DRUG REGULATIONDRUG REGULATION

the bmj | 18 April 2015 15

FUTURE OF THE NHS

Labour and the Conservatives clashed over their NHS funding pledges this week, as the main political parties launched their pre-election manifestos.

The head of NHS England, Simon Stevens, has estimated that the next government—whichever party or parties it comprises—will need to find an additional 1.5% above inflation each year as a bare minimum between now and 2020 to close the projected £30bn (€41.5bn; $44bn) gap in funding. This is projected to amount to an extra £8bn over the next five years, on the basis of NHS achieving £22bn in efficiency savings.1

The current coalition partners, the Liberal Democrats and the Tories, have each committed to this £8bn target,2 but Labour has not, accusing the Tories of making unfunded promises.

Ahead of the launch of his party’s manifesto the incumbent Tory health secretary, Jeremy Hunt, said that a future Tory government would give the NHS in England “whatever” it needed to fill the predicted funding gap.3 Hunt told the BBC that this could be “more or less” than the £8bn cited by Stevens, but neither he nor Chancellor George Osborne was willing (or able?) to say where this money would come from.4

Labour’s shadow chancellor, Ed Balls, keen to counter repeated Tory claims that Labour was fiscally irresponsible, said that his party would not make funding promises without analysing how it would achieve them and accused the Tories of making unfunded commitments with the £8bn pledge.5

Whether or not this approach from Labour is sensible, it is a gamble. With the Tories seizing the initiative, Labour’s failure to commit to Stevens’s plan leaves the party vulnerable to being outflanked by the Tories on the NHS, traditionally one of Labour’s strongest areas in terms of public trust.

Although Labour did not commit to £8bn in its manifesto, it did pledge £2.5bn to recruit 8000 more GPs, 20 000 more nurses, and 3000 more midwives—paid for by a “mansion tax” on properties worth over £2m, a levy on tobacco firms, and tackling tax avoidance.

But health economists warned that this was unlikely to be enough, especially given that Stevens’s £8bn target was predicated on the assumption that the NHS could achieve hugely ambitious efficiency savings of £22bn by 2020, equivalent to around 2-3% a year.

As Anita Charlesworth, the chief economist at the Health Foundation, pointed out, “Our recent analysis is a stark reminder of the huge effort that will be needed to find efficiency savings and productivity improvements on the scale required if funding growth is to be kept to the absolute minimum of £8bn.”

The graph, which was included in the foundation’s analysis,6 illustrates Charlesworth’s point. The NHS’s recent efficiency drive between 2009-10 and 2013-14 increased efficiency only by an average of 0.4% a year, a long way short of what Stevens is targeting for the next parliament.

What’s more, as the think tank the King’s Fund recently pointed out, achieving efficiency savings on the scale set out by Stevens will be exceptionally tough, given that the methods used to make savings so far, such as staff pay restraint and reductions in management costs, “have now been largely exhausted.”7

Charlesworth highlighted the declining state of NHS hospital trust finances as proof that more money will be needed: “The financial performance of NHS providers in England has deteriorated sharply since 2013, from a net surplus of £582m in

2012-13 to a net deficit of £789m at the end of Q3 of 2014-15 and despite an expected underspend from commissioners of £197m. The NHS is projected to overspend by £626m by the end of 2014-15.”

Reflecting on Labour’s manifesto, Nigel Edwards, the chief executive of the health policy think tank the Nuffield Trust, said that although many of the principles it outlined, such as integrating health and social care, were “entirely sensible and are to be welcomed,” its overall offering seemed to fall short of what was urgently needed from a financial point of view.

Edwards said, “Labour are now the only party not to have committed to this £8bn, and yet their proposals are likely to require more, not less, spending on the NHS. It would be greatly welcomed if all major parties could reach a consensus on this required funding so that the NHS can go into the next parliament with certainty about its future.”

