Achieving Better Access To 24/7 Urgent And Emergency .
Achieving Better Access to 24/7 Urgent andEmergency Mental Health Care – Part 2:Implementing the Evidence-based TreatmentPathway for Urgent and Emergency LiaisonMental Health Services for Adults and OlderAdults – Guidance1
OFFICIALAchieving Better Access to 24/7 Urgent and Emergency Mental HealthCare – Part 2: Implementing the Evidence-based Treatment Pathwayfor Urgent and Emergency Liaison Mental Health Services for Adultsand Older Adults – GuidanceVersion number: 1First published:November 2016Prepared by:NHS England, the National Collaborating Centre for Mental Healthand the National Institute for Health and Care ExcellenceClassification:OFFICIALNHS England Publications Gateway Reference 059582
OFFICIALForewordThe Independent Mental Health TaskforceFive Year Forward View (February 2016) madeit clear that improving access to high-qualitymental health care must now become anational priority. The Achieving Better Accessto Mental Health Services programme hasbeen developed by NHS England, the NationalInstitute for Health and Care Excellence andthe National Collaborating Centre for MentalHealth to introduce standards for mentalhealth care and ensure that these can beproperly measured across the country. Theaim? To begin a major national implementationprogramme to make sure people withmental health problems get prompt access toevidence-based NICE-recommended care, on apar with the care provided for physical healthproblems. Nowhere within mental health careis the issue of parity more important than inthe provision of urgent and emergency care forpeople experiencing a mental health crisis.Improving liaison mental health provision hasbeen a long-standing goal for the NHS andis a ‘must do’ in the most recent two-yearplanning guidance for 2017-19. In April 2016, aspart of the CCG Improvement and AssessmentFramework 2016/17, CCGs were also asked toensure that agreed and funded plans are inplace to aim for a core 24 (24 hours, 7 days aweek) service by 2020/21.The pathway set out in this guide will help NHScommissioners and providers to ensure thatliaison mental health services can meet thesestandards and deliver on their improvementplans. If these goals are achieved, adults andolder adults presenting in crisis in emergencydepartments and on physical health generalwards will have access to high-quality NICErecommended care, any time of the day ornight, every day of the week.This implementation guide is one of a series forurgent and emergency mental health care thatalso covers ‘blue light’ services (for all ages),community-based crisis response services (foradults and older adults) and children and youngpeople’s crisis services. Together they will forma crucial part of the overall implementationplan for transforming urgent and emergencymental health care in England.Proper funding for mental health crisis careand its full integration within NHS urgent andemergency care was one of the commitmentsmade in the Five Year Forward View for MentalHealth. With the publication of Implementingthe Five Year Forward View for Mental Health(July 2016), and this implementation guidancefor Achieving Better Access to 24/7 Urgent andEmergency Mental Health Care, commissionersand service providers now have some powerfultools at their disposal to improve crisis care forpeople of all ages across the country.Never before has timely access to highquality mental health care been accepted asso necessary by the whole health and socialcare community. Now we, as commissioners,providers, health and social care workersand partners across the whole urgent andemergency care pathway, must rise to thischallenge and meet these expectations.Liaison mental health services already play avaluable role in supporting people in a crisis,as well as adults and older adults who haveboth mental and physical health problems in ageneral hospital setting. They can help peopleto avoid lengthy stays in hospital and canspeed up discharge. We now want to makesure people who experience a mental healthcrisis have received a response from an urgentand emergency mental health service withinan hour, and that within four hours they havereceived the appropriate support to meet theirneeds and an evidence-based package of careis in place.Professor Tim KendallNational Clinical Director for Mental Health3
