The Gloucester Assertive Outreach Team Presentation for NFAO Dr Rob Macpherson July 2009

Gloucester AO team development Gloucester AO team – developed from community rehab team 2000, through change management process led by consultant/manager. 12 month training involving Sainsbury Centre with team major Trust service redesign, new team & new management, new locality (forest of Dean) -move from caseload to team management, clearer discipline specialism

Audit/Service Development 1 Gloucester Pan London (Priebe et al, 2003) Dartmouth score4.3? Average age3837 Unemployed82%80% Living alone41%52% Av illness duration15 yrs15 yrs Compulsory admission23% over 1 yr25% over 9 mths Police contact34% over 1 yr21% over 9 mths Admission rate31% over 1 yr39% over 9 mths Substance misuse29%29%

Audit/Service Development 2 Carer’s needs 36/75 patients on caseload have carer (NSF definition = min 12 homes/week support). Staff, patients and carers rated CANSAS. Agreement on ratings – “good/excellent” between staff and patient - mostly “poor” between carer and patient and between staff and patient. Carers rate higher unmet needs around care of home, lower ratings on risk to others. Carers assessments completed for all – given up careers (29%), independence (18%) - problems tiredness (36%), unpredictability of patient (29%) - need someone to talk to, practical help (finance/break/respite).

Audit/Service Development 3 Changing patients’ needs From 2003 started routinely using CANSAS and EM, 6 monthly. Changes:- reduced patient rated unmet need no change staff rated met/unmet need no change in engagement measures accommodation changes: 4 to independent living, 3 to supported accommodation, 3 to homelessness, 2 to prison 10 started Clozapine. 9 stopped depot antipsychotic 16 started regular day time activity. 0 stopped.

Audit/Service Development 4 Audit Vs NICE guidelines in schizophrenia All keyworkers completed audit proforma for each of 61 cases of schizophrenia in AO team. Compliance with guidelines: Formal family intervention 20% (51% no contact, 10% declined, 15% other family work) CBT 40% (23% unable to participate, 18% no persisting symptoms) Advance directives 0% Antipsychotic Polypharmacy 15% (others: 5% “patient choice”, 3% Clozaril augmentation, 7% reduction of AP caused relapse).

Audit/service development 5 SEAT: A Service Evaluation of AO Teams Set up 2008, overseen by steering group Evaluate 1 st year in AO: baseline, 6 & 12 months: CANSAS staff + SU Engagement Measure HONOS Service activity: admission/crisis/work/contact with CJS/homelessness/contacts

Audit/service development 6 AO handbook ‘What we do’ Simple language Pictures To be used- training & induction -development of team -to address new challenges- CTO

The Gloucester AO Team structure Team manager band 7 CPNs- 4 band 6 -1 band 5 Social workers- 2 band 6, AMPs OTs- 1 band band 5 Support workers- 3 Sports therapist- 0.5 Team secretary- 0.8 Psychologist band Art therapy band Psychiatry- 0.7 consultant (2 individuals), 1 Associate Specialist, core + advanced trainee Caseload: 81 (70 Gloucester city)

Team strengths Journey to work: team led programme of support in 3 localities, supporting all with SMI through challenges of return to work Allotment Groups- walking, gym, snooker, women’s group, badminton. Focus in normal, non- NHS settings Holidays- caravan, Butlins, walking

Team strengths CPA review cycle, service users seen 3 monthly In team training in housing, medication management, dual diagnosis 3 yearly AO half day external training Team supervision, daily meetings, reflective practice Red/amber/green service user assessment

Team strengths Appraisal of all team members 3 monthly Close working team manager/consultant/psychologist Team away days twice yearly Whole team caseload management 3 monthly Better working with recovery team, regular meetings with seniors 4 yearly. Transfer of cases greatly improved

Team strengths Flexibility working with other teams- LD, recovery, CRT, in-patient Development of specific tailor made care packages very effective in some cases Collaboration with non-stat accommodation providers

Challenges Rural/urban working in single team, “urban drift”. Lack of accommodation & work/rehab opportunities in rural area. Consultant input to Forest arm of team. Interface issues: recovery teams (capacity); crisis teams; forensic cases. Ongoing work. Use of CTO: team development, reflective practice

Challenges 2gether Trust information systems: how to use for team development Requirement to input data for service evaluation & PCT contract monitoring Payment by results – quality improvement Vs managerial imperatives. Increasingly drives service change (activity, not outcome or effectiveness)

Future Raise profile of AO team locally & nationally Applying for AO demonstration team Refocus project- recovery focused working Maintain clear AO focus, by team caseload management & training/team support Closer working across teams re group & other work RIO electronic patient record

Thanks for listening