Could the Tories’ £8bn pledge trigger such a consensus? Watch this space.Gareth Iacobucci is news reporter, The BMJ giacobucci@bmj.comReferences are in the version on bmj.com.Cite this as: BMJ 2015;350:h2009

ELECTION WATCH Gareth Iacobucci

NHS fundingIn the second of a weekly column in the run up to polling day on 7 May, Gareth Iacobucci looks at the crucial issue of funding, which has been the focus of much debate this week

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18 18 April 2015 | the bmj

ANALYSISQUALITY OF CARE

In July 2013, Basildon and Thurrock Uni-versity Hospitals was one of 11 foundation trusts placed in special measures because of high death rates.

“It was a low point, a shock. Obviously we’d all rather be known for our excellent out-comes than our special measures journey,” says associate medical director Charlotte Hopkins.

It also felt a “little late,” according to chief executive Clare Panniker, who had joined the trust in September 2012 and had already begun to introduce radical changes.

“It was diffi cult,” Panniker says. “For me, it felt this was a point when we were on a trajectory of improvement, but of course all of the trusts with a high mortality rate were put in special measures.

“So we used it as a way to galvanise more energy and more effort and improve the out-comes, to keep the improvement going.”

Hopkins says hospital staff overwhelmingly responded in the right fashion.

“I think hospitals that fi ght against what the regulators say are the ones that are in trouble. You’ve got to have insight and say, ‘Yes, we are falling short of the standard here,’” she says.

The journey out of special measures took 11 months and involved work on many fronts. The trust recruited more staff, opened new beds, restructured its leadership team, and brought in external advisers to support staff on a range of initiatives designed to help reduce mortality and avoidable harm, increase incident reporting and learning, and create a more open, sharing, and compassionate culture.

The trust “buddied” with another hospi-tal, the Royal Free Hospital Trust, and devel-oped a programme of work. This arrangement

s upported Hopkins’ secondment from UCL P artners to develop the trust’s quality improve-ment c apability.

“The whole organisation, the whole system needed a shake-up,” says Hopkins.

“As an outsider it was clear to see there were lots of great bits of working going on that weren’t joined up. We had to bring people together with a common goal.”

Focus on patient safety Panniker ensured the trust was “clinically led” and more sharply focused on patient safety.

She says, “We put doctors in charge . . .supported by senior nurses and general manag-ers to really try to get the clinical engagement in the change.”

A hospital mortality review group was estab-lished, chaired by the medical director and a qual-ity and patient safety subcommittee was set up to provide the board with assurance on quality.

The board’s governance structure was revised following a review by the Good Governance I nstitute.

Richard Bohmer, a healthcare management expert and Harvard Business School professor, was brought in to help the trust with key com-ponents of its turnaround work. Bohmer ran a leadership development programme for around 60 hospital staff ; not just the senior tier of clinical and managerial leaders but the “middle tier and deeper,” whom he says tend all too oft en to be neglected by such initiatives. Clinicians worked on redesigning aspects of care they thought were not working within their own units.

Bohmer says, “I think having clinician engage-ment and involvement in the day to day design and management of the institution is now pivotal and central to long term stability.”

The danger with turnaround initiatives, he says, is that they focus on short term interventions on unsafe areas or hotspots of poor performance to score quick results.

It means trusts can “go off the boil” aft er a year or so when the impetus subsides and “risk falling back into business as usual.”

He explains, “It becomes really important to think through how you are going to position the organisation for stability and sustainability and how you really hardwire a new way of doing things that’s diff erent from what you had been doing previously.”

Emergency care The trust had been under pressure from rising emergency department attendances—up 5000 in three years.

Hopkins says, “Staff felt very stretched and were concerned staffi ng levels weren’t safe.”

Some 200 extra clinical staff , mostly nurses, were recruited and consultant cover was

From “special measures” to “good” in less than a year Matthew Limb hears how clinicians and managers turned around a troubled Essex trust with a series of rapid changes

Transformers: Clare Panniker and, inset, Charlotte Hopkins

thebmj.com � News: Health secretary puts 11 hospital trusts in England into special measures

(BMJ 2013;347:f4602) � News: Fourteen hospital trusts are to be investigated for higher than expected

mortality rates (BMJ 2013;346:f960) � Letter: The BMJ report on mortality cuts in hospitals put into special measures in 2013

is misleading (BMJ 2015;350:h1794)

� Clare Panniker and Charlotte Hopkins will be speaking at BMJ’s International Forum on Quality and Safety in Healthcare in London on 21-24 April (http://internationalforum.bmj.com/)

the bmj | 18 April 2015 19

ANALYSIS

increased out of hours and at weekends to ensure improved care seven days a week.

