The BMJ Awards 2017: Mental HealthBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1917 (Published 20 April 2017) Cite this as: BMJ 2017;357:j1917
FREED from eating disorders
The longer it takes a young adult with an eating disorder to get treatment, the harder it is to achieve a full recovery. “The greater the delay, the more entrenched the disorder,” says Ulrike Schmidt, professor of eating disorders at the institute of psychiatry at King’s College, London. The disorder gets worse, patients drop out, and when treatment does begin the outcomes are worse. So in 2014 the institute launched FREED (First episode and Rapid Early intervention for Eating Disorders).
The service is for young adults aged between 18 and 25, the great majority of whom are female. Typically they would have had to wait an average of 19 months between the onset of symptoms and beginning treatment. FREED has reduced that to 13 months while uptake has risen to 100% compared with 73% before. After a year of treatment, 70% of patients are free of symptoms. Importantly, few need admission at a time when hospital beds for patients with eating disorders are in short supply.
Schmidt puts the improvements down to increased staffing and better organisation, in particular by creating a service that is user friendly. “Patients who come to us may be ambivalent. They have at least partially recognised that they are ill, but you still have to find a way of engaging them. Usually if you can bring them onside, they recognise that not all is well and want to get better.”
A pilot was funded by the Health Foundation, which then gave a further grant to scale up. The same model has been taken up in other parts of London and in Yorkshire, where it is going well. “Our ultimate aim is to see it as a national model,” she says.
Don't flush your life away
Cornish pub goers taking a break to visit the gents toilets are likely to find themselves face to face with a poster addressing their mental health. Those who spend a lot of time in the pub tend to be middle aged men, the group with the highest suicide risk, says Rohit Shankar, consultant neuropsychiatrist at Cornwall Partnership NHS Foundation Trust. On average they visit the toilet three times during a visit to the pub where, perforce, they are obliged to stand still. Why not give them something to read?
“There’s no such thing as an original idea,” admits Shankar, acknowledging that this one was pioneered in Budapest where signs in the gents are credited with dramatic reductions in drink driving. “But we thought it would be a good way of getting people’s attention. Thirty seconds standing still is gold dust if you want to get a public health message across.”
There were doubts about whether the initiative would be thought tasteless or trivialising, but focus groups and the response to stories on local radio put them to rest. St Austell Brewery welcomed the plan, and designs and produces the posters. The public has contributed many of the slogans (“toilet humour,” says Shankar, cheerfully) which include “Don’t flush your life away” and “It takes balls to talk.” Local celebrities together with policemen, firemen, and others have appeared on the posters, which now appear in more than 100 pubs as well as public toilets in other settings.
“We’ve had an overwhelming response,” he says. “The numbers of calls to the Samaritans has increased and in 2015 the number of suicides fell.” But an attempt to extend the campaign’s reach into the ladies’ loos fizzled. “They didn’t like strange men looking at them,” he says.
Devon CAMHS assertive outreach
Very few children suffer mental health conditions serious enough to warrant hospital admission but for those who do, the experience can be disruptive and traumatic. In Devon, says Vicky Hill, consultant child and adolescent psychiatrist, there were not enough beds for the numbers being referred for inpatient care, so many ended up hundreds of miles away. “For many, being admitted doesn’t help,” she says. “It takes away all their personal responsibility. It may appear to solve problems in the short term but at discharge they all come back.”
The service in Devon is contracted to Virgin Care, which launched an intensive support service to reduce the need for inpatient care. “At any time it manages up to 30 patients,” she explains. “We visit them at home several times a week, in addition to the services they are already getting. For those with eating disorders, for example, we supervise meals, make sure they’re getting enough nutrition, and liaise with families.” Most patients are aged between 14 and 18.
The assertive outreach service has achieved a steady reduction in the need for inpatient beds. “Currently it’s 12,” says Hill, “which means that we have enough beds locally. We keep in contact with those that have to be admitted and offer step-down care.”
Inpatient costs are very high, at around £190 000 per patient each year, so the initiative has saved a lot of money—more than £5.5m a year. “That’s good, but actually what’s more important is that the care is better, too,” she says. “Even if the programme cost more than inpatient care I still think it would be justified.”
