‘Every team in the acute system benefits from all of us collectively managing the system’
We are really proud to be part of these transformational changes that are delivering a higher quality of care with increased access to talking treatment as close to home as possible. For those who do need inpatient care this is being provided in dramatically improved healing environments with rapid access. It has taken a long time to get these changes in place. What’s made the difference? Joint working across the community and inpatient services so that all staff are able to view changes in the context of the wider system – every team in the acute system benefits from all of us collectively managing the system. The tight management of length of stay, a focus on outcomes and working together have been key – and, most of all, winning the hearts and minds of our staff and patients.
In 2012, acute bed occupancy in Sheffield was running at about 120% and there were large numbers of people out of town. At the time, Sheffield had four acute adult psychiatric wards with 24 beds each (96 beds); and two older adult wards with 22 beds (44 beds) and roughly a ward full of people out of town all the time. It was often difficult to admit, with beds frequently blocked due to a lack of access to rehabilitation beds and difficulty accessing social housing. The length of stay was long (50 days for an adult, 120 days for an older adult). This situation had gradually taken hold over the previous decade, despite numerous initiatives to change this.
In 2012 we set up a new managed acute care pathway from the community right through to developing a new, purpose-built PICU (just opened). Productivity work has taken place and length of stay is managed using a range of methods including: daily bed management for all wards together; daily ward team meetings with the consultant: discharge coordinators based on each ward; a new team for home treatment for older adults in crisis; we commissioned a crisis house (run by Rethink for all age groups over 18 years) and enhanced crisis and home treatment teams.
The impact: substantially reduced length of stay and greatly improved pathway management. We now have one older adult ward (18 beds); four adult wards (all 18 beds), each with existing staffing levels therefore increasing the staff to service user ratio. Most importantly, we have eliminated out of area treatments for acute beds and PICU due to lack of capacity for over a year. During this time there has been a maintained or slightly higher level of admissions and much better access to acute care. In 2016 we aim to shut one acute adult ward – on Monday this week we had 35 empty beds.
The total bed reductions over this time, including constant out of area bed use, has gone from 152 beds down to a new model in 2016 of 72 acute beds across the age range. Over the last year our inpatient unit has had no SUIs.
The reductions in inpatient care have been possible due a series of reinvestments, all funded by a reduction in OATs and given to us by our CCG, including:
• same staffing levels in acute wards with less service users
• a crisis house
• increased access to home treatment across the age range
• psychologists on inpatient wards
• improved environments with for example increased de-escalation space
• a new PICU
• ‘Respect’ programme to replace previous managing violence and aggression including elimination of face down restraint.
There have been no acute OATs due to a lack of availability of beds for 18 months now.
Over the same period (2012-15), we have also transformed the rehabilitation system by developing an ultra-intensive community rehabilitation team (Community Enhancing Recovery Team- CERT), also funded by reducing OATs in locked rehabilitation. We have so far returned 20 people (to live in their own flats in the community in Sheffield) from locked rehab OATs. The reduced OAT spend has been given to us by our CCG which has funded an investment of £2 million in our new CERT and still saved considerable sums of money. OAT bed nights for these patients has been reduced by an equally stunning 99%.
We continue to monitor the impact of the changes using quality measures. All indicators of quality suggest that quality is being enhanced by the reconfiguration.