The trust worked with local commissioners to try to manage demand better and opened more than 60 extra beds in emergency medi-cine.

“We built a ward to be ready for the next win-ter,” says Panniker. “We knew that overcrowd-ing and using outlier areas like the cardiac catheter lab to accommodate overnight patients was not good.”

The emergency department appointed a patient flow coordinator and adjusted staffing rotas to alleviate peaks of attendances.

Clinicians worked to reduce the overall mor-tality for the department by learning from inci-dents and better monitoring of high risk cases.

External specialists from UCL Partners worked with staff to identify early signs of deterioration among patients.

There was particular work looking at pneumo-nia and sepsis. The trust says interventions such as the national early warning score chart and treatment escalation planning have led to a significant reduction in cardiac arrests.

Hopkins says the trust adopted a quality improvement approach that encouraged staff to conduct “small tests of change,” measure their effect, and share the results with colleagues.

Hopkins says, “It’s about trying to get teams to think in a different way and be much more outcomes focused.

“It’s really empowering, and that method-ology is informing a lot of other safety work. We’ve now used that methodology with falls and pressure ulcers.”

Visible leadershipPanniker says it was clear the trust’s leader-ship team had to become more “visible” and “approachable” on a regular basis.

A new staff meeting, held every day at 8.30 am in a public area of the hospital can-teen, meant anyone could turn up to raise quality and safety issues with executives.

Hopkins says, “I’ve been part of those meet-ings, and they’re really powerful. It’s very action oriented; somebody has to put their hands up and take responsibility and will own that prob-

lem, go away, and feed-back the next day.”

“Face to face interaction is the key. I think you’ve got to speak to people on the ground, you’ve got to go into their clinical area and ask them as they’ve got the answers. Our job is then to hear those answers

and help them become a reality.”Panniker says, “We encouraged people to

report incidents and near misses, so we can learn from them.

“It was made clear to staff they had a respon-sibility, not merely a right to raise things of potential concern,” says Panniker.

“More recently,” she says, “we’ve done a huge amount of work on medicines management and the safe administration and storage of medi-

cines. That was our one remaining compliance action from the Care Quality Commission (CQC) report last year.”

She is hopeful the latest CQC visit, a sched-uled follow-up under special measures made last month, will confirm compliance.

Both Hopkins and Panniker praise the “col-lective effort” of trust staff over what has been a challenging period. “People have really rolled up their sleeves,” Hopkins says.

In September 2012, the trust’s summary hospital level mortality indicator (SHMI) was 113.96 and is now 104, which is “within the expected range,” according to the trust.

The CQC, in its June 2014 report, noted improvements had been made in many areas, although there was still much work to be done.1

Staff told the regulator they were “very well supported,” and the report said services were responsive to patients’ needs.

Hopkins says without a randomised con-trolled trial it is hard to “disaggregate” which actions have been most beneficial.

“I think when you have got more staff on a ward you get better clinical care, but it isn’t just about that. You can have more nurses but that doesn’t mean to say that your fall rate or pres-sure ulcer rate decreases—you’ve got to have a focus on that as well and bring the measure-ment and the programme of change with it.

“Now the focus is very much how you go from good to outstanding. It’s not sitting on your l aurels, it’s how you keep going. It’s always easy to slip back in healthcare.”Matthew Limb freelance journalist, London, UK limb@btinternet.comCite this as: BMJ 2015;350:h1976

QUALITY OF CARE

BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUSTA medium sized trust with some 670 beds, employing over 4000 staff and serving around 405 000 people, it was one of the first 10 NHS foundation trusts created in April 2004. In 2012, a coroner highlighted a catalogue of blunders in the care of a 10 year old girl who died after an epileptic seizure. The Care Quality Commission severely criticised the leadership and culture of the children’s service. Half the hospital’s staff said in one survey they would not recommend it to their friends and family. In July 2013, the trust was one of 11 placed in special measures2 after a review of 14 hospitals with high death rates by Bruce Keogh, then England’s medical director.3 Keogh’s team found fundamental breaches of care and said the trust’s culture had historically “prioritised” financial targets over quality.In June 2014 the trust was rated “good” overall by the CQC after an inspection in March.

