www.england.nhs.uk

London Mental Health

Delayed Transfers of

Care Workshop

19 May 2017

9:30 - 16:30

Coin Street neighbourhood centre,

108 Stamford Street,

South Bank,

London SE1 9NH

www.england.nhs.uk

# Item Lead Time

1 Welcome and introductions Andy Graham BEHMT (Chair) 09:30

2 Opening words Simon Pearce ADASS & Greenwich LA

Eileen Sutton NHSE & HLP

09:35

3 Making all inpatient days meaningful Emma Bagshaw , NHSI

Emergency Care Improvement Programme

09:55

4 Questions and discussion Andy Graham 10:30

5 What long hospital stays feel like Sara Litchfield Brown

Enfield Mental Health User Group

10:50

6 Questions and discussion Andy Graham 11:00

Break 11:10

7 What are colleagues doing to reduce delays?

• Tim Miller, Haringey CCG and Henk Vermeulen at BEHMT

• Bailey Mitchell ELFT

• Brent Withers: Lambeth

11:30

Lunch 12:45

8 Legal case studies Peggy Etiebet &

Cornerstone Barristers 13:30

9 National Policy Update Bobby Pratap, NHSE 14:30

Break 15:00

10 Table discussions What can we take away and do? 15:20

11 Plenary: Andy Graham 15:45

12 Close 16:00

Agenda

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1. Welcome and introductions

Please jot down any comments, ideas, and thoughts that spring to mind throughout the day.

No More Time “On Hold”

Reducing delays in Mental Health Trust

discharges

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2. Opening words

London Out of Hospital

Care Closer to Home Programme

6

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3. Making all inpatient days meaningful

#Red2Green Days Moving forward in Mental Health

Focus on the important not just the urgent – waiting isn’t passive

#last1000days #Red2Green #endPJparalysis 8

@ECISTNetwork

Aims • Encourage the implementation of the

Red2Green day approach across bedded and non-bedded areas

• Create a social movement with a compelling story that is clinically led and isn’t performance managed.

• Reduce the number of occupied beds and the number of stranded patients (patients with a length of stay 7 days or greater / need to determine appropriateness for mental health).

#last1000days #Red2Green #endPJparalysis

Red2Green Campaign Journey Approach

9

Red2Green

• Based on the theory of constraints

• Developed in acute physical settings- the compelling story

• Looking at transferability into mental health settings

• Keeping it simple – A to do list, todays work completed today

• MDT board round that is action focussed, flushes out internal and external constraints (top 3 and quick wins)

• Liberates the MDT

Health warning – do not try and performance management the number of red days! Encourage areas to declare them.

“Patients time is the greatest currency in health and social care”

#Red2Green #last1000days #endPJparalysis

@ECISTNetwork

Connect emotionally as well as logically ‘Need to develop the compelling story for Mental Health’

12

#Red2Green Mrs Andrews - https://www.youtube.com/watch?v=Fj_9HG_TWEM

Stanley’s Story – http://fabnhsstuff.net/2017/03/08/time-to-change

Patients time as the greatest currency

“Beds are where patients wait for the next thing to

happen”

Mind set should

be: You only get care from a bed if that is the only way we can deliver your care #last1000days

13 #Red2Green

Red2Green A red day is when a patient receives little or no added value by being in a bed

1. Could the care or intervention be delivered in a non acute setting?

2. If I saw the patient in outpatients would they require an admission

If 1 = yes 2 =No Red day

A green day. A day of added value

Added value care that progresses discharge

Everything planned or requested gets done

A green day is a day when the patient receives care that can only be delivered in a hospital bed

26/05/2017 14

Red2Green Days – Localise the approach • Start each day with all patients marked red

• Stay red if senior decision makers not present

• Stay red if there is not an EDD and CCD (clinical criteria for discharge)

• For discharge tomorrow – TTOs completed?

• Decide what will turn today green for each patient

• Ensure there are internal professional standards in place

• Allocate responsibility for actions

• Identify constraints and resolve within the team if possible

• Escalate constraints that cannot be resolved.

15

Red2Green Days – Mental Health Constraints • Development of a Rapid Improvement Guide

• Make sure discharge focus from day 1 – ABC!

• System Constraints being identified – Waiting for a tribunal

– Patient not willing to cooperate

– Awaiting funding panel

– Awaiting medical decision

– Home visit

– Nursing home decision

16

Red2Green local innovation

26/05/2017 17

Red2Green local innovation

26/05/2017 18

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4. Questions and discussion

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5. What long hospital stays feel like

Patients experience of long term stays on the wards.

It’s mainly cold and very boring!

Who we are. EMU is a mental health service user led group.

The Trustee Board are all people with lived experience of mental health issues. The majority of our staff have personal lived experience and all have an interest or background in mental health support and provision. We are all pretty passionate about what we do. Most of our volunteers are in recovery or have had lived experience. We do offer placements for volunteering to health care and social care Students, College and School students. We believe that to address stigma and make positive changes you have to start at the beginning and work in partnership.

How we gather feedback We believe that people are more open and honest if they feel they are

in a safe space and are talking to people who are non-judgemental and who have a personal understanding of the experiences they are sharing. We use Peer Mentors to: • Provide mentors on the wards. • Run activities that engage people and gain their confidence. • Mentor people in Recovery and encourage them to build confidence

and support networks. • Talk about their stories and view these in a positive way in their

Recovery and develop WRAPs to support future relapse. • Use their stories and experiences to give feedback to help improve

current services and develop future services that are meaningful and have impact.

Peer Support. • Our Peer Support uses trained volunteers who have personal lived experience of

mental health issues to facilitate groups, act as mentors, provide role models and encourage self-sufficiency and recovery.

• Our training is accredited by Middlesex University. • Training is seen as part of recovery and well-being and most volunteers started by

being encouraged by their Peer Support contact. • Peer Support programs are nationally recognised as http://www.mentalhealth.org.uk/help-information/mental-health-a-z/P/peer-support/

http://eprints.lse.ac.uk/60793/1/Trachtenberg_etal_Report-Peer-support-in-mental-health-care-is-it-good-value-for-money_2013.pdf • And also by Peer review – the Mental Elf!

http://www.thementalelf.net/mental-health-conditions/schizophrenia/peer-led-self-management-for-mental-health-impressive-programme-not-so-sure-about-the-research/

Who did we speak to.

