5 - IJB Report 7B Proposal V3
North Ayrshire Council · 20 October 2022
Back to Integration Joint Board — 20 October 2022 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Integration Joint Board 20th October 2022 Subject : Woodland View Ward 7B Service Redesign Proposals and future models of Care Delivery Purpose : To inform and seek IJB approval for service redesign proposals with delivery of new model of care at Woodland View and wider Community services which are in line with service demands and pressures, investment, national and local priorities. Recommendation : IJB to endorse the option appraisal recommendations and approve proposal for use of Ward 7B as a 72-hour Unscheduled Care Unit, delivery of an alternative outreach rehabilitation model from Warrix Avenue and future planning for delivery of a CAMHS Assessment Hub Direction Required to Council, Health Board or Both Direction to :- 1. No Direction Required 2. North Ayrshire Council 3. NHS Ayrshire & Arran 4. North Ayrshire Council and NHS Ayrshire & Arran X Glossary of Terms AMH Adult Mental Health AUCS Ayrshire Unscheduled Care Service (AUCS) CAMHS Child and Adolescent Mental Health Service CMHT Community Mental Health Team EMH Elderly Mental Health ECT Electro Convulsive Therapy ED Emergency Department HSCP Health and Social Care Parternship IPCU Intensive Psychiatric Care Unit MHANP Mental Health Advanced Nurse Practitioner UHA University Hospital Ayr UHC University Hospital Crosshouse 1. EXECUTIVE SUMMARY 1.1 As a requirement of Covid contingencies, mental health inpatient rehabilitation services were reconfigured – this has led to the development of an enhanced outreach
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model from Warrix Avenue that has released the Ward 7B physical ward environment for other purposes and the staffing budget for this area to be reallocated to support this new model. 1.2 Through an option appraisal, a proposal has been developed to re-open Ward 7B as a Nurse Led 72 Hour Assessment Unit with an expected impact of reducing Adult Mental Health (AMH) Acute beds. This freed bed capacity could be consolidated in one AMH acute bedroom wing to potentially become a self-contained unit for a Child and Adolescent Mental Health Service (CAMHS) Assessment/Support Hub. Ward 7A can also retain the additional space ‘borrowed’ from Ward 7B. 1.3 These proposals for new unscheduled care services are not reliant on the funding associated with previous Ward 7B staffing provision. Existing staffing resource has been redirected to sustain the enhancement to Warrix Avenue to continue to develop/provide their outreach model and remaining financial resource will be utilised to address pressures across inpatient services including Woodland View page-holder capacity, Electro Convulsive Therapy (ECT) staffing, Intensive Psychiatric Care Unit (IPCU) supplementary staffing avoidance and patient flow within Elderly Mental Health (EMH) inpatient services. 2. BACKGROUND 2.1 Ward 7B Availability As part of the response to the Coronavirus pandemic, the use of Warrix Avenue and Ward 7C (Forensic Rehabilitation) was optimised to allow a ward (7B) to be vacated as a contingency as a Covid ‘Red Zone‘ ward. This change later also facilitated the opportunity of the vacated ward to allow for a number of ward decants from 2020 until late 2021 to support Fire Damper/Fire Stop works across Woodland View. On the completion of this programme, it was agreed to invite pan-Ayrshire bids for alternative use of this valuable resource. 2.2 Staffing Resource and Funding Key to being able to keep Ward 7B vacated from its original purpose has been the development of the Warrix Avenue model. To allow for this reduction in beds at Wards 7B/7C a new model has been developed at Warrix Avenue - providing intensive outreach support to individuals for up to one year in their own homes (pan Ayrshire) – typically for those who have passed through Warrix Avenue as part of their rehabilitation programme, but also to individuals who may be referred direct from all adult community services or AMH acute for direct support. This new model also eases some of the pressure on pressured Community Mental Health Teams (CMHTs) with a very phased transition of persons with complex needs.
