Trigger template for Standard Variations to Health Services

NHS Trust & lead officer contacts:

Liz Clegg Assistant Director Integrated Commissioning - Older Adults Lambeth Clinical Commissioning Group and Borough of Lambeth

Dr Daniel Harwood Clinical Director Mental Health of Older Adults and Dementia Clinical Academic Group, South London and Maudsley NHS FT Vanessa Smith Service Director Mental Health of Older Adults and Dementia Clinical Academic Group, South London and Maudsley NHS FT

Date completed: 9th March 2017

Date submitted to Scrutiny

Trigger Please comment as applicable Reasons for the change – Please see attached paper for background information

What change is being proposed? To change the Mental Health Older Adult Acute bed configuration.

Any older patient living in Lambeth, , Lewisham or Croydon requiring admission to an acute inpatient unit is currently admitted to one of the three units (AL 1 – on Maudsley site (Southwark), Hayworth at University Hospital Lewisham (Lewisham) or Chelsham on the Bethlem Royal site (Bromley). This is irrespective of their diagnosis, presentation and care needs. What this has led to is a mix of patients with different disorders and presentations on each of three wards, which can be distressing for patients.

Because the average length of stay tends to be more than a week, and there is relatively slow turnover, compared with, say, an acute medical ward, this means that at any one time there are very few beds available, and patients needing an admission have to be admitted to the first available bed. So a Lambeth patient is equally likely at the moment to be admitted to any one of three wards.

In order to improve patient outcomes and ensure most effective use of resources it is proposed that acute admission inpatient units will be configured to manage different patient groups - one focusing on dementia care and the other two on the care of people with psychotic, mood and anxiety disorders (the so-called “functional” disorders). This will enable ward environments to be tailored towards the specific needs of the patients, staff will be able to specialise and become highly skilled in either dementia or functional illness care. The needs of people with dementia will rightly become an equal priority to that of functional illness.

To meet the needs of local people, the Trust will need one acute dementia unit, which it is proposed to be Chelsham House (Bethlem Royal Hospital site) and two units for people with functional disorders on AL1 () and Hayworth (University Hospital Lewisham). There will be no reduction in the service and the total number of beds will remain the same.

Following intensive collaboration with commissioners Why is this being proposed? from the four boroughs, a new service delivery model is being proposed in line with national guidance and recommendations.

In future, we are proposing that we will have a designated ward to meet the particular needs of patients experiencing moderate to severe dementia (Organic conditions). We are proposing that this ward should be Chelsham House. Chelsham House has been identified as the most appropriate ward, due to its facilities, layout and settings it lends itself to best- practice delivery of care for patients with dementia.

The remaining two wards will mainly focus on the care of patients with functional mental health conditions (psychotic, mood and anxiety disorders) and patients in the early stages of dementia whose primary diagnosis is of a functional one.

Allocating one ward for patients with dementia and two wards for those with functional mental health needs will mean that patients can be admitted to the ward which best meets their clinical needs. Staff will be experts in the treatment and care for patients with these distinctly different presentations.

There are 54 beds available across the 4 boroughs on 3 wards. When a decision is made that a person requires treatment on an inpatient ward this is discussed with the person and their family and carers. People are able to express a preference and will continue to be able to do so.

All the wards will have multidisciplinary teams that include doctors, nurses, psychologists and occupational therapists with sessional input from other professions for example Speech and Language Therapists and Physiotherapists. All teams are able to provide care and treatment for people whatever their diagnosis.

What stage is the proposal at and Discussing the proposed changes with what is the planned timescale for commissioners from the four boroughs - Lambeth, the change(s)? Southwark, Lewisham and Croydon and internal SLaM staff. Still in the planning stage but working towards implementation once agreed.

Are you planning to consult on TBA this?

Are changes proposed to the Briefly describe: accessibility to services?

