Amar Shah

Safer Wards: reducing violence on older people's mental health wards

Abstract Through the Safer Wards project we aimed to reduce the number of incidents of physical violence on older people’s mental health wards. This was done using quality improvement methods and supported by the Trust’s extensive programme of quality improvement, including training provided by the Institute for Healthcare Improvement. Violence can be an indicator of unmet needs in this patient population, with a negative effect on patient care and staff morale. Reducing harm to patients and staff is a strategic aim of our Trust. We established a multi-disciplinary group who led on the project on each ward and used a Pareto diagram to establish the focus of our work. We established a dashboard of measures based on our incident reporting system Datix, including number of incidents of violence, days between incidents, days of staff sickness, days between staff injury, use of restraint, and use of rapid tranquilisation (the last two being balancing measures in the reduction of violence). Each team identified factors driving physical violence on the wards, under headings of unmet patient needs, staff needs and staff awareness, which included lack of activity and a safe and therapeutic environment. Using driver diagrams, we identified change ideas that included hourly rounding (proactive checks on patient well-being), the addition of sensory rooms, flexible leave for patients, and a structured activity programme. We also introduced exercise to music, therapeutic groups led by patients, and focused on discharge planning and pet therapy, each of which starting sequentially over the course of a one year period from late 2013 and subject to a cycle of iterative learning using PDSA methods. The specific aim was a 20% decrease in violent incidents on three wards in City and Hackney, and Newham. Following our interventions, days between violent incidents increased from an average of three to an average of six. Days between staff injury due to physical violence rose from an average of eight (one violent incident resulting in staff injury every eight days) to 22 (one incident every 22 days). Incidents of physical violence reduced from 63 in 2013 to 39 in 2014. We were also able to quantify reduced costs associated with reduction in violence. The success of this project in our view lay in the involvement of ward staff in understanding the problems and generating local solutions which were also broadly evidenced based. Patients were also closely involved in generating ideas. We are currently incorporating much of this work into routine practice in order to sustain improvement, as well as continuing to generate new ideas for further improvement while using the skills learnt in this process to address other problems.

Is the Mental Health Review Tribunal Inherently Unfair to Patients

The Mental Health Act 1983 (UK), which governs the compulsory detention of psychiatric patients in England and Wales, includes a number of statutory safeguards to ensure that the patients continued detention is not unlawful. One of these safeguards is the Mental Health Review Tribunal (MHRT). The primary role of MHRTs is to review the legality of a patients detention in hospital and to direct discharge of those to whom the criteria for detention do not apply. Their powers, duties and procedures are contained within the Mental Health Act 1983 (UK) and the Tribunal Procedure (First-tier tribunal) Rules 2008. To hear individual cases, tribunals sit as a panel of three: a psychiatrist, a lay person and a legal chairperson. Article 5 of the European Convention of Human Rights (ECHR) enshrines the individuals right to liberty and security, but also includes a provision permitting the detention of persons of unsound mind. The ECHR also includes the right for an individual to have a periodic review of his or her detention and the lawfulness of it, a function that is fulfilled by the MHRT system. Currently approximately 40 000 patients per year are detained under the Mental Health Act, and almost 22 000 appeals are made to the MHRT, of which 12 000 are heard, in over 600 locations. The aim of this article is to examine the evidence as to whether MHRTs are inherently unfair to patients and biased towards overcautious professionals, and consider this in the light of various changes to the MHRT system proposed and adopted over recent years.

Improving physical health for people taking antipsychotic medication in the Community Learning Disabilities Service

Adherence with antipsychotic monitoring guidelines is notoriously low nationally. Without active monitoring and measures to improve metabolic abnormalities, more patients may develop related morbidity and mortality. An audit highlighted antipsychotic monitoring in this learning disability service in London did not match guideline recommendations. People with intellectual disability also experience health inequalities. Psychiatrists are well placed to provide advice and assistance that is suitable for those with complex communication, behaviour, and social needs. The QI team tested ideas to increase rates of antipsychotic reviews. The focus was the follow up monitoring of all universal measures recommended by NICE 2014, collected at 2-weekly intervals. We trialled interventions in four broad categories; Intervention 1: to make monitoring more structured and planned; Intervention 2: to increase staff and patient awareness of healthy eating and exercise programs; Intervention 3: to increase the collection of diet and exercise histories from patients; Intervention 4: to improve the uptake of blood tests. The interventions created an improvement in monitoring. There are lessons in the methodology for others carrying out similar projects.