• People who are currently on the wards.

• People who have been recently discharged.

• People who are in Recovery but attending our services.

• Volunteers.

• People who work for us.

• Carers, friends and relatives.

The main messages

• It’s very frightening on admittance. There is a lack of information and you don’t know anyone – you need a buddy or someone that will show you round. I was scared of the other patients.

• It’s really boring. When I’m bored I get more anxious.

• They take away your choice and this makes you very dependant. When I came out I couldn’t even decide what to have for dinner. I lost all confidence

• I didn’t have any clothes. I felt like a tramp.

Main messages • I got really isolated. My friends and family

were scared to visit me and I really felt alone.

• I lost the tenancy on my flat and my benefits stopped. When I was being discharged this caused a massive problem.

• If I’m really honest I didn’t want to leave. I’d lost all confidence and I felt safe there. I didn’t know what to do if I left.

• I needed people to talk to who weren’t ill or staff – just a normal conversation

What could be better? • Better communication with families, carers

and friends.

• Perhaps easier ways to visit. Its sometimes quite scary on the wards and parking and things are very expensive.

• More people to talk to.

• Knowing what will happen on discharge. Knowing what there will be to support me and maybe having a community link. More advice.

Good things. • I don’t want to go back but I do know I would be dead if I

hadn't been on the wards. I wish there was a better way though.

• I made friends – that seems quite strange now but I really did.

• The mentors gave me hope. Now I am a mentor.

• There are very good staff too.

• I was scared my son would kill himself. He was awful and we couldn’t cope but it did feel like he was safe when he was sectioned. It was just over time that he seemed to become so dependant and defeated and this has stayed with him. His volunteering is really a life line.

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6. Questions and discussion

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Break

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7. What are colleagues doing to reduce

delays

Haringey and Work to Reduce

Inpatient Delays

• Henk Vermeulen, Assistant Director, Barnet, Enfield and

Haringey Mental Health Trust

• Tim Miller, Joint Enablement Lead, Haringey Council

and NHS Haringey CCG

Haringey Context

41

Relatively low number of adult acute beds:

Haringey Context

42

Year on increase of referrals into Haringey Secondary

MH services of 15%:

Haringey Context

43

Relatively low rate of admissions:

Haringey Context

44

Highest bed occupancy

Haringey Context

45

Highest proportion of homeless people admitted to

hospital in London

Haringey Context

46

Highest proportion of patients detained under the

Mental Health Act in London

Haringey Context

47

Lowest number of emergency readmissions

Haringey Context

48

Relatively high number of DTOCs

Haringey Challenges

49

External challenges

•High number of homeless clients

•Availability of appropriate Housing Stock / historical development of Supported

Housing within Borough

•Complex housing pathways within Borough

•Dependency on cooperation from other Boroughs if housing duty lies

elsewhere – including escalation processes

•Increasing number of clients with No Recourse to Public Funding / complex

immigration status

•Delays in obtaining proof of benefits

Service / clinical challenges

•No in-house rehab / delays in referral process into Locked Rehab facilities

•Increased admin processes around various pathways, in context of increased

workload in community teams

•Increase in Court of Protection cases – increased awareness MCA and

implications

•Engaging clients who aren’t always willing to engage

Responses

50

Mondays: face to face Haringey DTOC meeting.

Senior Managers BEH inpatients and community and ward managers

Community teams with clients on DTOC list

Discharge Intervention Team

Crisis Response and Home Treatment Team

“Recovery House” representative

Homes for Haringey “Assessment & Referral” Team representative

Social Care / Brokerage

CCG

Thursdays: follow up Haringey DTOC teleconference:

Follow up on actions agreed on Monday

Attendees mainly internal BEH staff

Wednesdays: Trust-wide DTOC escalation teleconference:

Chaired by (deputy) COO

Attendees from all 3 boroughs: BEH ADs, 3 Social Work Leads, CCG,

Housing departments

1. DTOC and Bed Management Process

Responses:

51

• 72 Hour Formulation Meetings to identify at an early stage any issues that

may become barriers to discharge

• Pro-active involvement of Senior Managers from inpatient and

community; ongoing input of community teams during admission

• Creation of Discharge Intervention Team – moving community discharge

workers to work closer into wards

• Development of Accommodation Pathway Guidance

• Training for ward managers on Care Act, Ordinary Residence, s117

• “Adult Pathway” review

2. Improving practice

Accommodation Pathway Guidance

52

Guidance

includes: -

• Eligibility criteria

and referral

processes

• Timescales for

each pathway

• Escalation routes

• Advice and

resources on

common issues

and housing

problems

Responses:

53

3. Local System Response • Agreed Trust-wide DTOC reduction plan and trajectory

• Releasing CAB and floating support capacity to in-reach to wards

• Primary Care Link worker model – catching up to with Barnet,

Enfield

• Better Care Fund Small Grant – scoping a model of Discharge to

Assess into intermediate care / step-down from in-patient beds.

• Improved commissioning of housing support pathway

– Housing First

– Psychologically Informed Environment for women with experiences of

trauma

– Emerging joint pledges with social landlords to create a step change in

share response to tenants with mental health needs, particularly those

who experience crisis

• Emerging improvement plan on discharge and DTOC

management involving all key local partners

Reducing Delays

Newham Centre for Mental Health

The Newham Context • Population of over 340,000

people.

• Young and projected to grow

further due to natural growth.