“I think having clinician engagement and involvement in the day to day design and management of the institution is now pivotal and central to long term stability”

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ANALYSIS

the bmj | 18 April 2015 | AWARDS 35

PALLIATIVE CARE

2015 AWARDSFINALISTS

TEAM OF THE YEAR

In association with

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MENTAL HEALTHTEAM OF THE YEAR

★

AWARDS

36 AWARDS | 18 April 2015 | the bmj

ANALYSIS

Some cancer patients at the end of life experience pain that cannot be easily controlled by standard analgesics or even strong doses of opiates. More powerful methods exist, such as intrathecal drug delivery systems that deliver drugs direct to the spinal cord through an implanted pump. But these are complex systems delivering powerful drugs, says Alison Mitchell, consultant in palliative medicine in the West of Scotland Interventional Cancer Service. “To extend their use we needed a robust system in place for clinical governance, training staff, picking the right patients, and ensuring their safety.”

The service offers a range of nerve blocking techniques for controlling pain. It was based initially in Glasgow but now extends across the west of Scotland. Patients deemed suitable for intrathecal drug delivery have a catheter inserted into the spine and are then titrated up with drugs. A pump inserted under the skin delivers the appropriate dose and patients can be discharged home, returning fortnightly for the pump to be refilled. Most patients have a limited life expectancy, but the service tries if possible to select patients who will benefit for longer.

Results are excellent, Mitchell says. Pain scores typically fall from 6.8 on a 10 point scale to 3.0 within a week, an improvement sustained for six months. “One patient who had been in terrible pain had the pump installed and three weeks later he was able to go on a walking tour of the Pyrenees,” she says. “Another went on a trip to Spain. We had a letter explaining the medication translated into Spanish and he took it with him in case of difficulties.”

“A pump inserted under the skin delivers the appropriate dose and patients can be discharged home, returning fortnightly for the pump to be refilled”

AWARDS

Imaging at the bedside has become increasingly common to help clinical decision making and to guide procedures such as introducing a temporary drain to remove ascites (accumulation of fluid in the abdomen) from patients with cancer. But generally this procedure is done in acute hospitals, not in hospices. “That means making appointments, taking an ambulance ride to the hospital, maybe waiting a few days—it takes a lot out of patients,” says Claire Hookey, medical director of Douglas Macmillan Hospice in Stoke on Trent.

The decision was made to train doctors and nurses on the hospice staff to carry out the procedure on site using ultrasound guidance. A portable ultrasound scanner (Meditechnik N-5) is used for this, and it is also useful in a number of other diagnostic and therapeutic procedures. The response of staff and patients has been strongly positive.

An audit compared before and after introduction of the scanner. While patients referred to hospital typically had to wait eight days, those treated in the hospice waited only 25 hours. The drain was left in place for much shorter periods—52 hours in the hospice against 135 hours in hospital, and substantial savings were made. “The previous pathway cost £233 per patient, the new one £6.60. Now the cost falls on us, whereas before it didn’t, but it’s worth it for the benefit it brings to patients,” she says. “We also save the cost of sending a nurse to accompany patients to hospital.” One patient with peritoneal mesothelioma who needed repeated drainage, said: “The hospice is so much easier and more comfortable than the hospital and I see my specialist as well.”

“While patients referred to hospital typically had to wait eight days, those treated in the hospice waited only 25 hours”

Palliative care team of the year finalists 2015

Palliative care is a branch of medicine in which the UK has a long and creative record, and the shortlist for the Palliative Care Team award shows no evidence of any loss of momentum. Nigel Hawkes reports on the finalists and, overleaf, on the six teams shortlisted in the Mental Health team category

The Palliative Care Team of the Year award is sponsored by Macmillan. The awards ceremony takes place on 6 May at the Park Plaza, Westminster Bridge, London. To find out more go to thebmjawards.com

PALLIATIVE MEDICINE TEAM HOSPICE ULTRASOUND SERVICE

the bmj | 18 April 2015 | AWARDS 37

ANALYSISAWARDS

The decision by the Department of Health in 2013 to phase out the Liverpool Care Pathway has left palliative care teams to reinvent end of life care, says Andrew Daley, consultant in palliative medicine, who divides his time between three organisations—an acute trust, a care trust, and the service shortlisted for this award, the Bradford, Airedale, Wharfdale and Craven Palliative Care Managed Clinical Network.

