1. Crisis Resolution/Home Treatment Developing Critical Components Kevin Heffernan Honorary Research Fellow Centre for Community Mental Health Birmingham City University

2. Kevin Heffernan Nurse (RMN) 11 years leading HT developments in Birmingham services, (National award winning beacon site) Consultant for the World Health Organisation National Institute Mental Health England (Regional Implementation…5.5 M pop….39 HTT, 27 AOT) Honorary Research fellow Birmingham City University West Midlands Strategic Health Authority (Programme Specialist service development)

3. Overview of PresentationOverview of Presentation Critical components or fidelity principles of CRHT in England Advantages of CRHT in English context Community profile of 1 Birmingham area Tomorrow National/Regional Implementation of policy National Audit of CRHT in England Important data collection for CRHT

4. Characters that represent CRISIS Danger/risk and Adversity Opportunity for Personal Growth

5. Fidelity principles in CRHT Gatekeeper to all potential admissions Flexible visiting (duration/frequency/Intensity – protect capacity) Rapid Response (1-4 hour variable by geography) 24 hour/7 day availability Operating a corporate caseload (utilising MDT skill mix) Clearly targeted caseloads (Acute – not all things to all men!) Time limited (average length of stay 4-6 weeks) Fully Integrated (not operating in isolation, whole system responsibility)

6. Fidelity principles in CRHT Comprehensive Assessment Address social issues (in vivo) Medical staff involved/available Mobile not office based Practical problem solving approach Supervision and administration of medication Advice, support for Carers Early Discharge (not becoming discharge team) Effective communication and planning

7. Advantages of CRHT Interrupt cycle of admission (change expectations…David) Avoidance of admission (1 st presentations….Zacch) Facilitate early discharge Reduced bed use - admissions and length of stay Different framework for sustaining recovery focused engagement Support can be perceived as; More Personal/Individualised Increased Negotiation leading to a sense of increased autonomy Potential to develop more true Partnership working (Trialogue can emerge) Narrative scrutiny (exploration of the why now and true context becomes more possible)

8. Advantages of CRHT Can be more flexible/sensitive ethnic minority groups Extended Support for Carers Explanation and advice and post crisis planning Confront social problems directly Work closely with Dual Diagnosis issues Reduce stigma of hospitalisation Higher satisfaction users and carers Development of an acute team

9. Community teams in Birmingham Caseload size and distribution in a locality of 150,000 population Understandingyou can’t do it alone! Understanding where you fit in the system!

10. High Caseload Low Intensity Low Caseload High Intensity Primary Care MH team 1:30 20 staff 600 Cases Weekly - Monthly Assertive Outreach 1:10 12 staff 123 Cases Daily - Weekly Rehabilitation/Recovery 1:25 15 staff 370 Cases Weekly - Fortnightly Home Treatment 1:2 14 staff 25 Cases Multiple daily - decreasing Days Years

11. ACTIVITY TEAMCASELOAD/ Size/ Time VISITING Availability/ Frequency INTENSITY How long/where CMHT/ Primary Care Liaison ≤ 1:30 Up to 18 months 9am – 5pm 5 days Weekly – Monthly Clinic or Home Therapeutic Session Up to 1 hour Rehabilitation/ Recovery ≤ 1:25 Years 9am – 5pm 5 days Weekly - Fortnightly Activity based Home or community Assertive Outreach ≤ 1:12 Years 0900-2100 6-7 days Daily-Weekly Minutes to Hours Home or Community Crisis/ Home Treatment ≤ 1:2 Up to 3 months 24 hours, 7days Multiple Daily – 3 times per week Minutes to hours, as required Home or Community

12. Distribution of Cases CMHT’s 20 staff Rehab & recovery 15 staff Assertive Outreach 12 staff ***************** ***************** ***************** ***************** ************ ***************** 600 Cases Days Years Intensity of support & Length of stay in the service ***************************** ***************************** ************** ************** **************************** 370 Cases 123 cases ************ *********** *********** ************ *********************** Serious Mental Illness

13. Distribution of Cases CMHT’s 20 staff Rehab & recovery 15 staff Assertive Outreach 12 staff ***************** ***************** ***************** ***************** ************ ***************** 600 Cases Days Years Intensity of support & Length of stay in the service ****************************** *************************** ************** ************************* ************************* 370 Cases 123 cases ************ *********** *********** ************ ************************* Serious Mental Illness Crisis Resolution/Home Treatment 14 staff 20 cases ************************ ************************ ********************** ********************* ******************* ****************** ***************** *** **

