Outside ‐ In and Inside ‐ Out: Outreach as a Copernican moment in psychiatry? Prof. Mervyn Morris Birmingham City University presentation 17 th March 2011

Where is Birmingham?

‘De-institutionalisation’: Birmingham Beds: 722 (pop.1.2 million) BED TYPE nComments ‘Acute’234 = 1:5000 pop 8 sites across City and Solihull 17 units, 6-16 beds per unit Includes 2 Intensive Care Units Separate Male and Female ‘Longer Stay’ 112 = 1:10,000 Hospital type facilities Forensic152REGIONAL ‘medium secure’ Speciality30 REGIONAL Deaf (12), Eating Disorder (10) Mother and Baby (8) Older Adults years

Deprivation in Birmingham..

The ‘BIRMINGHAM MODEL’ A defined set of ‘functional’ outreach teams, providing a mobile/ ambulant community service, with different ways of working that reflect the different needs of people; Strong emphasis on multidisciplinary team-working; Different teams working in the same community..

COMMUNITY MENTAL HEALTH TEAM Primary CareContinuing Need: Liaison Rehab and Recovery CONTINUING NEED ASSERTIVE OUTREACH TEAM HOME TREATMENT TEAM Residential based care: Hospital Beds, Day services, Crisis Homes, PRIMARY CARE SERVICES Primary Care interface Hospital interface BIRMINGHAM MODEL..core teams

‘Functionalised’ Community Teams KEY CHARACTERISTICS 1 Same pattern of services found across City; Each team suited to work with different levels of need; Multi-disciplinary, integrated with social care; Depending on deprivation, serve smaller or larger populations..

COMMUNITY MENTAL HEALTH TEAM Primary CareContinuing Need: Liaison Rehab and Recovery CONTINUING NEED ASSERTIVE OUTREACH TEAM HOME TREATMENT TEAM Residential based care: Hospital Beds, Day services, Crisis Homes, PRIMARY CARE SERVICES Primary Care interface Hospital interface BIRMINGHAM MODEL X 21 teams X 5 teams X 17 wards X 7 teams

‘Functionalised’ Community Teams KEY CHARACTERISTICS 2 Differences in: Caseload; staffing ratio/population served/ working hours; Contact frequency/ location; Visiting patterns/ length of time on caseload;

CORE SERVICE TEAMS ACTIVITY FUNCTION CASELOAD Staffing ratio to Pt. Availability Population (av.morb) CONTACT Frequency Location VISITING Time on visit Time on caseload CMHT: Primary Care Liaison & Rehabilitation / Recovery ≤ 1:30 ‘working week’ 50,000 Weekly – Monthly Clinic or Home Therapeutic Session Up to 1 hour Up to 6 months ≤ 1:25‘ Working week’ 50,000 Weekly – Fortnightly Home or Community Activity based Years (ALAN) Assertive Outreach ≤ 1: days 150,000 Daily-Weekly Home or Community Minutes to Hours Years (ALAN) Crisis/ Home Treatment ≤ 1:2 24 hours, 7days 150,000 Multiple visits daily – 3 times per week Home or Community Minutes to hours, as required Up to 3 months

‘Functionalised’ Community Teams KEY CHARACTERISTICS 3 Integrated into care pathways: Acute and Continuing Care; Emphasis on avoiding hospital; Clearly defined boundaries and interface with hospital and primary care; Some outreach teams more specifically target vulnerable populations, for example; early intervention; homeless team.

COMMUNITY MENTAL HEALTH TEAM Primary CareContinuing Need: Liaison Rehab and Recovery CONTINUING NEED ASSERTIVE OUTREACH TEAM HOME TREATMENT TEAM Residential based care: Hospital Beds, Day services, Crisis Homes PRIMARY CARE SERVICES Acute Care pathway

COMMUNITY MENTAL HEALTH TEAM Primary CareContinuing Need: Liaison Rehab and Recovery CONTINUING NEED ASSERTIVE OUTREACH TEAM HOME TREATMENT TEAM Residential based care: Hospital Beds, Day services, Crisis Homes PRIMARY CARE SERVICES Continuing Care Pathway

COMMUNITY MENTAL HEALTH TEAM Primary CareContinuing Need: Liaison Rehab and Recovery CONTINUING NEED ASSERTIVE OUTREACH TEAM HOME TREATMENT TEAM Residential based care: Hospital Beds, Day services, Crisis Houses, PRIMARY CARE SERVICES Additional teams EARLY INTERVENTION SERVICE

COMMUNITY MENTAL HEALTH TEAM Primary CareContinuing Need: Liaison Rehab and Recovery CONTINUING NEED ASSERTIVE OUTREACH TEAM HOME TREATMENT TEAM Residential based care: Hospital Beds, Day services, Crisis Houses, PRIMARY CARE SERVICES Additional teams HOMELESS TEAM

The Copernican shift.. The service begins to revolve around the patient The Birmingham Model is not enough! There’s a difference between: “DOING THE RIGHT THING” and “DOING THE THING RIGHT” The Birmingham Model explains DOING THE THING RIGHT, about organising a system; it is then down to the teams to do the ‘right thing’..

The Copernican shift.. The service begins to revolve around the patient INSIDE – OUT Reduces the stigmatisation of Hospitalisation Relate to the person and their social network in a different way; Seeing mental illness in context: understand content of symptoms;

The Copernican shift.. The service begins to revolve around the patient OUTSIDE – IN A new model of psychiatric practice emerges: More personalised intervention: -empowerment through choice and negotiation of meaning; -in vivo, and with social network; -including not excluding people from each other. Recognise the social context of mental health problems; to be in a position to address directly vulnerability; exploitation, poverty, homelessness.

The Copernican shift.. The service begins to revolve around the patient Outreach is necessary, but not sufficient.. This is the moment to pause: We can take ‘psychiatry out of the hospital’, but we must also take the ‘hospital out of psychiatry’. If we continue to think and practice community outreach in the same way as we thought and practiced in the hospital, then we are not de-institutionalising, we are re-institutionalising..

Thank you for listening..

COMMUNITY MENTAL HEALTH TEAM Primary CareContinuing Need: Liaison Rehab and Recovery CONTINUING NEED ASSERTIVE OUTREACH TEAM HOME TREATMENT TEAM Residential based care: Hospital Beds, Day services, Crisis Homes PRIMARY CARE TEAM OTHER ADULT SERVICES DRUG & ALCOHOL SERVICES LIAISON SERVICES SOCIAL CARE

What made community services work? An integrated service pathway Effective boundary management between teams – ‘system of gateways and filters Integration with social care – housing, employment, benefits and ‘3 rd Sector’ Teams with competent team managers Preparation and learning as we go Data – targets and monitoring Continue to innovate and adapt

Gaps/ issues/areas for development Transition from child to adult services Biological v Social models: i.e. EVIDENCE!! (families, work) Fidelity (e.g. CRHT) CMHT’s – function Shifting/ diversifying provision Effective commissioning/ contracting

Pre-conditions for transformation A vision.. Being ready.. Evidence of effective community models Service user and carer support Existing competence amongst staff in independent community practice An opportunity e.g. psychiatric hospital that needs to close Courage