Palliative care is widely available to patients with cancer but they are less than 30% of those who are approaching the end of their lives, he says. “The other 70% include patients with COPD [chronic obstructive pulmonary disease], heart failure, neurological conditions, dementia. The majority of these deaths are predictable with hindsight but not acknowledged in advance with patients and carers.” The service set out to change that by improving identification, using electronic systems to record people’s preferences about the care, and introducing what Daley calls the most original element—a 24 hour telephone advisory service staffed by nurses, called Goldline.

“It’s a much better alternative to the 111 number,” he says. “When patients ring the Goldline number they are through to a senior nurse with full access to record, care plans, and all the notes. They manage the calls by advice or reassurance, send a community nurse or a doctor, or seek advice from consultants. Having just one number to ring is hugely beneficial.”

Of more than 200 calls in six months in 2014, only one resulted in an admission. Over that period it is estimated that 89 admissions or A&E attendances were avoided. In 2013-14 the data show 4172 deaths, only 14% in hospital and 75% at home.

The Liverpool Care Pathway assumed that it was impossible for local palliative care teams to see every patient reaching the end of their lives, providing instead a template for non-specialists to use. At Royal Surrey County Hospital the idea has been turned on its head. There, the personalised end of life care plan (PELiCan) enables all those identified as likely to die within a week to be seen and reviewed daily. To achieve this, says Andrew Davies, consultant in palliative medicine at the trust, “We had to change working practices, looked at everything we did, and prioritised looking after the dying.”

Patients remain under the care of their normal surgical and medical teams, but the plan ensures that their wishes—about where they would prefer to die, and about hydration and nutrition, for example—are taken into account and their opinions about the quality of their care regularly canvassed. “If they prefer to die in a hospice, we’ll trigger a referral and not wait until the last minute,” he says. “We also include any spiritual needs they may have. The reviews stimulate staff to do things which they might otherwise forget.”

The new approach incorporates a daily medical review, a four hourly nursing review, and a section for recording individual care plans, responses to interventions, and other information. Its introduction was cost neutral, since it reallocated effort rather than recruiting staff. Feedback from staff and carers has been universally positive.

Patients with Parkinson’s disease have in the past been excluded from hospices, though their needs at the end of life are similar to those who are admitted. “The main reason is the complexity of the condition and the fact that Parkinson’s patients are on medicines that people don’t understand,” says Edward Jones, consultant physician in elderly care at Scarborough Hospital and St Catherine’s Hospice in Scarborough. “There have also been concerns about the long palliative phase and a fear of being overwhelmed.”

The answer was found in a palliative care service designed for Parkinson’s patients, made possible by better staff training and a partnership of care between the hospice and the hospital specialists. Eligible patients remain under the care of their movement disorder specialist and monthly team meetings are held to discuss referrals, case management, and end of life issues.

So far 74 patients have been referred to the service, with the data showing that only 20% died in an acute hospital (against a national average of 43%), 20% died in the hospice (0.6% nationally), and 60% in their own homes (45% nationally). “We’re proud of the small percentage who end their life in hospital,” Jones says. “At first we were nervous about raising the issue of palliative care with patients, but I’ve never had a patient who’s reacted in a bad way.”

Training was helped by a £25 000 grant from the Burdett Trust for Nursing, but ongoing costs are modest. “It’s just a collaboration,” he says.

“At first we were nervous about raising the issue of palliative care with patients, but we needn’t have been”

“Patients remain under the care of their normal surgical and medical teams, but the plan ensures that their wishes . . . are taken into account and their opinions”

2 015PARKINSON’S PALLIATIVE CARE TEAM

LAST YEAR OF LIFE PROJECT SUPPORTIVE AND PALLIATIVE CARE TEAM

38 AWARDS | 18 April 2015 | the bmj

ANALYSIS

Mental health team of the year finalists 2015

Improving outcomes for children and adolescents was the focus at Lincolnshire Partnership NHS Trust. It is an open secret in psychiatry, says Sami Timimi, that matching treatment to diagnosis has less effect on outcomes in this group than non-therapeutic factors such as social support and a good relationship between client and therapist.