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Staff displaced by the restructuring of rehabilitation services as a Covid contingency temporarily supported Warrix Avenue as this model was developed and funding released from Ward 7B requires to be vired to substantively support the required increased staffing resource to sustain this model and allow Ward 7B to remain vacated. 3. PROPOSALS 3.1 Nurse Led 72 Hour Unscheduled Care Unit Approval be given for the six beds and associated public spaces within Ward 7B not utilised as additional space for Ward 7A (4 bedrooms) to be utilised to provide a nurse led Unscheduled Care service. 3.2 CAMHS Assessment/Support Hub Approval be given to further explore the anticipated released resource within AMH Acute to be redeveloped to provide a CAMHS Assessment/Support Hub. The anticipated function would be to provide inpatient care for young people aged 12-18 years for crisis admissions, mealtime support (Eating Disorders) and complex neurodevelopmental assessments. 3.3 Impact/Anticipated Outcomes Nurse Led 72-hour Assessment Unit • Reducing need for Adult AMH Acute beds • Reducing length of stay through very focused assessment on admission with clear decision point within 72 hours of admission • Improved patient care experience, simpler pathway and removing risk of multiple assessments and waits within busy emergency departments • Releasing time from ambulance and police services accompanying persons requiring psychiatric assessment to Emergency Departments (EDs) • Reduce need for sole practitioner assessments, pressure for these assessing staff and benefit of joint assessments • Benefit of wider support from Woodland View in case of distressed or agitated persons • Maximise use of condition appropriate environment at Woodland View – better for service user and families • 24/7 hub for unscheduled care including crisis and Mental Health Advanced Nurse Practitioners (MHANP) services with links to NHS 24 overnight, Ayrshire Unscheduled Care Service (AUCS) and out of hours social work. • Bringing together numerous unscheduled functions (one stop shop) to ensure seamless care / rapid transition. • Video assessment room for ‘Attend Anywhere’ assessment to support remote urgent psychiatric assessment
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• Reduce workload for AMH Acute staff group in terms of reduced number of admissions CAMHS Assessment/Support Hub • Would allow for a significant number of young persons requiring inpatient assessment, short term care to remain in Ayrshire and Arran • Would reduce burden/expectation of pressured paediatric services within University Hospital Crosshouse (UHC) currently asked to support young persons requiring a place of safety during psychiatric crisis • Reduce requirement for a young person to be admitted to an AMH Acute ward • Address increasing concern as to accessibility of Skye House due to service changes/limitations set by NHS Greater Glasgow & Clyde and identifies a local solution • Meets with Caring for Ayrshire ambitions and would lead to better care experience and maintaining connections with families • Whilst Nurse Led 72-hour assessment becomes operational and impact is assessed, allows time for this model to be further considered including required physical changes to released AMH Acute environment, staffing model required and proposed pathways to see if would be viable • Increase likelihood of recruiting and retaining staff with commitment to development of service model having specific NHS Ayrshire and Arran CAMHS inpatient provision • Would test aim/ambition to develop a new build bespoke unit for CAMHS in longer term • Maximises use of valuable Woodland View estate and support that can be offered from wider staff group 4. IMPLICATIONS 4.1 Financial Staffing for the Nurse Led 72-hour assessment unit will be delivered from within existing funded Unscheduled Care staff group. Monies for Ward 7B running costs, domestic, meals, portering etc will be met within previous funded services. Physical works – bid has been included within Mental Health Infrastructure requests for one off spend for preparatory works to make small number of changes to make Ward 7B fit for new proposed use. Costs of required works are awaited. The Warrix Avenue outreach model will require to be vired and funded from the existing Ward 7B rehabilitation service budget to substantively support the required increased staffing resource to sustain this model and allow Ward 7B to remain vacated. There has also been other reinvestment in cost pressure areas at Woodland
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View including ECT delivery and Ward 8 staffing model to address resource required for enhanced observations. There is further financial modelling work underway to fully develop the CAMHS assessment hub proposal which is predicated on the successful delivery of the 72- hour Mental Health Unscheduled Care Unit. 4.2 Human Resources Remaining previous Ward 7B staff group have gone through organisational change process and been matched in to posts at Woodland View or Warrix Avenue (assumed uplift to Warrix Avenue to offer outreach model). There would be no-one remaining in redeployment situation if uplift to Warrix Avenue is agreed. 4.3 Legal None. 4.4 Equality/Socio-Economic Both proposals allow for persons experiencing mental disorder/distress opportunity to have urgent condition specific assessment/support in an appropriate environment within their own Board area – the right service, at the right time by appropriate competent staff. 4.5 Risk Overall If funding changes for augmentation to Warrix Avenue staffing are not agreed, then this model of rehabilitation is not sustainable and Adult Acute service will become increasingly occupied by persons not requiring that level of care and be unable to accept admissions of those requiring that care as a result – High risk of adverse event in community. Ward 7B would therefore need to be retained for its original function and the space afforded to Ward 7A to be reclaimed. As alluded to in the paper, the remaining staffing budget from current Ward 7B would be utilised to address a number of service pressures across inpatient services including supporting page holder function at Woodland View, supporting development of ECT Team, addressing reliance on supplementary staff within our Intensive Psychiatric Care Unit and further progressing test of change work around facilitating earlier discharge from Elderly Mental Health inpatient setting. Cumulatively, not progressing with these requested changes would have significant impact financially and clinically across inpatient services. Nurse Led Unscheduled Care and CAMHS Hub proposal. There are currently care pathways for both these client groups – based in community and Emergency Departments.
