Guest blog: Need of flow in mental health - our principles

29 January 2018

In the first of their regular joint blogs, Strategic Lead for Complex Care Clair Jones and CRAC Team Consultant Psychiatrist Dr Ian Davidson discuss the main principles underpinning our approach to patient flow.

Why are we creating this series of blogs?

We started working together in an intensive inpatient rehabilitation unit. We both had multiple prior experiences and expertise and found a common theme in wanting to improve access and delivery of services for those with most complex needs. This was driven by the realities that people with most complex needs often faced the biggest barriers and least joined up services whether in or outside hospital. In turn this led to us becoming interested in inpatient care pathways and what could make them more effective and reduce the number and impact of barriers. We have presented on aspects of our work at multiple meetings and have been asked by NHSE and NHSI to pull together what has been the key learning for us over those years. This series of blogs will attempt to do that.


It is important to note that nothing we have done has been in isolation and all of it depended on multiple other inputs. We have led on some of it, contributed to other bits and have drawn upon and learned from work in which we have had no direct input ourselves. We have done this work within the Quality and Innovation frameworks within Cheshire and Wirral Partnership NHS FT (CWP). These have changed names over the years but are underpinned by increasing commitment in developing and using analytical skills including Quality Improvement (QI). The overall aim is to work with and build on the strengths, needs and aspirations of those accessing services, those delivering and commissioning them to deliver the best services feasible within funding available to the Trust.

Who are we?

Dr Ian Davidson: I first started in Psychiatry in 1981 and have had multiple roles involving education, training, audit, research, service innovation and evaluation, clinical management, executive management whilst at the same times always maintaining clinical practice as a psychiatrist working in adult services of differing types. My roles have included local, regional and national duties at various times. I am currently part time Consultant Psychiatrist lead to the Complex Recovery Assessment Consultation (CRAC) team, part time lead for Quality Improvement in CWP and am RCPsych Autism Champion and a Medical Member of First Tier Tribunal Mental Health amongst other roles outside my part time CWP roles. Underpinning all of my work has been my passion for trying to help improve outcomes for those in need of health services.

Clair Jones: I am an Occupational Therapist and the Strategic Lead for Complex Care for CWP, I am passionate about quality improvement in healthcare and promoting the best mental health for people.  I have worked in multiple settings in different parts of England and Wales and have given presentations on various aspects of my work at local, regional, national and international meetings. I have worked in and led multidisciplinary teams, set up the CRAC and Adult Autism services and have been fortunate to maintain a clinical aspect to my role.  As well as providing leadership for CRAC services, I am leading on strategic developments for people with complex mental needs, learning disabilities and people with Autism, both locally and regionally.

Together, we work as part of the CWP Team in addressing flow through our services and want to share what we have done and what we have learned, good and bad. By having a Trust culture that actively embeds human factors in everything it does, enables true quality improvement whereby trying to improve quality and safety is more important than failing.

We are delighted that we have had the opportunity to share this work nationally via the support offer from NHSE national programme to eliminate out of area acute care in mental health.

About CWP

CWP has a footprint of 1400 square miles and a population of just over 1 million. We work for 5 main CCGs and a across 3 local authorities and have 3 acute inpatient units. According to NHS National benchmarking 2017 we have the fifth lowest number of acute beds per weighted population and we rarely send anybody out of area for acute care, in 2017 this figure was zero.

Patient Flow

CWP has a very clear aim:

No one receiving CWP input to lose one more day in the community than essential for their care and treatment, but everyone needing an inpatient bed to be in the best bed for their needs that day.

CWP always  had a focus on patient flow, recognising that it needs to be a whole system approach but similarly requires specific specialist focus on different parts of the care pathway to work.  Since the economic recession in 2008/9 available resources across all public services have become tighter.  CWP recognises that there is only a finite resource in a given area in a given year for mental health and so the more that is spent on inpatient treatment (especially out of area) for a few, the less that is available for community services. This means fewer people can access any service. We work hard to make the best use of our resources, to put the person and their supporters at the centre of our care and to use an evidence base to inform development and improvements.

All of the work on flow has been underpinned by the following 6 main principles:

  1. Maximum investment in the community and making best use of community based assets to reduce need for acute care.
  1. If in crisis, wherever possible Crisis Resolution Home Treatment Team to support a person’s needs at home - recognising ADMISSION IS NOT NEUTRAL.
  1. If acute inpatient treatment is required, admission should have clear purpose, expected duration and PEOPLE SHOULD NOT BE TURNED AWAY because no local bed is available when it is clear that community treatment is a worse option than admission.
  1. In inpatient acute everyday should be effective in moving towards discharge - CRHT should lead on discharge where a person’s needs could be met by them at home.
  1. People at higher risk of getting stranded in acute inpatient care need early identification to take account of complex needs and put an appropriate package of care together.
  1. If tertiary inpatient treatment is required, this should be the best bed for needs, least restrictive, closest to home. Active care co-ordination should ensure discharge at the earliest opportunity.

Principles of bed flow in mental health services.

We are going to share a series of blogs focusing on these principles and the work we have done at CWP to increase flow and provide safe and effective care.

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