“A focus on diagnosis is not the most important thing—you have to spend more time trying to figure out what they want to change than in managing their symptoms,” he says. “For example, if the diagnosis is depression, it could be caused by loss of contact with a father. It is better to try to get the father in than to treat the depressive symptoms. The danger is that if the patient doesn’t respond to treatment, you assume the problem is more serious and add on more treatments, creating chronic patients. Less is more, sometimes.”

The service was changed by adopting a model called outcome oriented child and adolescent mental health services, which focuses on addressing external factors first, monitoring outcomes and relationships session by session, and functioning as a team. The change is difficult at first but once learnt becomes more rewarding for staff, and outcomes for patients are better. Referrals for inpatient treatment have dropped by two thirds, the number of open cases halved in two years, and clinics are better attended. The gap often observed between what is achieved in clinical trials and what is achieved in the real world has narrowed.

Violence on psychiatric wards is a serious issue, threatening both patients and staff and reducing the chances of patients getting the best care. “You think ‘how can we possibly provide good care in this atmosphere?’” says Ferdinand Jonsson, consultant psychiatrist at East London NHS Foundation Trust.

The answer was closer team working, better anticipation of impending violence, and providing antidotes to boredom on the ward. To begin with, Jonsson says, staff feared it was “just another checklist” but after a day meeting in 2012 things started to happen.

The team uses a simple assessment tool, the Brøset Violence rating scale, that uses the presence or absence of three patient characteristics (confusion, irritability, and boisterousness) and three patient behaviours (verbal threats, physical threats, and attacks on objects) to anticipate potential violent behaviour. “All staff are aware of it, and rate patients three times a day,” Jonsson says. “If a patient exhibits two or more of these, then the team comes together for a safety huddle and decides what to do. This might be de-escalation, medication, or referral to the psychiatric intensive care unit.”

Use of the tool has empowered the nurses and together with other changes such as alleviating boredom has halved the incidence of violence on the ward. “We were getting an incident on average once every five days,” he says. “Now it’s once every 12 days.” The key, he says, “is the sustained engagement of staff in building a positive culture of change.”

“You have to spend more time trying to figure out what they want to change than in managing their symptoms”

AWARDS

Wards for older mental health patients are generally supposed to be less violent, says consultant psychiatrist Waleed Fawzi, but that isn’t invariably the case. On three older adults’ wards in Hackney and Newham in east London the problem of violence was serious. “Nearly two thirds of our staff had been attacked,” he says. “I was attacked twice myself.” The three wards between them have 50 inpatient beds, caring for patients over 65 with severe conditions, or dementia complicated by challenging behaviour, that cannot be managed elsewhere.

East London NHS Foundation Trust set the target of reducing violence on these wards by 20%. Teams were established in each of the wards and violent incidents monitored and recorded. Visits to patients were increased through the policy of hourly “intentional rounding” designed to better assess their wellbeing. More activities for patients were introduced, including exercise to music, therapeutic groups led by patients, sensory rooms, a theatre group, and pet therapy. The sensory room provides a soothing environment enabling patients showing signs of agitation to relax. In one ward special efforts were made to reduce noise, which is often a trigger.

The target reduction in violence was far exceeded, with the interval between injuries to staff rising from 11 days to 30, a 50% reduction in violent incidents, and sick leave among staff falling markedly. Fawzi believes the same approach could help other hospitals make their wards safer for staff and patients.

“Visits to patients were increased through the policy of hourly “intentional rounding”

“The answer was closer team working, better anticipation of impending violent behaviour, and providing antidotes to boredom”

OUTCOME ORIENTED CAMHS GLOBE WARD VIOLENCE PROJECT

SAFER WARDS

the bmj | 18 April 2015 | AWARDS 39

ANALYSIS

Manchester Mental Health and Social Care Trust faced a mismatch between supply and demand: “A long length of stay and not enough beds,” summarises Genese Warburton, interim service improvement lead at the trust. The result was that many patients had to be placed out of area, at a cost in 2013-14 of £3.5 million. The failure to match demand and capacity across the city resulted in poor access, poor patient experience, and rising costs.

