International, Mobile Integrated Healthcare

London’s Innovative Response for Patients Presenting with Mental Health Problems

Issue 11 and Volume 41.

Mobile integrated healthcare in London

In March 2014, the London Ambulance Service (LAS) identified that demand from mental health patients calling 9-9-9 (London’s 9-1-1) for crisis support was significantly increasing in line with overall activity and demand for emergency services. But despite this increase in demand, resources available to LAS didn’t increase, which had two main effects on the service:

  1. Impact on our ability to respond to other life-threatening emergencies; and
  2. Poor patient experiences for mental health callers who often fall within the lower triage categories of the Medical Priority Dispatch System.

Drivers for patients with mental health needs accessing help via the 9-9-9 system include the limited availability of crisis mental health service provision out of normal hours, the increased focus on community care, and poor access to alternative care pathways for patients with mental health problems. This left LAS as one of the only services accessible 24 hours a day for this patient population, albeit with extremely limited options other than dispatching a resource to the scene and transporting patients to the ED.

Mobile integrated healthcare in London
Between March 2015 and March 2016, mental health practitioners responded to 5,961 calls, with 15.9% (948) managed with a hear-and-treat function. To date, there have been no complaints or incidents reported.

Care Inconsistencies

A 2015 Care Quality Commission report explored experiences of people during a mental health crisis and highlighted huge variations and inconsistencies in the quality of care received.1 The U.K. government also published the Mental Health Crisis Care Concordat: Improving Care, it’s main objective being to ensure that people experiencing a mental health crisis can easily access help and support 24 hours a day.2 The Mental Health Crisis Care Concordat also emphasises that a mental health crisis can be just as debilitating as a physical health crisis, and, in some cases, life-threatening. And, like major physical injury, may only get worse if not dealt with in a timely and appropriate way. Additionally, the National Health System (NHS) England Urgent and Emergency Care Review highlighted the need for new models of care to provide safer, faster and improved responses to patients ensuring that mental health emergencies are treated with the same urgency as physical health emergencies.3

Given these factors, LAS had to examine other ways of supporting the specific needs of mental health patients to ensure the delivery of high-quality patient care. There was also the desire to increase the knowledge and skills of our existing staff in line with the NHS England Urgent and Emergency Care Review.

Mental Health Clinical Advisory Service

Introduced to our Emergency Operations Centre (EOC) in January 2015, the Mental Health Clinical Advisory service has evolved into a nationally recognized specialty mental health response.

The decision to use mental health practitioners to carry out a hear-and-treat function needs the support of local mental health trusts, as the evidence suggests the ED isn’t always the most appropriate place to take some of these patients.1–3

The mental health practitioner needs to demonstrate awareness of the limits of their knowledge, skills and abilities. Close working between the mental health practitioners and other staff within the service is essential in developing a shared understanding of the scope and nature of the service.

The LAS already had a clinical support function within our EOC, which was staffed by paramedic clinical advisors whose main role is to provide assessment for those calls being held by the service awaiting a resource to become available as well as to target those calls where it’s believed an enhanced hear-and-treat response from a clinician may provide an effective alternative to dispatching a resource. To morph this into the Mental Health Clinical Advisory, the service committed to convert six of the existing clinical advisor posts traditionally held by paramedics into specialist mental health clinical advisor posts. A leadership position was also established to allow for professional leadership of the new nursing roles.

The Mental Health Clinical Advisory service now has five mental health practitioners who work alongside paramedics and general nurses to deliver a specialist “hear-and-treat service,” or support over the phone. All five practitioners were recruited on a permanent basis to join the clinical support desk. They are allocated to specific shifts and work autonomously.

How the Team Works

The work of the mental health practitioners is broad and varied. They’re expected to have an understanding of the mental health referral pathways and crisis services available to patients throughout London and beyond. They also advise frontline crews and fellow EOC staff, and have the ability to directly take on challenging calls from call takers.

Training was provided for the new recruits to carry out telephone triage of patients including command point training, Manchester triage system training, risk screening and generic clinical advisor training relevant to the LAS. The nurses completed a week-long computer software course, followed by a period of observation and then supervised practice for an additional six weeks.

Introduction of the service was communicated to our patients, as well as engagement work with mental health trusts to support the effective use of alternative care pathways.

The mental health practitioners’ main functions are divided into three main areas.