Changes in opening times for a service None

Withdrawal of in-patient, out- None patient, day patient or diagnostic facilities for one or more speciality from the same location

Relocating an existing service People who require an inpatient bed at the moment are admitted to the first available bed regardless of site. The proposal is that in future people are admitted to the ward that is best able to meet their needs. Patient and carer preferences will continue to be accommodated (there will be flexibility should they prefer to be cared for on a particular ward), and all staff teams will be able to provide patients on all wards with the necessary care.

Changing methods of accessing a The wards are located across the three hospital sites. service such as the appointment People are admitted to any one of the three wards. system etc. The proposal is that people with a moderate or severe dementia will be admitted to the Bethlem Royal site and people with a functional illness to the Maudsley or Lewisham site.

Impact on health inequalities - reduced or improved access to all The purpose of the change is to provide care and sections of the community e.g. treatments based on the best evidence and facilitate older people; people with learning ward environments that promote patient safety, difficulties/physical and sensory effective and responsive care and provide an disabilities/mental health needs; improved patient experience. black and ethnic minority communities; lone parents. It is anticipated that providing care in this way will have a positive impact on length of stay, readmission rate, and use of antipsychotic medication in patients with dementia. Validated clinical outcome measures will be used to assess efficacy of the interventions offered during a spell of care as well as patient (where possible and appropriate) and carer experience measures.

What patients will be affected? Briefly describe:

Changes that affect a local or the whole population, or a particular This proposal only affects people over 65 with a area in the borough. mental illness that require admission to secondary care beds. Some aspects of the service will be provided at a different site. One ward will be for patients with moderate to severe dementia who are experiencing behaviour that challenges within the context of their dementia. The other two wards will predominantly admit patients with functional mental health needs. Patients with mixed disorders e.g. both depression and dementia – will be admitted to the ward best suited to managing their predominant need – for example a person with a mild dementia experiencing severe depression will continue to be admitted to the wards designated for patients with functional mental health needs. As is the case now every effort will be made to meet patient and carer choice.

The proposed split is:

 Chelsham House , Bethlem Royal Hospital, Bromley :

Will be the ward for people experiencing a moderate to severe dementia and behavioural and psychological symptoms. Chelsham House has been identified as the most appropriate ward, due to its facilities, layout and settings it lends itself to best- practice delivery of care for patients with dementia.

 ALI Maudsley Hospital, Southwark;  Hayworth on the Ladywell Unit, Lewisham:

Will be the wards for people with functional mental health needs.

Changes that affect a group of patients accessing a specialised service As described in the trigger template

Changes that affect particular These changes are for people over 65 who require communities or groups admission to a secondary care mental health bed and for people under 65 with a diagnosis of dementia who require admission to a secondary care mental health bed.

For a small number of service users and their carers the proposed change will mean that the patient is receiving treatment relatively far away from their home. Chelsham House, in particular, can be difficult to access by public transport which can be of significant impact for this population. This is a problem that a small number of patients and their families are already experiencing.

All the wards are signed up to ‘John’s Campaign’ John’s Campaign is a movement to help NHS staff recognise the importance of working with family carers as equal partners in the care and support of people with a dementia who are in hospital..

John’s Campaign is a promise from , that carers of people with dementia have the same rights as parents of sick children to accompany them in hospital, to be their cognitive ramps, their experts in experiences, and a voice for the voiceless. The key focus is an open visiting culture; supporting carer access to the hospital outside of normal visiting hours, to enable them to be with the person with a dementia when they may be stressed, anxious, upset or lonely.

SLaM also provides a shuttle bus service that runs between the Maudsley and the Bethlam site that families can use.

Are changes proposed to the Briefly describe: methods of service delivery?

Moving a service into a community No setting rather than being hospital based or vice versa

No Delivering care using new technology

No Reorganising services at a strategic level

What impact is foreseeable on the Briefly describe: wider community?

Impact on other services (e.g. Improved expertise and skills of staff on Chelsham in children’s / adult social care) discharge planning, including better understanding of how to work jointly with social care colleagues to avoid duplication and provide good care.