Low stimulus environments: reducing noise levels in continuing care

Abstract In the low stimulus environment project, we aimed to reduce the levels of intrusive background noise on an older adult mental health ward, combining a very straightforward measure on decibel levels with a downstream measure of reduced distress and agitation as expressed in incidents of violence. This project on reducing background noise levels on older adult wards stemmed from work the team had done on reducing levels of violence and aggression. We approached the problem using quality improvement methods. Reducing harm to patients and staff is a strategic aim of our Trust and in our efforts we were supported by the Trust’s extensive programme of quality improvement, including training and support provided by the Institute for Healthcare Improvement and the trust’s own Quality Improvement team. Prior to the project we were running a weekly multi-disciplinary quality improvement group on the ward. We established from this a sub-group to address the specific problem of noise levels and invited carers of people with dementia on our ward to the group. The project was led by nursing staff. We used a noise meter app readily downloadable from the internet to monitor background noise levels on the ward and establish a baseline measure. As a group we used a driver diagram to identify an overall aim and a clear understanding of the major factors that would drive improvements. We also used a staff and carer survey to identify further areas to work on. Change ideas that came from staff and carers included the use of the noise meter to track and report back on noise levels, the use of posters to remind staff about noise levels, the introduction of a visual indication of current noise levels (the Yacker Tracker), the addition of relaxing background music, and adaptations to furniture and environment. We tested many of these over the course of nine months in 2015, using the iterative learning gained from multiple PDSA cycles. The specific aim was a decrease from above 60dB to below 50dB in background noise on the wards. Following our interventions, we have managed to decrease noise levels on the ward to 53dB on average. The success of this project to date has relied on the involvement of ward staff and carers - those most affected by the problem - in generating workable local solutions. As many of the change ideas amounted to harm free interventions it was easier for us to make a case to test them out in the real-life setting. Nevertheless we were surprised at how effective such seemingly simple ideas have been in improving the environment on the ward. We have incorporated the change ideas into routine practice and are advising other wards on similar projects.

Human rights and mentally disordered offenders

Defendants with mental health problems find themselves caught between the healthcare system and the criminal justice system, with the inevitable debate in relation to care versus control in society. Cases taken to the European Court of Human Rights by mentally disordered offenders demonstrate the inherent challenges in ensuring appropriate care to individuals whilst safeguarding the public. The Department of Health/Home Office Circular 66/90 advised that no person detainable under the Mental Health Act 1983 should be detained in prison, although in practice, this seemingly sensible principle remains extremely difficult to achieve, almost two decades later.1 This article will examine the human rights of defendants, the incorporation of the European Convention of Human Rights into UK legislation, the effect that this has had on the care and diversion of mentally disordered defendants from the criminal justice system, and finally the limitations to the Human Rights Act 1998.

Improving access to services through a collaborative learning system at East London NHS Foundation Trust

Early intervention following initial referral into healthcare services can have a significant impact on the prognosis and outcomes of patients. Long waiting times and non-attendance can have an immediate and enduring negative impact on patients and healthcare service providers. The traditional management options in reducing waiting times have largely revolved around setting performance targets, providing financial incentives or additional resourcing. This large-scale quality improvement project aimed to reduce waiting times from referral to first appointment and non-attendance for a wide range of services providing primary and secondary care mental health and community health services at East London NHS Foundation Trust (ELFT). Fifteen community-based teams across ELFT came together with the shared goal of improving access. These teams were diverse in both nature and geography and included adult community mental health teams, child and adolescent mental health services, secondary care psychological therapy services, memory services, a musculoskeletal physiotherapy service and a sickle cell service. A collaborative learning system was developed to support the teams to come together at regular intervals, share data, test and scale-up ideas through quality improvement and have access to coaching from skilled improvement advisors in the ELFT central quality improvement team. Over the course of the 2-year project, waiting time from referral to first face-to-face appointment reduced from an average of 60.6 days to 46.7 days (a 23% reduction), non-attendance at first face-to-face appointment reduced from an average of 31.7% to an average of 20.5% (a 36% reduction), while referral volume increased from an average of 1021 per month to an average of 1280 per month (a 25% increase).

Reducing DNA Rates and Increasing Positive Contacts in an Outpatient Chronic Fatigue Service

The Chronic Fatigue Service at East London NHS Foundation Trust recognised and coalesced around its major issue of engaging its service users. Using the systematic approach of quality improvement, and the infrastructure provided within East London NHS FTs quality improvement programme, it tested a number of change ideas which saw a significant reduction in non-attendance at appointments, an increase in patient cancellations when they could not attend, and an increase in positive contacts with the service. All these improvements surpassed the initial aims set within the project, and have been sustained over the course of 18 months.

The Handy Approach - Quick Integrated Person Centred Support Preparation.