Community REACT team
Older people with dementia, depression, or psychosis may suffer a crisis which usually ends in admission to hospital, for the lack of any alternative. In the area covered by Cardiff and Vale University Health Board a community service was launched to fill this gap—starting small in February 2012 but growing rapidly to meet demand.
“The aim is to treat them safely in their own home environment,” says Sabarigirivasan Muthukrishnan, consultant to the REACT (Response Enhanced Assessment Crisis Treatment) service. “Referrals are usually made by secondary mental health services, though recently we’ve extended that to GPs. We have found that 80% of admissions can be avoided, and we also help in supporting the discharge of those that have been admitted.”
Jane Hydon, a former GP who now works full time for the service, says it’s the most satisfying job she’s ever done. “We’re genuinely helping people to get better where they want to be. Having to be admitted to hospital is always a big fear for patients, and they deteriorate and lose independence when they are admitted. My background as a GP has been helpful because I know GPs’ problems and I can liaise successfully with them.”
Between 2012 and 2015 the service had 1057 referrals, and among those 440 would have been admitted. In all but 88 cases admission was avoided. The team now has a core of 22 permanent staff and costs around £750 000 a year. “For every pound it costs, we save £6.34,” says Muthukrishnan. “We needed support from the health board to get it started but after that it has been self supporting. Feedback from patients and carers has been overwhelmingly positive.”
Bolton CAMHS SPOA and risk team
Meeting growing demand within a fixed budget while achieving waiting time targets is a central issue for many NHS services. Service redesign is a never ending process. “We’ve done redesigns before,” says Ian Dufton, consultant with Bolton Child and Adolescent Mental Health Services, “and I’ve learned that if you run them long enough, they all eventually fail.”
The problem the service faced was long waiting times which had been reduced by a crash programme thanks to additional short term funds and the use of extra agency staff—not a sustainable solution. So a “future proof” redesign was sought by creating a small group of five whose task it was to see new referrals within the four week standard. All referrals were triaged by senior decision makers on the day of receipt and around a fifth who didn’t meet referral criteria were sent elsewhere. The remainder were given slots within four weeks.
Job descriptions were rewritten and the system designed so that it could respond flexibly to demand while still meeting the unpredictable needs of on-call work. Overcoming “redesign fatigue” was the hardest part. Since the beginning of 2015 waiting times have remained under four weeks and the service provides more face to face contacts than average, with a smaller than average workforce. Growth in demand has been successfully accommodated.
Two years’ of success suggest that this model may disprove Dufton’s thesis, but he is a realist. “The trouble arises when peaks stop being peaks and become the norm,” he says. Recruitment is difficult and the agency staff on which the service has relied are being actively discouraged by central direction and taxation changes. Without a small staff increase he fears that the good results may not be sustained.
South region EIP programme
When the first access and waiting time standards for mental care were introduced in 2016, the gap between aspiration and reality was wide, especially for young people suffering their first episode of psychosis. Belinda Lennox, senior clinical lecturer and honorary consultant psychiatrist at Oxford University’s department of psychiatry, helped draw up the standards and wasn’t surprised when an audit in the south of England showed a lack of the necessary staff and skills to meet them.
“I kind of knew it,” she says, “but it was still shocking when we looked at every person working in every early intervention in psychosis (EIP) service across the south of England. The vast majority didn’t have the skills needed.” Only half the 16 units could meet the 14 day access and waiting time standards. One trust reported zero compliance as its EIP team had been dismantled. “In southern England we were spending only half of what we estimated was needed,” she says.
By setting up a web based data collection tool—the EIP Matrix—the team generated the evidence to convince NHS England and Health Education England of the need for workforce development and greater funding for services. £1m was allocated for training and spent filling the gaps the data had exposed. NHS England promised £40m to clinical commissioning groups, though the money is not ring-fenced and, she says, “we’ve seen significantly less than promised reach the front line.”
Nevertheless, all 16 providers can now meet the waiting time target; many clinicians have been trained; 45% of patients are in work or education; and admissions have been reduced. The influence has come, she says, from getting all interested parties to engage.
The awards ceremony takes place on 4 May at the Park Plaza Hotel, Westminster. To find out more go to thebmjawards.bmj.com.
Provenance and peer reviewed: Commissioned; not externally peer reviewed.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
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