An integrated, multi-professional psychiatric emergency care system

Manchester is a very busy inner city area with high levels of mental illness. Manchester Mental Health and Social Care Trust faces constant pressures on bed availability and patients staying longer than usual when admitted.

A new service called SAFIRE (swift assessment for the immediate resolution of emergencies) was developed to combat this problem. This six-bed nurse-led unit with medical support focuses on intensive assessment and preparation for discharge to the community.

Evaluation of that unit showed that it was very successful and exceeded the initial optimistic target of two thirds discharged straight to home and at times manages to discharge 75% within the two days or slightly longer. The risk assessments were generally very good with careful consideration taken to any adverse incidents or near misses.

Calling Time spoke to medical director, Frank Margison at Manchester Mental Health and Social Care Trust about the implications of WTD in a mental health setting and how the development of the new services has helped them to achieve the 2009 requirement.

"An audit was completed across Greater Manchester which confirmed the findings from our earlier survey that the biggest pressures (even when there was a crisis resolution team) were people who needed a little longer than four hours in A&E to do a thorough assessment and engagement with community support. More than half A&E attendances were in Central Manchester so we have worked closely with the acute trusts and community services to design a short stay unit (similar to a medical assessment unit or clinical decision unit for mental health) that could assess and support people for up to 12 hours, having arranged for the more ill people to go to SAFIRE or occasionally to an acute bed directly.

That will pick up a lot of the pressures in managing a timely service and there is the option to move people from the other two A&E departments in the city where it is clear that a 12 hour stay will be sufficient.

However, the team will have enough capacity to also act as the main telephone contact point out of hours for known patients and their carers or to provide advice to colleagues on how to manage mental health crises. It will have the trust bed management system and our clinical electronic records available to provide advice 24/7.

During day time hours it will work alongside the three crisis teams in the city and overnight it will take on the additional function of being the crisis resolution team and main contact point for existing patients."

Frank admits that the changes to mental health were not only necessary to reach the WTD 2009 requirement, but would also improve continuity and quality of patient care, "We have to comply with four hour targets in mental health and in the main we do that but a proportion of patients need a little longer for a full assessment and to put in place the crisis plan. We think this will reduce even further the need for admission; even lower than that achieved by crisis teams alone. We were also aware that we had three teams running almost independently with a traditional three tier medical rota and separate nurse managers and separate social work rotas. We decided that we could improve the overall care of patients and could also meet our 2009 WTD targets by a redesign of how work was done. The eventual aim involves radical workforce redesign, but within the time of the project we aim to get compliance, improved education opportunities and a better patient experience.

Manchester Mental Health and Social Care Trust held a benefits realisation day in July bringing together key stakeholders and operational managers supported by the 24/7 team. "The day was a great success and helped to produce a good working draft of the project initiation document with a list of key risks and actions. More importantly, it was an opportunity for the first time to see how the bits of the jigsaw we have been planning for two years can come together and achieve real patient and carer benefits."

Frank cites Skills for Health - Workforce Projects Team and management support for the success of the pilot, "It is perhaps stating the obvious, but the support and enthusiasm of the Workforce Projects Team and the programme management support we will fund through the grant will really help to move the project on. Our Board, and particularly the non-executive director linking with carers has been totally committed to this as a way of putting the patient and their carer centre stage and as an enabler for culture change. We have built very good links already with A&E and although we cannot solve 100% of four hour waits they know we are working as a team on this."

"We have had the usual glitches with building works which slowed progress by a few weeks, but that has in fact enabled us to do some preparatory work with the crisis resolution teams to prepare them for a different model of working. We have been bringing this in right at the peak demand of MMC and the project leads have had to focus attention on that for a few months but we are now in clear blue water and ready to start this project with our full focused attention!"

As well as benefits to patients and carers this project has tried to put doctors' working lives as a key objective. A recent survey showed how disruptive shift patterns have been, but Frank is confident that the project will make improvements all round, "We think we can reduce rota frequency, provide a supportive working environment and give excellent training experiences in emergency mental health in one of the busiest units in the country. So there will be a wealth of experience, but provided in a structured and safe environment where tasks are allocated according to competence not position, with a commitment to a learning culture. The changed rotas should allow much improved work life balance with less nights on call, more standard day working and protected learning time with a different environment for learning the very different skills needed to manage emergencies in a safe way."