To address the problem the acute care pathway was redesigned. A gate keeping team, available 24 hours a day and led by a consultant, was established to reduce the number of inappropriate admissions, after a review of 50 admissions found, says Warburton, that 35-50% of them could have been managed alternatively. Home treatment teams were strengthened by additional consultants, pharmacists, and support workers and a patient flow team was set up to oversee admission and discharge, among other changes.

The results have justified the effort. “Recent figures show a 20% reduction in admissions,” Warburton says. “Last month we avoided 55 admissions. Length of stay is down from 64 to 57 days and patient experience has improved. They are more than happy at being able to be managed at home, and the redesigned home treatment teams mean that they can visit more often, up to two to three times a day. We wouldn’t have been able to do that before because they were pulled in too many directions. Savings are running at more than £2 million a year.”

Patients on antipsychotic medications run a greater risk of several unwanted side effects, including falls, delirium, and strokes. And just like everybody else, they may suffer from physical illnesses that require admission to an acute trust. In an ideal world, every such admission should be flagged to the psychiatric liaison service, says Julie Brooks, RAID Liaison Psychiatry, who splits her time between Sandwell and West Birmingham Hospital and teaching at Aston University in Birmingham.

“These patients tend to be dotted over every ward,” she says, “particularly respiratory and cardiology. It’s a good opportunity to go and see them to ensure that all is well with the medication, that their admission isn’t the result of an adverse reaction, and that they are under a mental health liaison team.” But a survey in the city in 2011 found that only a third of such patients were referred to the service during their admission.

The solution she identified was to set up a real time information system to find patients on antipsychotic drugs, with access to the data available to a pharmacist who can then refer the liaison team to make contact. “The system triggers email alerts to tell us that Mr X, who’s on antipsychotics, has been admitted, and where he is.” It is then possible for the patient to be referred to liaison services and action taken. Liaison psychiatry saves money by better diagnosis and reduced length of stay.

In the first year of the intervention, the proportion of patients reviewed increased from 33% to 47%, and 70% of those on antipsychotics received specialist intervention during their stay.

AWARDS

Some patients fall between the gaps in care—too complex for the talking therapies provided under the Improving Access to Psychological Therapies programme, but not severe enough for referral to community mental health services. “They take up a lot of GPs’ time and are frequent attenders at A&E,” says Julian Stern, consultant psychiatrist in psychotherapy at the Tavistock and Portman NHS Foundation Trust in London. They include those with medically unexplained symptoms, those with complex personality difficulties, and those with psychiatric diagnoses not treated in secondary care.

“We were commissioned to provide a service for these patients serving 40 GP practices in east London,” Stern says. “We provide two types of consultation, either directly with a GP to discuss cases and help GPs improve their skills, or three-way consultations with the GP, the patient, and the psychotherapist. They take place in the GP surgery—we’re bringing psychotherapeutic thinking into general practice.”

GPs, he says, are under particular pressure as mental health trusts are told to discharge patients to community care. Some present time after time with symptoms such as irritable bowel syndrome, headaches, or joint and muscle pains. GPs are often at a loss. “But there are sometimes underlying psychological stresses that can be explored and in many cases, such an intervention has helped reduce symptoms,” he says.

The cost per patient averages £1348 for typically 12-13 sessions, but there are savings in reduced subsequent use of services and the cost per QALY (quality adjusted life year), at £10 900, is well within the threshold of cost effectiveness.

“We’re bringing psychotherapeutic thinking into general practice”

“Liaison psychiatry saves money by better diagnosis and reduced length of stay”

2 015CITY AND HACKNEY PRIMARY CARE AND PSYCHOTHERAPY CONSULTATION SERVICE

PHARMACY AND PSYCHIATRY PROJECT

ACUTE CARE REDESIGN

“Last month we avoided 55 admissions. Length of stay is down from 64 to 57 days and patient experience has improved”

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