• Separate provision of Health

and Social Care for Adult

Mental Health Services since

April 2016 with 1 point of entry

for adult mental health referrals

and 1 point of entry for Mental

Health Social Care

London Borough Police Section 136 Detentions Children and Young People Detentions

Borough/U&EC network Total Rate per 100,000

Population

Total Rate per 100,000

Population

City of London 157 2842.7 3 923.1

Hackney 144 78.5 3 13.3

Newham 187 85.1 11 34.9

Tower Hamlets 107 52.3 6 25.7

*Aggregated s136 activity data from London’s three police forces over 2015/16 is outlined below. The data is presented in absolute numbers and also

weighted for the relative size of each borough’s resident population to allow for comparisons that take each borough’s relative size into account.

Inpatient Care in Newham • Mixed Gender Triage Ward (15 beds) with an average length of

stay of 5 days and maximum stay of 14 days.

• Those that require a longer term admission are transferred to

one of four single gender wards (34 female beds and 36 male

beds).

• One Adult Male PICU on site (12 beds).

• Admissions average 121 per month. Discharges average 116

per month.

• Average Length of Stay: 25 Days (including Triage: 19)

• Average Occupancy: 79%

Pre-Bed Management Weekly internal pre-

bed management

meeting with all ward

matrons and

managers in

attendance and

Consultant

Psychiatrists invited.

Chaired by Borough

Lead Nurse and

Associate Clinical

Director. Borough

Director or Deputy

Borough Director in

attendance. All

admissions discussed.

Bed Management Weekly bed management

meeting with matrons and

managers in attendance.

LBN senior management

and hospital assessment

team in attendance.

Chaired by Borough Lead

Nurse and Associate

Clinical Director. Borough

Director or Deputy

Borough Director in

attendance. DToCs and

requests for DSTs agreed

in this meeting. Only

those cases where there

is a barrier to discharge

are discussed.

Key Relationships

• Service level agreement with Local Authority Housing

department to assess and offer accommodation

where appropriate within 14 days. Housing officer

attends the wards regularly to assess directly.

• A robust interface with LBN mental health social care

with regular reviews of systems and processes.

Sharing of admission information and links with no

recourse worker (NRPF Connect).

• Strong links with the Home Office and 3rd sector

organisations (Routes Home, Open Doors).

Lambeth Barriers to Discharge Group

- Meets fortnightly

- Group coordinated and led by SLaM Acute Care Pathway Lead

- Group focuses not only on DTOC patients but all inpatients who have potential and real barriers to discharge

- Ward managers identify inpatients on ward who have real and potential barriers which forms focus of fortnightly meetings

- Also focuses on those in private overspill

Membership of Group

• Statutory Sector

• Acute care pathway lead

• Inpatient ward managers

• Home treatment team representation

• Social care panel chair/co-chair

• Complex care panel chair/co-chair (IPSA)

• Commissioning

• Supported Housing pathways coordinator

• Kings Health Partners Homelessness project (work with inpatients on the ward who have a history of homelessness)

• Voluntary Sector

• One Support – provide practical support in benefits, tenancy and purchasing of furniture and appliances. Also coordinate deep clean of flats and liaise with Lambeth housing/RSL to facilitate repairs

• Lorrimore Home and Dry – work in partnership with One Support in undertaking deep cleans of flats

Barriers to Discharge

• Housing repair, deep clean and other practical issues related to patient’s accommodation

• Tenancy issues – unable to return to accommodation because of ill health or circumstances and therefore needs to give tenancy – requires court of protection

• Delays in putting together necessary paperwork through to completion of the panel process

• For complex inpatients availability of suitable supported accommodation/residential care home

• Awaiting void in identified placement i.e. supported housing

• Lack of ID paperwork that prevents access of housing benefit

• Complex personal circumstances

Process of the group

• Discussions are brief and action focussed

• Action holder and timescales are identified

• Meeting chair oversees that actions have been completed

• Cases are brought back until the barrier to discharge has been resolved

Benefits of Group

• Early identification of barriers – leading to discharge planning at point of admission

• Very practical and patient focussed

• Collective expertise across all sectors

• Track through patients from potential / real delay to successful discharge

• Gain insight into system wide issues that can be addressed long-term i.e. panel delays

• Case Study

• Patient delayed because of repairs that needed to be done to flat i.e. One support liaised with Council to facilitate the completion of the repairs, as well as attained funding for furniture and cooking utensils. Patient also required 7 hours personal support package to assist with tasks related to daily living i.e. cooking, cleaning and prompting around medication. Barriers to discharge group assisted in the planning & coordination, assertive follow-up and monitoring of the key tasks required to successfully discharge patient.

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Lunch

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8. Legal case studies

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9. National policy update

Reducing Delayed Transfers of

Care from Mental Health Settings

Bobby Pratap, Senior Programme Manager, Crisis and Acute

Mental Health Care

Mental Health Clinical Policy & Strategy Team NHS England

70

Contents

1. Policy background – CAAPC and FYFV-MH

2. Delayed transfers of care and mental health: what do

we know about the data?

3. Crisis Resolution & Home Treatment Teams

4. Acute mental health care, including out of area

placements

5. Annex: London Region – CRHTT and OAPs

indicative data

71

CAAPC (Crisp commission) – what did it say? Some of the recommendations

• End the practice of sending acutely ill patients long distances for treatment by October 2017

• Strengthening CR/HTs, with a particular focus on ensuring that home treatment teams are adequately resourced to provide a safe and effective alternative to acute inpatient care where this is appropriate

• A single set of measurable quality standards needs to be created spanning the acute care pathway, including a maximum four-hour wait for admission to an acute psychiatric ward for adults or acceptance for home-based treatment following assessment

• DTOC data – national data poor quality on DTOCs – RCPsych thinks figure is around 16% national unify data shows somewhere around 2-4%?

• Housing, social care, community MH services – biggest reasons for DTOC

www.england.nhs.uk

Recommendation 17:

• By 2020/21 24/7 community crisis response across

all areas that are adequately resourced to offer

intensive home treatment, backed by investment in

CRHTTs.

Recommendation 22:

• Introduce standards for acute mental health care,

with the expectation that care is provided in the least

restrictive way and as close to home as possible.

• Eliminate the practice of sending people out of

area for acute inpatient care as a result of local acute

bed pressures by no later than 2020/21.

72

Mental Health Task Force – acute mental health

2. Delayed transfers of care and

mental health: what do we know

about the data?