Cost effective care requires comprehensive person-centred formulation of solutions. The East London NHS Foundation Trust Community Health Services in Newham have piloted models of Integrated Care called ‘Virtual Wards’ which aim to keep people living with multiple long-term conditions, well at home by minimising system complexity. These Virtual Wards comprise Interdisciplinary Teams (IDTs) with a General Practitioner (GP) seconded to provide leadership. Historically assessments have been dominated by biomedical approaches with disability emphasised over personal aspirations and ability. New professional skills are needed to organise information from diverse approaches into a common framework, which can enable agreed goals of care to be delivered collaboratively. From June 2014 to January 2016 we aimed to improve the documentation of person-centred goals of care in 100% of our assessments. Change ideas were tested and team development addressed to improve documentation of aspirations for care for people being referred and if achieved, then to test ideas to improve coproduction of care. Change ideas included Enhanced Clinical Supervision (ECS) by a GP with additional expert skills; Flash Teaching (FT) defined as five-minute weekly discussion on topics generated from the case-mix to develop a shared understanding of Integrated Care; Structured Formulation using a novel, quick, integrated assessment framework called the Handy Approach (HA) with the hand as a memory prompt to bring the personal together with the mental, social and physical domains and finally we tested focusing on ‘Team Primacy’ (mutual regard within the team) to embed behaviour change. 181 cases were tracked and documentation of personal aspirations for care by case showed: ECS 0/21 (0%); FT 5/50 (10%); ECS/FT plus the HA 35/83 (42%); Team Primacy plus ECS/FT/HA 27/27 (100%). By January 2016 prompted by using the Handy Approach in a highly functional team, all members of the IDT consistently documented personal aspirations.

Improving the patient booking service to reduce the number of missed appointments at East London NHS Foundation Trust Community Musculoskeletal Physiotherapy Service

The East London National Health Service Foundation Trust (ELFT) Community Musculoskeletal (MSK) Physiotherapy Service had reported a high rate of non-attendance at scheduled appointments. This was leading to delayed access to treatment for patients and a reduced capacity for service users, as well as a waste of clinical resources. The aim of this quality improvement project was therefore to reduce the percentage of missed appointments within this department. This study was undertaken by the ELFT community MSK service, with support from the ELFT Quality Improvement team. To begin with, patient complaints were explored; these indicated that the main reason for missing appointments was due to issues with the patient booking service. Baseline data were initially collected for both new referrals and follow-up patients. The proposed changes were then introduced, which included text message reminders, first via a manual platform and then via an automated system. Ongoing data were recorded to note the effectiveness of these changes.Following the intervention, non-attendance of newly referred patients reduced by 43.35% (23.76%–13.46%) after both cycles. Non-attendance of follow-up patients reduced by 44.14% (23.74%–13.26%) after the second cycle alone. By listening to the opinions of service users, it was possible to improve the patient booking system and the flexibility of appointments. This resulted in a reduction in the percentage of appointments missed. These changes will continue to be monitored within this department to ensure sustainability but there is also now potential for similar interventions to be trialled in other health service departments.

Improving access to City and Hackney adult mental health services

City and Hackney Adult Mental Health Referral and Assessment Service (CHAMHRAS) is the single point of entry for all mental health referrals to secondary services, with the exception of perinatal referrals, in the City and Hackney region of London, UK. CHAMHRAS was established in 2013 with the objective of providing a one-stop point of referral which screens urgent and non-urgent referrals of adults aged 18–65 to mental health services. This single point of entry simplifies the referral process to secondary mental health services—something service users have requested. It also enables rapid feedback on all referrals taken from general practitioners as well as other sources. The centralised nature of CHAMHRAS has also facilitated the monitoring of waiting times from receipt of referral to first face-to-face assessment across services. It was noted that the waiting time for the majority of patients was exceeding the 28-day target set by local commissioners. Indeed, in December 2014, only 30% of patients were being seen within this time frame. The aim of this quality improvement project has been to decrease the average waiting time from referral to first face-to-face assessment, and concomitantly increase the proportion of patients being assessed within the 28-day target period. The team identified potential sources of delay in the process of handling referrals, from receipt and triage, to forwarding to the relevant secondary service, and have tested change ideas such as the implementation of daily meetings to review referrals and the centralisation of appointment bookings to streamline the processes and minimise delays. The average waiting time from referral to first face-to-face assessment decreased by 34% and the proportion of patients being assessed within 28 days increased accordingly, exceeding 95% in the case of referrals from general practitioners (GP). We have listed changes that we intend to introduce with the aim of bringing waiting times down further.