Case Study - Manchester Mental Health and Social Care Trust
SAFIRE (swift assessment for the immediate resolution of emergencies)
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 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 showed it was very successful and exceeded the initial target of two thirds discharged straight home and at times manages to discharge 75% within two days or slightly longer.
Frank Margison, medical director at the trust said: "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.
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.
“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.
“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."
Key Learning
Board and executive support is vital
Changed rotas can lead to improved work/life balance
Important to keep staff up to date on changes.
Frank admits the changes to mental health were not only necessary to reach the EWTD 2009, but would also improve continuity and quality of patient care, he said: "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 EWTD 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.”
This project tried to make doctors' working lives 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."
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Working Time Directive 2009 