74

National DTOC data: Mental health, what do we know?

• At least 20% (probably more) of all NHS delays are from MH providers

(unify) – it is not just about older people!!

• More are attributed to social care for mental health that non-MH delays

However……..

• Unify national reports do not even differentiate between mental health

and community providers delays. Just ‘acute’ and ‘non-acute’

• ……Let alone differentiating between MH bed types. e.g. if you have a

high secure hospital, delays likely to be much higher

• Targets: when Monitor’s risk assessment framework had a target of no

greater than 7.5%. Most reported DTOCs at……….. 7.4-7.5%!!!

• In conclusion, national data for MH DTOCs we have very little confidence

in being able to understand pressures / comparisons between providers

75

What are we doing to improve data?

• Proposal to move to MHSDS only for mental health providers (currently

providers submit to unify and MHSDS)

• Crucially, MHSDS will allow analysis by bed type for the first time at a

national. Will give a truer picture of delays, understanding where pressures

are highest

• New categories for MH delay reasons from this April that are more

suitable for mental health (see next slide)

• However, because they are submitting to unify, many providers are not

submitting MHSDS returns – so we need to drive data quality via

MHSDS from 2017/18

• Will be a challenge politically to ‘switch off’ unify for MH, e.g.

taking MH out of national unify statistics will remove 20% of total

delays

improving data quality will probably show a rise in delays

DToC – new MHSDS v.2 data categories

Categories Attributable to…

A: Awaiting Care coordinator allocation NHS

B: Awaiting public funding NHS/ social care/ both

C: Awaiting further non-acute (including community and mental health) NHS care (including intermediate

care, rehabilitation services etc.) NHS

D: Awaiting Care Home With/Without Nursing placement or availability NHS/ social care/ both

E: Awaiting care package in own home NHS/ social care/ both

F: Awaiting community equipment, telecare and/or adaptations NHS/ social care/ both

G: Patient or Family choice (category expanded with large number of explanatory reasons to select from) NHS/ social care

H: Disputes NHS/ social care

I: Housing - patients not covered by Care Act (number of explanatory reasons to select from) NHS/ social care / housing

J: Housing - Awaiting supported accommodation NHS/ social care / housing

K: Housing - Awaiting emergency accommodation from the Local Authority under the Housing Act NHS/ social care / housing

L: Child or young person awaiting social care or family placement NHS/ social care

M: Awaiting Ministry of Justice agreement/permission of proposed placement -

N: Awaiting outcome of legal requirements (mental capacity/mental health legislation) NHS/ social care / housing

These expanded categories acknowledge the range of factors that can lead to delays, attributable to the NHS, social care and housing. The enhanced transparency around the number and causes of delays, will enable them to be addressed at a national and local level. Please see MH SDS to MSitDT Guidance and Mapping for more information on MHSDS categories

Inpatient activity – split by bed type for the first time:

For inpatient and HTT

• Referrals / referral rates

• Gatekeeping

• Admission / admission rates

• Readmission

• NICE-recommended interventions

• Average length of stay

• Follow up post-discharge

• Time from decision to admit to admission

Delayed Transfers of Care - by bed type

• With new categories for mental health

Out of area placements – MHSDS to replace special interim collection

• Numbers, bed days, reasons, distance, duration

Mental Health Act

• Including waiting times

77

Data: new national reports coming in 2017-2019 for inpatient acute care

78

Out of area placements: new data collection - a better indicator of acute MH pressures for now?

79 www.england.nhs.uk

Headline Data Q4 2016/17

Inappropriate OAPs started in period

Total no. of OAP days over the period

Total recorded costs over the period

No. of OAPs that ended in the period with a length of 31 or more nights (1)

No. of OAPs active during the period with a distance of 100km or greater

Average recorded daily cost over the period (2)

England 1,853 52,577 £18,792,900 316 790 £530

North 530 13,476 £2,466,090 90 115 £505

Mids & East

420 15,113 £6,298,090 90 345 £525

London 305 7,462 £3,847,700 40 25 £525

South 565 14,375 £5,582,340 85 250 £580

Unknown 30 2,145 £598,653 10 25 £530

• The regional data in this table for ‘Inappropriate OAPs started in period’ is subject to NHS Digital’s suppression rules -

counts have been rounded to the nearest five.

• (1) Only includes OAPs that ended during February and that started on or after the 17th October 2016. This means

that the current maximum duration for an OAP included in the March report is 166 nights. It is not yet known what

percentage of OAPs last longer than this, but it will become clearer collection runs for more time.

• (2) Recorded Cost – since January cost has only been recorded where a provider has been charged by a different

organisation for making the placement. (There are some scenarios where an OAP may take place within a provider

organisation where the provider covers a very large geographical patch). As such the costs reported for 2017 should

not be compared with those in 2016.

3. Crisis Resolution & Home

Treatment Teams FYFV Deliverable: By 2020/21, NHS England should

expand Crisis Resolution and Home Treatment Teams

(CRHTTs) across England to ensure that:

- a 24/7 community-based mental health crisis

response is available in all areas

- these teams are adequately resourced to offer

intensive home treatment as an alternative to an acute

inpatient admission.

www.england.nhs.uk

“By 2020, there should be 24-hour access to mental

health crisis care, 7 days a week, 365 days a year –

a ‘7 Day NHS for people’s mental health’.”

81

Spending Review – Headlines for Crisis & Acute Care

• over £400m for crisis resolution and home

treatment teams (CRHTTs) to deliver 24/7

treatment in communities and homes as a safe

and effective alternative to hospitals (over 4

years from 2017/18);

• £247m for liaison mental health services in every hospital emergency

department (over 4 years from 2017/18);

• £15m capital funding for Health Based Places of Safety in 2016-18 (non-

recurrent)

Intensive home treatment:

• Short term intensive care spell: aims to transfer patients according to an ongoing plan of care

• As many visits as necessary, 24/7, likely to need visits of up to three times per day initially, with frequency reducing as patient recovers

• Visit duration that meets the person’s needs and allows for therapeutic care

• Multi-professional team approach with effective handover (at a minimum, daily), which allows case-load sharing and the offer of a range of interventions

• Partnership working with other community services to facilitate ongoing care

• Facilitate early discharge from inpatient settings.

