Mental Health Provider Collaboratives during the Pandemic

Dr Jason Fee is a forensic psychiatrist who has been working with mentally ill people who offend for over 20 years. This is an area of mental health that is largely hidden from public view because of the nature of the people forensic psychiatrists work with. Over the years, this absence from public view meant that the commissioning of these services has been quite haphazard.

Hospitals were commissioned nationally and not necessarily on a basis of the needs of the local population. There were no policies to keep this national spending in check which resulted in quite a few inquiries into the commissioning of these services. These enquiries found that the forensic mental health sector was not meeting increasing demand yet had a massively increasing financial overspend trajectory.

The Department of Health, then headed by Sir Simon Stevens, created Provider Collaboratives (originally called New Care Models) to design services that meet the needs of the local population within a sustainable financial envelope. Dr Jason Fee and Anne Forbes became part of the first wave of New Care Models wherein they were given the remit of redesigning and providing all forensic mental health services for people from the South West of England.

Their task was to reassess the needs of the population and develop inpatient and community services. They have been on this journey of totally redesigning clinical care pathways for the past five years and are exploring how any efficiency savings can be reinvested into alternative treatment strategies.

Assessing patient need

When Dr Fee and Anne Forbes began to explore where things could be improved it quickly became apparent that there was no standardised idea of what made somebody in need of forensic services:

‘Different services all worked to different referral needs, different referral mechanisms, different assessment mechanisms. So there was no one true version of the truth across the entire South West.

We saw the need for a single point of entry that enabled providers to make standardised decisions on who was appropriate for forensic services. Cambio became that single point of access and also became the single point of access for referral and assessment.’

A similar picture was painted of the bed management systems: each hospital operated under a different system making it difficult to make use of wider availability across the trust. Cambio was subsequently developed into a bed management tool for all South West forensic inpatient wards.

‘So Cambio has since been refined to become a true patient flow management system from referral to discharge of that entire episode of care. Once we had that overview  we were able to develop things like estimated discharges, triaging of delayed discharges and how we might unblock that.’

This comprehensive and unified overview makes it easier to track how well services are performing. If hospitals are operating on different systems with different methods of performance tracking it is incredibly difficult to find points of comparison in these disparate data points.

The COVID mental health landscape

The pandemic has had a huge impact on mental health across the board, but much of the coverage focuses on depression and anxiety in the general population. Dr Fee works one day a week as a prison psychiatrist so has personal insight into how COVID has affected those living behind locked doors:

‘One of the things that we saw with COVID restrictions in the prison was basically a lockdown in the prison 23 and a half hours a day. Prisoners were banged up (those are their words) in their prison cell behind a locked door for over 23 hours a day. They were in interaction with other people for 45 minutes a day, which has had a very significant impact on mental health.’

For some mental health treatments, prisoners need to be transferred under the Mental Health Act by the Secretary of State into a hospital. During the pandemic, forensic mental health services saw a huge rise in demand for beds coming out of prisons:

‘Prior to the COVID pandemic, I had only transferred one person out in four years for emergency mental health services. In the first 18 months of the pandemic, I’d transferred seven.’

Alongside the rising need coming out of prisons, there has also been a dramatic delay in hospital discharges due to community services being closed. Local authority services – such as housing, etc. – have been shut down so there is a backlog of people waiting for discharge. This increase and referrals and bottleneck of discharges have massively impacted patient flow.

Dr Fee’s remit now extends to children and adolescent forensic mental health and adult eating disorders. During the pandemic, services have seen a 30% increase in both adults and children needing eating disordered services, clearly illustrating the psychological effects of the pandemic on children and adults that manifest in eating disorders.

Treatment close to home

Dr Fee’s other work focuses around providing patients with treatment closer to home. Keeping patients close to family makes visiting easier and it’s good to keep patients within their familiar areas as much as possible. Unfortunately, this has been difficult during the pandemic.

‘Prior to the pandemic, we were doing really well; we had managed to repatriate a lot of people from out of region back into their home hospitals. It was rare we were having to place people out of our region.

During the pandemic, some of our in-region hospitals had to be shut to admissions due to COVID outbreaks so we had to place people out of the region.

Since things have eased and people have been vaccinated, etc, we’ve seen a dramatic reduction in the number of COVID cases so almost all our hospitals are fully functioning again now. We’re almost back to that pre-COVID position where we’re not using any outreach anymore.

This quick recovery is a refreshing picture given how much the NHS is still struggling in the wake of the pandemic. The single point of referral, bed management, and end-to-end flow system created by Cambio has helped the South West’s forensic mental health teams find their feet quickly despite the ongoing challenges the health service faces.

The benefits and learnings from Cambio’s PFM are being carried into other services Dr Fee is working on:

‘We’ve applied the same principles for both our child and adolescent forensic mental health service and our adult eating disorder service. We expect to see the same efficiencies in both those two service lines in terms of flow in, bed management, and flow out.’

His team has also begun a pilot of incorporating some community teams into the patient flow system to help form a triage function prior to referral. Their use of the system and their overall practices are ever-changing and adapting to feedback from stakeholders which includes everyone from the staff using it on the frontlines to operational managers.

‘It’s been a very positive journey, we’ve certainly seen the benefits of having information systems that actually help and support senior clinicians and operational managers. It’s quite rare that you find that in the NHS.’

Other Provider Collaboratives have seen ‘the benefit of having a singular version of the truth at the touch of a button’ that Cambio provides and have since signed up themselves. Devon Partnership NHS Trust, under which Dr Fee works, are considering the potential applications of the PFM in other less specialist aspects of mental health care such as community mental health services, anxiety and depression services, and perinatal mental health services.