge arrangements, then all we will be creating is a bottleneck somewhere in the system. In consequence of this, major transformation work is now underway to improve all aspects of care provided by NTW in partnership with users and carers and other agencies. Contact details if you want to know more about this service: Service Lead Denise Pickersgill Service Manager Access & Treatment Services Northumberland, Tyne and Wear NHS Foundation Trust Phone: 0191 566 7344 Email: denise.pickersgill@ntw.nhs.uk Commissioner Ian Holliday Head of Joint Commissioning NHS Sunderland Clinical Commissioning Group Phone: 0191 529 7000 Email: Ian.Holliday@sotw.nhs.uk