• Subject to similar ‘bed management’ approaches as inpatient care

82

CRHTTs – what are their key functions?

Community crisis assessment:

• Accessible 24/7

• Rapid assessment to the community and people’s homes for urgent and emergency referrals

• Gate-keeping function (managing access to local acute inpatient beds)

• Initial treatment package (medical and brief psychological intervention)

• Management of immediate risk

The UCL Core study has a 39 point

fidelity scale for teams to assess

themselves against

24/7 access to mental health crisis services Timely assessment in an appropriate place Avoids unnecessary admission when home treatment may be more suitable Therapeutic care to support recovery: in people’s home environment, social

triggers to crisis, and barriers to independent living can be more visible, and therefore assessed and acted upon in situ, providing potential for more sustainable coping skills - including for instance family relationships, shopping, banking etc. As such, teams should be multi-disciplinary, not just doctors, nurses but psychology, pharmacist, social work, OT input in the skill mix

Usually people report a more positive experience of care than for inpatient care Facilitate early discharge / supports people to go home on leave from the ward Avoid A&E attendances, free up acute hospital liaison service for ward in-reach When part of tight bed management process and acute care pathway, can help

reduce out of area placement Where teams implemented with high fidelity, that incorporates gatekeeping and

has 24-hour community-facing provision have been associated with reduced admission rates with an associated reduction in costs

Published evidence of impact (1) ; Evidence (2) ; Evidence (3) ; Evidence (4)

83

Benefits of CRHTTs when implemented in line with

evidence base as part of well managed acute system

84

Early considerations from the ERGs on quality benchmarks:

response times and interventions for emergency referrals

• 24/7 UEMHC/crisis lines - calls should be answered within a maximum of 2

minutes

• Within a maximum of 1 hour of contact, the urgent and emergency mental

health service should provide the person who contacted the service with an

update/feedback on care and support to be provided;

• Within 4 hours of a request for help, the person in crisis should have been

provided with an assessment and have an urgent and emergency mental

health care plan in place (the assessment should be biopsychosocial, but if

this is not possible, an initial face-face crisis assessment should be

undertaken as a minimum), and

- been accepted and scheduled for follow-up care by an appropriate

service (this could include support provided at home),

or

- been discharged because the crisis has resolved; or

- started an assessment under the Mental Health Act.

85

Early considerations from the ERGs on quality benchmarks:

response times and interventions for emergency referrals

• As well as the initial emergency response to a crisis within 4 hours, services

should ensure continuity of ongoing care outside of the 4-hour response

(this could include further assessment if necessary, for example to complete a

biopsychosocial assessment if this was not possible within 4 hours)

• Advice should be sought from an appropriately trained and competent mental

health professional immediately in the event of a mental health crisis. Each

professional should ensure that they:

• provide a kind, compassionate and empathetic response

• plan for the short-term safety of the person, if necessary

• undertake an initial risk assessment

• plan appropriate observations for both mental and physical health

• access any existing mental health Plan, where available

• notify the local authority if the person is an ‘at risk’ adult or older adult.

Response time targets

• 45.4 % have target to commence an assessment in under 4 hours

• 20.0 % have target to complete an assessment in under 4 hours

86

What do we know about CRHTTs – selected stats from

UCL survey, 2016 (1/2)

PR PSCSUANRNH

SANRH VCSAH

Adults 92.6 91.1 84.7 67.4 69.5

0102030405060708090

100

% t

eam

s

CRHTT 24/7 offers PR Phone referral

PSCSU

Phone Support to current CRHTT Service Users

ANRNHS

Assessment of New Referrals on NHS premises

ANRH

Assessment of new referrals at home

VCSAT

Visit current CRHTT Service users At Home

87

Eligible Referrer Adult CRHTTs n/N (%)

Psych Liaison 180/184 (97.8)

GPs 148/184 (80.4)

NHS 111 108/184 (58.7)

Police 132/184 (71.7)

Self referral (known patient)

127/184 (67.4)

Self-referral (new patient)

79/184 (42.9)

Staffing and caseloads

• 35.4 – mean caseload of CRHTTS

• Around 55-65% of teams have staffing: caseload ratio in line with 2000 policy

implementation guidance

What do we know about CRHTTs – selected stats from UCL

survey, 2016 (2/2)

4. Acute mental health care, inc.

out of area placements

FYFV Deliverables:

- the practice of sending people out of area for acute

inpatient care due to local acute bed pressures

eliminated entirely by no later than 2020/21

- standards for acute care introduced

- full response to the Independent Commission on

Acute Adult Psychiatric Care, established and

supported by the Royal College of Psychiatrists

89

Early considerations from acute care ERG – quality

benchmarks: time from referral to admission

• Any person requiring acute mental health care in an inpatient setting

should receive orientation onto the ward as well as verbal and written

information about who their named care team will be within 4 hours of

referral.

• Any person requiring acute mental health care in a community-based setting

should be accepted for care within 4 hours of referral and receive their

first face-to-face NICE Concordant treatment contact within 24 hours of

referral.

1. A comprehensive physical health assessment made within 24 hours of the start of treatment;

2. A care plan to be initiated within 72 hours of the start of treatment

3. A Care Act-compliant assessment to be completed within 72 hours of the start of treatment to identify any social care issues

4. The discharge destination to be considered within the first 72 hours of care for those who have housing needs

5. Access to daily meaningful and recovery-focused activities while receiving care

6. One-to-one face-to-face time with a care professional that the person knows, every day

7. Feedback on service experience to be sought to improve the delivery of care

8. Follow-up after discharge from an acute mental health inpatient setting to be made within 48 hours.

90

Early considerations from acute care ERG - what is NICE

recommended acute mental health care? (inpatient and community)

91

Case study: Sheffield (1/2) – headlines

In 2011 bed occupancy 120%, 142 beds, almost 3000 bed days out of area Wards now reduced in size, (69 beds) staffing has stayed the same, so patient-to-staff

ratios have improved, zero out of area . Because of the reduction of wards, SHSC has been able to significantly reduce the use of

agency staff, £2 million was invested in community services to ensure its sustainability. This included

investment in IHTTs and new services for people with highly complex problems often associated with a diagnosis of personality disorder. In addition to this reinvestment, cost savings of over £1.5 million were made

No increase in incidents, close monitoring of quality markers – which have improved.