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The need for urgent decisions to be made around need for inpatient admission within pressured circumstances (and in case of EDs inappropriate environments) can lead to decision for admission to be made when, if time could be afforded for de-escalation and longer assessment, there could frequently be opportunity to identify alternative support in community setting when there is increased confidence situation has de- escalated and there has been time for community supports to be mobilised/engaged. High risk - avoidable admission being agreed in need to make decision in pressured situation. Medium risk – adverse event - harm to self or others of person in ED setting engaging in act of deliberate self-harm more possible within that environment or person exhibiting stress/distress behaviours assaulting staff. High risk – adverse outcome of assessment due to lone practitioner assessment/decision making that could be mitigated through joint assessment. Being admitted to adult acute inpatient care can lead to a lengthy inpatient stay whilst all assessments are completed, time until consultant review and the risks of being in a busy adult inpatient ward. High risk – lengthier inpatient stay than is required. Currently for young persons, the admission pathway would preferably be to Skye House via our Service Level Agreement meaning care out with Ayrshire and Arran and High risk of challenge for families to keep in contact, increasing young person’s isolation and medium risk for services in liaising with the Skye House care team. High risk – admission to Adult Acute bed due to lack of availability at Skye House or young person remaining in Paediatric care setting, increased opportunity of adverse event due to risk to self/others of being in a non-age/condition specific environment. 4.6 Community Wealth Building Progressing proposed changes should allow for significant part of monies being spent out-of-area care for CAMHS persons to be spent instead within Ayrshire and Arran. When supplementary staff are required, this can often require to be escalated to agency level for shifts to be filled and such staff often reside out with Ayrshire. Use of released Ward 7B staff budget for other purposes will lead to a number of new substantive posts within our service. If agreed enablement works for Ward 7B and to scope required works for CAMHS development should lead to opportunity for Ayrshire based companies/businesses both in design and physical work changes.
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4.7 Key Priorities As described throughout the paper progression of these proposals align with North Ayrshire Council and North Ayrshire Health and Social Care Partnership (North HSCP) Strategic ambitions of • Tacking and reducing inequalities • Improving individual and family wellbeing • Prevention and early intervention • Bringing services together • Improving mental health and wellbeing As well as according with the Caring for Ayrshire ambitions of Ayrshire residents receiving the right care, locally and by staff with appropriate skills to do so. 5. CONSULTATION A pan-Ayrshire approach has been maintained throughout this process from asking for ideas/bids for alternative usage of Ward 7B to inclusion on the option appraisal panel to finalise preferred bid for future use of Ward 7B. Papers around these proposals have already been presented to the Partnership Senior Management team (PSMT) and NHS Ayrshire and Arran Corporate Management Team, approval was given by these groups to submit to Integrated Joint Board for final approval. Copies of papers have also been provided for sharing/discussion at South and East HSCP equivalent groups and Strategic Planning and Operational Group. Caroline Cameron, Director William Lauder, General Manager Ayrshire Central Hospital William.Lauder@aapct.scot.nhs.uk 01294 323489