1. Hear-and-treat service.

This involves providing a full mental health assessment using a risk-assessment tool, and deciding on the most appropriate course of action, including transferring them to alternative services, while advising patients over the phone. Depending on the outcome of the assessment, clinical advisors have numerous options available to them including:

  • Upgrade the call due to a clinical concern and request that a resource is dispatched;
  • Refer patients to be seen immediately. In some circumstances, they’re able to arrange for the patient to be further assessed at a mental health team base or hospital;
  • Book a taxi to transfer the patient to an appropriate destination;
  • Advise the patient to make their own way to a hospital or mental health team;
  • Refer for follow up by community mental health teams or their general practitioner (GP); or
  • Discharge the patient with appropriate advice or GP referral.

2. Warm transfers.

This involves assisting call handlers and fellow clinical advisors with the management of difficult calls, which can be of an extended duration. This function works to allow call takers to respond to new incoming calls, which reduces the risk posed by unanswered 9-9-9 calls and also ensures people who are distressed and vulnerable are supported by an appropriately trained clinician as early as possible.

3. Staff advice.

This involves advising frontline ambulance crews carrying out face-to-face mental health assessments compliant with mental health legislation, as well as providing support with accessing mental health services and other alternative care pathways.

Impact

The initiative commenced in January 2015 with the first mental health practitioners becoming fully operational in May 2015. An initial evaluation of the mental health clinical advisory service has shown that mental health clinicians have been a source of knowledge and expertise and have been able to provide support to emergency operations center staff and paramedics in their day-to-day management of mental health patients as well as assisting call handlers with challenging mental health calls.

Between March 2015 and March 2016, mental health practitioners responded to 5,961 calls, with 15.9% (948) managed with a hear-and-treat function. To date, there have been no complaints or incidents reported.

Quality assurance reports have been excellent, with our mental health practitioners achieving an average compliance of 99.6% on their individual performance reviews. The accepted compliance level for clinical hub staff is 95%.

The LAS will continue to audit and evaluate the role at regular intervals while expanding the number of mental health practitioners it employs. In addition to collecting activity and outcome data, there are plans to include staff perceptions and quality of interaction with the practitioners though semi-structured interviews and through an online anonymized questionnaire. Although this hasn’t yet commenced, informal feedback suggests that the mental health clinical advisory service has been very well received and is now a well-embedded and popular resource within the service. Enabling a process to secure meaningful feedback from patients and carers who have accessed the service is also in development.

Mental health practitioners have responded to all categories of calls, and supported effective upgrading and downgrading of calls to ensure the patient receives the right level of response to meet their urgent and emergency care needs. On average, a practitioner will respond to 19 calls per 12-hour shift.

Specialist mental health triage has already demonstrated benefits for both the organization and the patient, including improved response times for patients who would potentially wait for an ambulance for long periods of time.

Ambulance resources that were once dispatched for mental health emergencies are now able to respond more efficiently with an increased availability of resources to respond to life- and limb-threatening emergencies.

Anecdotally, LAS staff members report positive experiences since the introduction of mental health nurses, including quicker patient assessment and support ensuring the patient receives the right care the first time, and a more positive patient experience.

Mental health practitioners have been instrumental in facilitating development and access to alternative care pathways as well as building and maintaining relationships and communication lines with external stakeholders.

Introduction of the mental health nurses has also gone a long way in addressing the notion that mental health must be given equal priority to physical health, which was one of the initiatives for the ambulance service.

Conclusion

The LAS remains driven in our commitment to improve our response to mental health patients, with additional goals to improve patient outcomes and experience, and reduce the mental health stigma. The future development of the mental health practitioner role within the ambulance service to include face-to-face assessments with paramedics, support for the training and education team and secondment/rotation opportunities with mental health trusts.

Mobile integrated healthcare in London

References

1. Annual report and accounts 2014/15. (July 21, 2015.) Care Quality Commission. Retrieved Sept. 12, 2016, from www.cqc.org.uk/sites/default/files/20150721_annual-report-accounts-2014-15-final.pdf.

2. Department of Health and Concordat signatories. (Feb. 18, 2014.) Mental health crisis care concordat: Improving outcomes for people experiencing mental health crisis. Gov.UK. Retrieved Sept. 12, 2016, from www.gov.uk/government/uploads/system/uploads/attachment_data/file/281242/36353_
Mental_Health_Crisis_accessible.pdf
.

3. NHS England. (Nov. 13, 2013.) High quality care for all, now and for future generations: Transforming urgent and emergency care services in England—Urgent and emergency care review end of phase 1 report. Retrieved Sept. 12, 2016, from www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.FV.pdf.