92

Case study: Sheffield (2/2) – how did they do this?

Risk-sharing agreement between SHSC and the Sheffield CCG. SHSC took responsibility for the budget for out-of-area placements.

Efficiency programmes reduction in average length of stay from 56 to 31 days. Work focused on improving time spent with patients on the wards, discharge facilitators on every ward, planning for discharge on admission, particularly in relation to social factors and daily bed management meetings with consultants.

Quality initiatives : included: psychology posts on wards; reflective practice supervision for staff; reduction in seclusion and restraint; service user-led, all-staff training programme to improve the management of violence and aggression.

Bed management weekly bed-management meetings chaired by the clinical director, and including all consultants, ward managers, discharge coordinators, partner services (crisis house, respite provision, community teams). Meetings use live data and focus on patient flow.

Investment in intensive home treatment bed-management processes were applied to manage the flow of people. Fewer people accessing home treatment, smaller team caseloads but more intensive treatment for those in HTT.

Whole system approach - vital. Rethink crisis house and helpline, Wainwright Crescent respite and step-down beds; joined-up management/governance between inpatient and community services, live data showing flow across the whole system; and engagement with service users, carers and staff throughout.

93 www.england.nhs.uk

Common themes from other areas that have / are

attempting to reduce out of area placements

Intensive focus on OAPs as a priority – agreement of system priority at all levels

• Agreement at all levels that OAPs are a priority

• Principle that bed / HTT must always be available where that is the right

choice

• Board-level responsibility

• Clinical and/or Service Director who is personally responsible

• Strengthened community services, savings reinvested back into MH

• Financial risk/benefit sharing agreement between providers and

commissioners

• Whole system coming together in partnership to redesign pathways and

agree processes – inpatient staff, CRHTTs , social care, AMHPs, CMHTs,

vol sector, patients, IAPT, primary care

• Intensive focus on flow, bed management

• Community and inpatient teams attend regular MDT discharge meetings

• Use of real time data, including info on bed availability, capacity of HTTs,

community alternatives (e.g. crisis houses)

• Info on patients who have passed discharge dates, reviews / new

discharge dates

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

No

rth

Eas

t Lo

nd

on

NH

S Fo

un

dat

ion

Tru

st

Barking & Dagenham (B&D) & Havering HTT

Y Y Y 65 38.60 0.59

0 0 Redbridge HTT

Y Y N 60 37.50 0.63

Waltham Forest HTT

Y Y N 60 30.55 0.51

North East London FT – CRHTTS and OAPs Indicative Data

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

Oxl

eas

NH

S Fo

un

dat

ion

Tru

st

Bromley N N N 25 16.50 0.66

2713 £1,519,940 Bexley N Y N 33 14.40 0.44

Greenwich Y Y N 52 24.50 0.47

Oxleas – CRHTTS and OAPs Indicative Data

96 www.england.nhs.uk

East London NHS Foundation Trust Tower Hamlets acute mental health service

Camden and Islington NHS FT, Drayton Park Women’s Crisis House

Mersey Care NHS FT has introduced No Force First, an award-winning restraint reduction

initiative.

South London and Maudsley NHS FT Gresham Unit Carers’ initiative

Addressing inequalities in acute mental health

Resources from Joint Commissioning Panel on mental health for people from:

• BAME backgrounds,

• older people

• learning disabilities

• physical health needs

Case study: African Caribbean Community Initiative, Wolverhampton

Further positive practice case studies: acute care

97 www.england.nhs.uk

Sheffield – blog from clinical lead, Dr Mike Hunter – now associate national clinical director at

NHS Improvement. Further detail can be found here.

North East London Foundation Trust – highlighted in RCPsych Commission on adult acute

psychiatric care (p27) – NELFT has eliminated out of area placements for many years, with one

of the lowest bed bases in the country - through investment in community services and

intensive focus on acute pathway management.

Leeds and York Partnership NHS FT: Efforts underway in ‘Leeds mental health flow’ project

with write up of the how the whole system is coming together to reduce out of area

placements to save £1.5m for the local health economy.

Bradford: adopted an approach with similar principles to Sheffield. Highlights include:

Vital partnership working with social care and local authority services – detail overleaf!

Whole system approach to eliminating out of area placements in Bradford.

Focus on acute inpatient ward flow, DTOCs, including a 10 point discharge tracker (below):

Further OAPs case studies and resources

98 www.england.nhs.uk

Take a look at Mark Trewin’s (Mental Health, Service Manager at Bradford Council and Social Care

Advisor to the NHSE Adult Mental Health Team) blog on the importance of partnership working

with social care and local authority services to reduce DToC, MHA detentions, admissions, OAPs

and support recovery in the community.

In Bradford, social care is integrated across a range of acute and community mental health

services and people are supported at home wherever possible using collaborative work between

health, social care and voluntary services to achieve the least restrictive and most appropriate

care through a single point of access.

Mental health social workers are based or involved in: The 24/7 First Response crisis service ;

The Haven (non-clinical community alternative to A&E); the Intensive Home Treatment (IHT) team;

the Police Hub; the AMHP service; Specialist housing social worker; Community mental health

teams, Early Intervention teams, Assertive Outreach teams and community support services;

Supported Accommodation. There are also joint commissioning arrangements in place and

increasingly joint decisions are being made between NHS and LAs around funding (e.g. s117).

Key advice for any CCG, Trust or LA struggling with OAPs or private sector bed usage - join

together all NHS, local authority, VCS, police, housing and service user groups, and review how

integrated working and joint commissioning together might change the way that people are cared

for locally.