14. Distribution of Cases CMHT’s 20 staff Rehab & recovery 15 staff Assertive Outreach 12 staff ***************** ***************** ***************** ***************** ************ ***************** 600 Cases Days Years Intensity of support & Length of stay in the service ****************************** *************************** ************** ************************* ************************* 370 Cases 123 cases *********** *********** ************ ************************* Serious Mental Illness Crisis Resolution/Home Treatment 14 staff 20 cases ************************ ************************ ********************** ********************* ******************* ****************** ***************** Most Impact on diverting cases From Hospital admission

15. Distribution of Cases CMHT’s 20 staff Rehab & recovery 15 staff Assertive Outreach 12 staff ***************** ***************** ***************** ***************** ************ ***************** 600 Cases Days Years Intensity of support & Length of stay in the service ************** ************** ************** 370 Cases 123 cases *********** *********** ************ *********************** Serious Mental Illness Norway ACUTE Teams ************** ************** Most Impact on diverting cases From Hospital admission

16. Let today's collaboration be another important step to inspiring and giving each other hope for the future development of local community based mental health services across Norway This is your opportunity! And not a danger or risk

17. From Policy to Implementation The role of regional development centre’s. How did the Department of Health support a national roll out of policy based on some of the Birmingham success story?

18. National Institute of Mental Health in England (NIMHE) was formed by the Department of Health in 2002 to help the mental health system implement the National Service Framework (1999) for Mental Health and the NHS Plan (2000). Policy Implementation guidelines for CRHT were published in 2002 The DH said 335 CRHT teams delivering 100,000 contacts by 2005 8 regional development centres were set up One in the West Midlands covering a population of 5.5 million Also regional centres in East Midlands London South East South West Eastern region North East North West

19. The main aim of NIMHE was to help improve the quality of life of people of all ages who experience mental distress. Working beyond the NHS, it helped all those involved in mental health to implement positive change, providing a gateway to learning and development, offering new opportunities to share experiences and one place to find information. Through NIMHE's local development centre’s and national programmes of work, it supported staff to put policy into practice and to resolve local challenges in developing and sustaining new mental health services.

20. Workstream examples within the Regional Development Centre's Specialist mental health services Acute Inpatient Community teams (Crisis Resolution/Home Treatment, Assertive Outreach teams) Child & Adolescent Mental Health Dual Diagnosis Early Intervention Personality Disorder Improving access to Psychological therapies Improving access to psychological therapies for people with common mental health problems. Equalities – Race, Gender & Age Delivering Race Equality Gender, Equality and Women's Mental Health Programme Mental Health in Later Life Well being and Inclusion Social Inclusion Programme, mental health first aid training programme Legislation The Mental Health Legislation programme supported the implementation of service changes and changes in roles that are required to meet any changes set out in the Mental Health Act

21. Day in the life of a staff member Not official performance management/monitoring, but focus on service Improvement and development, therefore viewed as honest brokers Identify good practice areas Link areas together Protect and champion ‘fidelity’ and ‘values’ Develop regional network’s (e.g. CRHT, AO and EI) Influence policy review and refinement Strength in having a national profile (sharing across RDC’s) Challenge with kindness!! (e.g. not if, but how!, rural v inner city)

22. Context Part of my role was to offer support & guidance across the West Midlands to 25 Assertive Outreach teams 39 Crisis Resolution/Home Treatment teams Regional forums (organise& chair) Specific developmental in vivo programmes to address local issues (not ‘off the shelf’) Coaching & mentoring of managers/leaders Ensure fidelity to the model All staff were recruited based on their experience and/or commitment to the new vision of services. The values of staff were a critical factor, to embrace the complex and unique issues of different areas who were at different stages of evolution was an essential skill

23. Systems are systems the world over, getting the right people in the right place at the right time is what makes it work! You are the catalysts for change. Your role will be to inspire and give people hope that things can change. How you get support will be important I hope you are the right people with all the commitment, energy, passion, empathy, humour and perseverance required to move your mental health system forward. This ultimately will lead to the improvement in the quality of experience for Users and families that access your services

24. Happy to take questions or to be contacted on kevin.heffernan@westmidlands.nhs.uk