OFFICIALKey statementsThese statements were developed by the Expert Reference Group based on what they considered tobe the key messages for this implementation guide. They have been worded from the perspective ofa person experiencing a mental health crisis to highlight the need to develop urgent and emergencymental health services with the person at the centre. When I visit hospital experiencing a mental health crisis and I require help and support, this istreated with as much urgency and respect as a physical health emergency and I am able to get aresponse no matter what time of the day it is, or which day of the week. When I experience a mental health crisis in an emergencydepartment or on a general hospital ward, I receive atimely and compassionate response from trained andcompetent professionals in liaison mental health. If I aman older adult I will receive specialist support from a teamskilled in working with older people. I am treated withkindness, compassion and dignity and in accordance withmy legal rights.EBTP STANDARDAny person experiencing a mentalhealth crisis should receive aresponse from the liaison mentalhealth service within a maximumof 1 hour of the service receivinga referral. My physical and mental health needs should not be seen as separate from each other and I receiveeffective care for both in a general hospital setting. Within one hour of a liaison mental health service being contacted, I have received a response andknow that help is on its way. Within four hours of arriving in an emergency departmentor being referred from a ward, I receive a response andsupport that meets my needs. Depending on my situation: I have had a full assessment of my physical,psychological and social needs, and an urgentand emergency care plan is in place, and I am on my way to another service or location, ifneeded, or I have been accepted for follow-upcare by another serviceEBTP STANDARDWithin 4 hours of arriving at anemergency department or beingreferred from a ward, any personexperiencing a mental healthcrisis should have received theappropriate response or outcometo meet their needs and have anevidence-based care package(informed by NICE) in place.OR I have started assessment under the Mental Health Act. If I feel better within four hours, I can go home. When I am on a general hospital ward and require an urgent response from a liaison mental healthservice, I receive a full assessment within 24 hours. If I am an older adult I will receive specialistsupport from a team skilled in working with older people. Liaison mental health services have access to appropriate staff either on the team or throughcontractual arrangements to ensure that there are no delays to the start of a Mental Health Actassessment, should I require one. If the difficulties I am facing during a mental health crisis cannot be resolved where I am, I amprovided with appropriate support to access and travel to an appropriate and safe place where helpis available. If I need longer-term support to manage my mental health problems, this is arranged.4
OFFICIALContents1 Introduction71.1Background71.2Purpose and scope of this document71.3How was this document developed?91.4The evidence-based treatment pathway91.4.1Emergency pathway91.4.2Urgent pathway1.510Expectations of commissioners102 W hat is a mental health crisis and why is rapid access to a liaisonmental health service so important?122.1What is a mental health crisis?122.2Attending the ED when in a mental health crisis122.3How liaison mental health services can help people in a mental health crisis132.3.1Identify, assess and respond to mental health crises132.3.2Treat the symptoms of the mental health crisis132.3.3Provide access to ongoing support132.3.4Provide service-level support133 What are liaison mental health services?3.13.23.33.414Current provision of liaison mental health services143.1.124-hour services143.1.2Distinct specialty153.1.3On-site service15Benefits of liaison mental health services163.2.1Benefits for people experiencing a mental health crisis163.2.2Benefits to service providers163.2.3Economic benefits of liaison mental health services16Liaison mental health service models173.3.1Core 24173.3.2Enhanced 24173.3.3Comprehensive183.3.4Core18The workforce183.4.1Workforce for core 24, enhanced 24 and comprehensive service models183.4.2Other staffing203.4.3Integrated governance205
OFFICIAL4 The evidence-based treatment pathway234.1Evidence-based treatment234.2Emergency care pathway254.2.1EBTP CLOCK STARTS – Identification254.2.2Step 1 – Response274.2.3Step 2 – Assess274.2.4EBTP CLOCK STOPS – Agreed treatment plan in place284.3Urgent care pathway294.4Pathway principles304.4.1Providing age-appropriate treatment304.4.2Using referrals and alerts324.4.3Mental Managing intoxication due to drug or alcohol intake334.4.7Managing people who leave (or are likely to leave) before an assessment344.4.8Supporting a person when they no longer need urgent and emergency care344.4.9Collecting data344.5Measuring and reporting performance against the pathway and standards354.5.1Submission of data items354.5.2Outcomes measurement354.5.3Quality assessment and improvement programme375 Key commissioning considerations and service