Role of social care and the voluntary sector in managing

the acute MH system

99 www.england.nhs.uk

Cheshire and Wirral Partnership NHS Foundation Trust, Complex Recovery Assessment and

Consultation service that has contributed to the elimination of out of area placements

Cornwall Partnership NHS FT, Fettle House rehabilitation service

Northumberland Tyne & Wear NHS FT Rehabilitation and Recovery Services

Mental health supported housing examples

St Martin of Tours Housing Association, Islington

Living Well, South Yorkshire Housing Association

Mental health rehabilitation service examples

www.england.nhs.uk

Community MH Care

IAPT

Crisis Care

Acute Care

Rehab Care

Secure Care

Primary

Care

Recognition

& referral

PC treatment

Primary Care

Physical health, dental health

Primary

Care

Step-down

care

Sustaining

recovery

So

c C

are

+ H

ou

sin

g +

SM

S +

Vo

l S

ecto

r +

Le

isu

re S

oc C

are

+ H

ou

sin

g +

SM

S +

Vo

l Se

cto

r + L

eis

ure

Social Care + Housing + SMS + Vol Sector + Leisure

Social Care + Housing + SMS + Vol Sector + Leisure

…. thank you and questions

Bobby Pratap Senior Programme Manager, Crisis & Acute Mental Health, NHS England Twitter: @BobbyPratapMH Email: bobby.pratap@nhs.net

5. Annex: London Region –

CRHTT and OAPs indicative data

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

No

rth

Eas

t Lo

nd

on

NH

S Fo

un

dat

ion

Tru

st

Barking & Dagenham (B&D) & Havering HTT

Y Y Y 65 38.60 0.59

0 0 Redbridge HTT

Y Y N 60 37.50 0.63

Waltham Forest HTT

Y Y N 60 30.55 0.51

North East London FT – CRHTTS and OAPs Indicative Data

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

Oxl

eas

NH

S Fo

un

dat

ion

Tru

st

Bromley N N N 25 16.50 0.66

2713 £1,519,940 Bexley N Y N 33 14.40 0.44

Greenwich Y Y N 52 24.50 0.47

Oxleas – CRHTTS and OAPs Indicative Data

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

Bar

net

, En

fie

ld a

nd

Har

inge

y

Barnet Y Y N 80 30.40 0.38

313 £166,680 Haringey Y Y N No data 28.00 No data

ECRHT Y Y Y 86 31.00 0.36

Barnet, Enfield and Haringey – CRHTTS and OAPs Indicative Data

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

Ce

ntr

al a

nd

No

rth

We

st L

on

do

n N

HS

Fou

nd

atio

n T

rust

Hillingdon Y Y N 25 19.00 0.76

1138 £388,593

Westminster

Y Y N 60 30.20 0.50

CNWL – CRHTTS and OAPs Indicative Data 1/2

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

Ce

ntr

al a

nd

No

rth

We

st L

on

do

n N

HS

Fou

nd

atio

n T

rust

Brent Y N N 75 27.00 0.36

1138 £388,593 Harrow Y N N 52 16.00 0.31

Milton Keynes

N N N 25 17.55 0.70

CNWL – CRHTTS and OAPs Indicative Data 2/2

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

Cam

de

n a

nd

Isl

ingt

on

NH

S Fo

un

dat

ion

Tru

st

South Camden Y Y N 35 15.80 0.45

1135 £660,225 North Camden Y Y N 35 19.60 0.56

Islington N Y N 70 31.60 0.45

Camden & Islington – CRHTTS and OAPs Indicative Data

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

East

Lo

nd

on

NH

S Fo

un

dat

ion

Tru

st

Tower Hamlets

N N N 45 19.80 0.44

298 *

Luton and South Bedfordshire

Y N N 45 28.50 0.63

City and Hackney

Y N Y 80 26.50 0.33

East London FT – CRHTTS and OAPs Indicative Data 1/2

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

East

Lo

nd

on

NH

S Fo

un

dat

ion

Tru

st

Psychiatric Acute Community Treatment

N N Y 65 20.30 0.31

298 *

Bedford Y N Y 35 20.00 0.57

East London FT – CRHTTS and OAPs Indicative Data 2/2

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

Sou

th L

on

do

n a

nd

Mau

dsl

ey N

HS

Fou

nd

atio

n T

rust

Lambeth Y N N 45 18.00 0.40

1745 £879,430

Southwark N N Y 50 34.30 0.69

Lewisham Y N N 45 23.60 0.52

Croydon N N N 45 34.00 0.76

SLaM – CRHTTS and OAPs Indicative Data

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

Sou

th W

est

Lo

nd

on

an

d S

t G

eo

rge

s M

en

tal H

eal

th N

HS

Tru

st

Kingston Y Y N 25 5.00 0.20

No data submitted

No data submitted

Wandsworth N N N 44 23.60 0.54

Sutton Y N N 39 11.00 0.28

SWLSTG – CRHTTS and OAPs Indicative Data

Trust HTT Team/ Catchment area

Can the CRHTT visit current CRHTT service users at home 24/7?

Does the team accept self-referrals from new patients?

Does CRHTT have a 4 hour target for all new assessments?

CRHTT Caseload upper limit

CRHTT staffing (FTE)

FTE staff to upper caseload ratio

No. of OAP days Q4 16/17

Total recorded cost Q4 16/17

We

st L

on

do

n M

en

tal H

eal

th N

HS

Tru

st

Crisis Assessment & Treatment Team Y

N Y N 35 34.00 0.97

257 £146,019

Crisis Assessment and Treatment Team 2

N Y N 50 32.80 0.66

Ealing Y Y Y 100 43.00 0.43

West London MH Trust – CRHTTS and OAPs Indicative Data

www.england.nhs.uk

10. Table discussions

Please introduce yourself to your table colleagues.

On your tables agree a facilitator and use the post-it notes to capture:

• What will you take away and do?

• What do you think would add value regionally?

• What will you lead on or contribute to affect change?

