Thinking differently about length of stay in acute mental health
How can we develop imaginative approaches to reduce length of stay and improve patients’ care in acute mental health settings, that enthuses staff and empowers them to effect change? Find out what we learned from our roundtable.
Earlier this month, the PSC hosted a virtual roundtable discussion with presenters from Camden and Islington NHS Foundation Trust, Sussex Partnership Foundation Trust (SPFT), and a range of health and care colleagues from across the country.
Our speakers considered the value of intra and inter team communication, the importance of working closely with frontline workers on designing quality improvement projects and the benefits of early discharge planning and community transformation to reduce length of stay in mental health trusts.
In this article, we explore their perspectives and thoughtful approaches to reduce length of stay and improve mental health care for patients.
First, why is it important to reduce length of stay at Mental Health Trusts?
Reducing length of stay is first and foremost about patient care – as noted by roundtable participants, reducing this in a safe and clinically appropriate manner enables patients to progress on their journey of care. This can encourage early recovery-focused conversations, supporting patients as they transition to life outside the hospital environment.
The magic of interconnections
“Healthcare delivery is not just a team sport; it is a system sport – how are the ‘team of teams’ functioning?”
Our first roundtable speaker, Dr Fredrik Johansson (Camden and Islington NHS Foundation Trust), emphasised that one of the important ways of achieving this shared goal is through interconnections, and breaking down silos.
Dr Fredrik, consultant psychiatrist and Patient Flow Quality Improvement Lead, spoke about the positive strides the Trust has made in reducing bed occupancy, bringing levels down to the London average.
What did Freddie and his team do? In response to pressures faced by the Emergency Department during Covid, the Trust set up an Emergency Department for mental health called the Crisis Assessment Service. This offers a therapeutic mental health setting where professionals can assess patients who would otherwise go to an Emergency Department for mental health reasons, and who are without an urgent medical need.
This made a significant impact, reducing admissions by 10% post Covid – Dr Fredrik explained that he expects this reduction to continue, based on weekly admission numbers observed in 2022. What does he feel contributed to the success of this initiative?
“Connections between the service, and inpatient services…helped with alignment in terms of objectives” explained Dr Fredrik. Crucial to making these connections are levels of trust, and the strength of relationships across services.
Freddie also emphasised the importance of clinical leadership, as not all who open similar diversion systems see the same levels of impact: “When speaking to many involved in patient flow, they often have innovations such as crisis teams, and discharge teams, but it still doesn’t seem to shift the dial on patient flow.”
Team of teams
This is where systems thinking comes in. Taking inspiration from McChrystal’s “Team of Teams,” Dr Fredrik described how we can apply this form of thinking to quality improvement work in patient flow. He familiarised roundtable participants with the concept of transitioning from a ‘top-down (command)’ structure, to a ‘command of teams' structure, and reaching a ‘team of teams’ structure. This would mean relationships between teams function in a similar manner to individuals within teams.
What does this ‘team of teams’ structure look like in practice? John Child, Chief Delivery Officer at SPFT, described how the Trust decided to take a locally-driven, centrally-supported approach to Quality Improvement (QI) as part of their Reducing Length of Stay programme. Working with colleagues from The PSC, the Trust reached out to clinical staff to design a range of improvement projects, aimed at maximising opportunities to reduce length of stay. This involved action-oriented Multidisciplinary Team (MDT) daily huddles, enhancing communications between acute and community mental health teams, early discharge planning and more; culminating in the development of over ten improvement projects.
Looking beyond the role of inpatient teams
We can extend these ways of working to beyond our inpatient teams. Community transformation can greatly enhance information-sharing between services, and plays a key part in supporting initiatives for reducing LoS. This is illustrated by the work of Anna Kemp, a Specialist Transition Practitioner in Sussex. As part of SPFT’s Reducing Length of Stay programme, Anna focused on opportunities to improve communication between inpatient and community mental health teams; this would also support early discharge planning for patients. This work led to a greater proportion of lead practitioners from Community Mental Health Teams (CMHTs) attending ward rounds, providing staff with early opportunities to share information and enhance patient care.
Amber Graeme (SPFT) also spoke to roundtable participants about the important work carried out by The Haven, a 24/7 crisis assessment unit, to support reducing LoS on inpatient wards. The team set out to develop a trauma-informed collaborative discharge planning document, bringing together a range of voices such as trauma-informed experts by experience (EbEs), members of the Multidisciplinary Team (MDT) from inpatient wards, and colleagues from urgent care. This aim of this document was to enable earlier recovery-focused conversations and discharge planning as patients await admission while at The Haven.
Through reaching out to other services and colleagues, and seeking diversity of input, “The Haven, as a team, felt connected with inpatient wards in the shared vision of reducing LoS” explained Amber.
As we opened the floor to questions, colleagues discussed the future of emergency services, and of setting a psychiatric provision in place to divert patients away from emergency departments to a specialist unit.
Dr Fredrik Johansson cautioned that this is not a one size fits all option – there is more to be discovered on the impact of diversion schemes. He also emphasised the need for sufficient staff numbers and the importance of good clinicians who are committed to addressing housing needs.
Do processes that rely on individuals and relationships risk breaking down?
Our chair, Harris Lorie (The PSC), raised the question of whether processes that rely on individuals and relationships risk breaking down when individuals and relationships change.
Dr Fredrik responded that processes are necessary but not sufficient for joint working; “Unless you have got trust or underlying relationships, then these processes won’t matter…for example, if you have an Emergency Department liaison team in charge of admitting [a patient], after admission, they may now view this as another Team’s problem.”
Adding to this, colleagues from Barnet, Enfield and Haringey Mental Health Trust (BEH) spoke of developing a trusted assessment framework and working with system partners over the years – highlighting similar challenges around setting up the right interfaces and processes to do so. There was also recognition that occupancy is dependent on the size of trusts – and so the collective bed base – as well as factors relating to acuity/case mix.
Key takeaways from the roundtable
The brilliant initiatives and insights of roundtable speakers and participants illustrate the benefits in shifting towards system thinking, to address pressing issues of patient flow. By enabling better interconnections across a range of services from the outset, this can make a huge impact on a Trust’s ability to facilitate earlier recovery-focused conversations for patients, offer alternatives to admissions where appropriate, and to ensure patients receive the timely care and support they need.
To learn more about Amber Graeme’s work on Early discharge planning at The Haven, and Anna Kemp’s work on Improving information-sharing between inpatient and community teams, read our article on the Reducing LoS programme at SPFT.
Author: Nivedita Prasad, The PSC Transformation Team
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