development5.15.238Step 1: Understand local demand385.1.139Commissioning for a hospital populationStep 2: Develop an outline service model395.2.1Consider the appropriate service model395.2.2Identify and understand current referral pathways395.2.3Consider establishing drug and alcohol use services395.3Step 3: Obtain baseline current service provision and identify gaps405.4Step 4: Agree staffing, recruitment and training plans405.5Step 5: Design local referral to treatment pathways and accompanying protocolsand guidance405.5.1Providing appropriate and safe environments for assessments405.5.2Providing support for people with drug or alcohol use problems405.5.3Managing frequent attenders415.5.4Providing care between assessments and reviews415.65.7Step 6: Establish data collection and outcomes measurement protocols415.6.1Overview415.6.2Developing reports for monitoring performance42Step 7: Create a benefits realisation plan42Definitions of terms and abbreviationsReferences44647
OFFICIAL1 Introduction1.1 BackgroundThis guide covers the first 24 hours of urgentand emergency mental health care followingreferral or presentation. The pathway andassociated standards should be applied equallyregardless of the nature of the mental orphysical health problem and any disabilities(including learning disabilities) of the personpresenting in a mental health crisis.This guide builds on a number of policydrivers, reviews and publications includingThe Mental Health Crisis Care Concordat,1 theCare Quality Commission (CQC) report RightHere, Right Now,2 the Urgent and EmergencyCare Review3 and the Five Year Forward Viewfor Mental Health.4 Together these made anoverwhelming case for improving urgent andemergency mental health services, includingliaison mental health services.a The additionalfunding announced in the Spending Reviewand detailed further in Implementing the FiveYear Forward View for Mental Health5 will beused to improve coverage and availability ofurgent and emergency mental health care, sothat by 2020/21 all general hospitals will have aliaison mental health service and at least 50%will meet the standard for adults and olderadults of a core 24 service as a minimum. Thiswill be supported by 120 million additionalcentral funding by 2020/21.The primary aim of this document is to provideguidance on establishing, developing andmaintaining urgent and emergency liaisonmental health services for adults and olderadults in emergency departments (EDs) andgeneral hospital wards. It is acknowledged thatliaison mental health teams provide a widerrange of services than urgent and emergencymental health care. However, these activitiesare beyond the remit of this guide and willbe addressed in forthcoming implementationguides on integrated mental and physicalhealth services in 2017.This guide is aimed at commissioners andproviders of services for adults and olderadults. It is recognised that some adult servicesprovide an urgent and emergency mentalhealth response to young people aged 16 to 18years. See Part 4 in this series (listed below) forthe implementation guidance for urgent andemergency mental health services for childrenand young people.1.2 Purpose and scope ofthis documentThis guide supports implementation of theambitions set out in the Five Year ForwardView for Mental Health to introduce evidencebased treatment pathways across mentalhealth services. It states: ‘by 2020/21, NHSEngland should invest to ensure that no acutehospital is without all-age mental healthliaison services in emergency departmentsand inpatient wards, and at least 50 per centof acute hospitals are meeting the ‘core 24’bservice standard as a minimum’ to ensureprovision of liaison mental health services in allgeneral hospitals.This document is one in a series ofAchieving Better Access to 24/7 Urgentand Emergency Mental Health Careimplementation guides, which includes:Part 1: Implementing the Evidence-basedTreatment Pathway for ‘Blue Light’ ServicesProviding an Urgent and Emergency MentalHealth Response for All Ages (forthcoming)Also commonly known as ‘liaison psychiatry’ or ‘psychologicalmedicine’, the term ‘liaison mental health’ is used in this guideto reflect the multidisciplinary nature of liaison teams.aCore 24 is a liaison mental health service model provided 24hours, 7 days a week; it is commonly provided across urgentand emerg
mental health care in England. Never before has timely access to high quality mental health care been accepted as so necessary by the whole health and social care community. Now we, as commissioners, providers, health and social care workers and partners across the whole urgent and emergency care pathway, must rise to this challenge and meet these expectations. Professor Tim Kendall National .
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