No More Time “On Hold”

Reducing delays in Mental Health Trust

discharges

www.england.nhs.uk

11. Plenary

The Care Closer to Home programme

Staying home longer and coming home sooner

The Care Closer to Home programme emerged from a growing awareness of the need for health and social

care organisations to partner and put structure, governance and resource around a plethora of targets,

deliverables and initiatives relating to out of hospital care.

It builds on work already underway across London in CCGs, Local Authorities, with A&E delivery boards

and Trusts.

The programme has three key components

1. Working to improve outcomes in key areas: Hospital to Home, so that people can stay at home for

longer and get home quicker, End of Life Care and aspects of Ambulance performance

2. An understanding of the capacity required to support a shift in the focus of care into community

settings – and what that means for the system , social care, health, housing and others

3. Engagement and collaboration with key partners

117

www.england.nhs.uk

Appendix: DToC data

Source: NHS England Monthly DToC Situation Report

Data excludes organisations representing lowest 1% of delays

0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

WEST LONDON MENTAL HEALTH NHS TRUST

ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

SOUTH WEST LONDON AND ST GEORGE'S MENTAL HEALTH NHS TRUST

SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST

ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST

ROYAL FREE LONDON NHS FOUNDATION TRUST

OXLEAS NHS FOUNDATION TRUST

NORTH EAST LONDON NHS FOUNDATION TRUST

LONDON NORTH WEST HEALTHCARE NHS TRUST

HOUNSLOW AND RICHMOND COMMUNITY HEALTHCARE NHS TRUST

EAST LONDON NHS FOUNDATION TRUST

CENTRAL LONDON COMMUNITY HEALTHCARE NHS TRUST

CENTRAL AND NORTH WEST LONDON NHS FOUNDATION TRUST

BUCKINGHAMSHIRE HEALTHCARE NHS TRUST

BARTS HEALTH NHS TRUST

BARNET, ENFIELD AND HARINGEY MENTAL HEALTH NHS TRUST

NON-ACUTE BED DAYS

All London Boroughs

A_COMPLETION_ASSESSMENT

B_PUBLIC_FUNDING

C_FURTHER_NON_ACUTE_NHS

DI_RESIDENTIAL_HOME

DII_NURSING_HOME

E_CARE_PACKAGE_IN_HOME

F_COMMUNITY_EQUIP_ADAPT

G_PATIENT_FAMILY_CHOICE

H_DISPUTES

I_HOUSING

NHS12M

Non-acute bed days by provider and reason for delay (12 months)

Non-acute bed days by provider and reason for delay (12 months)

Source: NHS England Monthly DToC Situation Report

Data excludes organisations representing lowest 1% of delays

0 1000 2000 3000 4000 5000 6000 7000 8000 9000

WEST LONDON MENTAL HEALTH NHS TRUST

THE WHITTINGTO N HOSPITAL NHS TRUST

ST GEO RGE'S UNIVERSITY HO SPITALS NHS FOUNDATION TRUST

SOUTH WEST LONDON AND ST GEORGE'S MENTAL HEALTH N HS TRUST

SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST

ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST

ROYAL FREE LONDON NHS FOUNDATION TRUST

OXLEAS NHS FOUNDATION TRUST

NORTH EAST LONDON NHS FOUNDATION TR UST

LONDON NORTH WEST HEALTHCARE NHS TRUST

HOUNSLOW AND RICHMOND CO MMUNITY HEALTHCAR E NHS TRUST

EAST LONDON NHS FOUNDATION TRUST

CENTRAL LONDO N COMMUNITY HEALTHCARE NHS TR UST

CENTRAL AND NORTH WEST LO NDO N NHS FOUNDATIO N TRUST

CAMDEN AND ISLINGTON NHS FOUNDATION TRUST

BAR TS HEALTH NHS TR UST

BAR NET, ENFIELD AND HARINGEY MENTAL HEALTH NHS TRUST

NON-ACUTE BED DAYS

All London Boroughs

A_COMPLETION_ASSESSMENT

B_PUBLIC_FUNDING

DI_RESIDENTIAL_HOME

DII_NURSING_HOME

E_CARE_PACKAGE_IN_HOME

F_COMMUNITY_EQUIP_ADAPT

H_DISPUTES

ASC12M

0

200

400

600

800

1000

1200

AP

RIL

MA

Y

JUN

E

JULY

AU

GU

ST

SEP

TEM

BE

R

OC

TOB

ER

NO

VE

MB

ER

DE

CEM

BE

R

JAN

UA

RY

FEB

RU

AR

Y

MA

RC

H2016-17

NO

N-A

CU

TEB

EDD

AYS

All London Non-Acute Providers

A_COMPLETION_ASSESSMENT

B_PUBLIC_FUNDING

C_FURTHER_NON_ACUTE_NHS

DI_RESIDENTIAL_HOME

DII_NURSING_HOME

E_CARE_PACKAGE_IN_HOME

F_COMMUNITY_EQUIP_ADAPT

G_PATIENT_FAMILY_CHOICE

H_DISPUTES

I_HOUSING

NHS12M

Source: NHS England Monthly DToC Situation Report

Data excludes organisations representing lowest 1% of delays

0

200

400

600

800

1000

1200

1400

AP

RIL

MA

Y

JUN

E

JULY

AU

GU

ST

SEP

TEM

BE

R

OC

TOB

ER

NO

VE

MB

ER

DE

CEM

BE

R

JAN

UA

RY

FEB

RU

AR

Y

MA

RC

H2016-17

NO

N-A

CU

TEB

EDD

AYS

All London Non-Acute Providers

A_COMPLETION_ASSESSMENT

B_PUBLIC_FUNDING

DI_RESIDENTIAL_HOME

DII_NURSING_HOME

E_CARE_PACKAGE_IN_HOME

F_COMMUNITY_EQUIP_ADAPT

H_DISPUTES

ASC12M

Source: NHS England Monthly DToC Situation Report

Data excludes organisations representing lowest 1% of delays

www.england.nhs.uk

View full reports on the LondonADASS website:

https://londonadass.org.uk/dtoc/londonadass-sitrep-analysis/