Northamptonshire Healthcare's mental health recovery pathway

Key benefits and outcomes:

• Long-term out of area hospital placements reduced from 100 to around 30
• Referrals for locked rehabilitation significantly reduced
• Very few new referrals for patients with Emotionally Unstable Personality Disorder
• Considerable reduction in admissions to acute inpatient settings

What the organisation faced

Up to 2016, Northamptonshire Integrated Care Board’s locked rehabilitation budget was steadily increasing due to greater demand. Northamptonshire Healthcare NHS Foundation Trust had very few inpatient rehabilitation beds following closures and reductions in services, so most patients were sent out of area. Placements tended to be a great distance from home and the person’s loved ones. At times people were placed in hospitals with a less than outstanding CQC rating. 

What the organisation did

The trust spoke to patients about what was wrong with the current model, which included struggling with the transition from a highly restrictive setting to one with very little support and not disclosing thoughts and feelings due to fear of their discharge being delayed.

They then asked the ICB to devolve its locked rehabilitation budget, arguing they could better review and monitor placements and thereby reduce demand. The ICB initially provided additional funds for a new community recovery team on the agreement that out-of-area spend would be reduced by supporting individuals post-discharge and providing intensive support to avoid admission.

The Community Recovery Team was set up in 2017 and sits within the Recovery Pathway. The team is clinically led by a psychologist and ultimately grew to include a drug and alcohol worker and a peer support worker.  Significantly, a psychiatrist is not attached to the team, which has helped to build trust with its clients (the clients remain able to access Community Mental Health Trust services, including statutory services, as required).

The team developed a psychological, non-medical model of care, with a strong recovery ethos, following the CHIME model. This aims to give the service user more choice and empowerment and build up their connections, hope, identity and sense of meaning.  Staff take time to review new clients’ notes, focusing on understanding their formative experiences and history of mental health services usage to assess what has and hasn’t worked well ahead of their first meeting.  

Where someone is moving to the pathway from a long-term hospital placement, the recovery model includes an ‘in-reach’ period starting three months before the end of a hospital placement. This is used to build a relationship with the client, help them feel safe, understand what they need, help them think about what they want from their life, and support them to become familiar with the area and residence they will be moving into post-discharge.  The subsequent intervention period lasts around 18 months (though can be extended), beginning with 15 months of very intensive support, which can involve client contact five days per week. In the final three months support is tailed down, signs of relapse are monitored, information is handed over to the client and to their supported accommodation providers (if applicable) about how to maintain progress, and clients are supported to identify their network of support after discharge.

The individual funding team within the pathway has also transformed its approach to procuring, monitoring and supporting community rehabilitation accommodation services, with the aim of avoiding the breakdown of placements.  

Working with social care colleagues, it developed a framework of approved providers to assure minimum standards of quality. Support for housing providers included providing training to understand clients’ risk behaviours and needs, aiming to help retain skilled workers by supporting them to better manage situations.

Results and benefits

The trust focused on reducing use of locked rehabilitation in its first year, moving from 100 long-term out of area hospital placements to around 30, and has maintained this level.  Referrals for locked rehabilitation have been significantly reduced, with very few new referrals for patients with Emotionally Unstable Personality Disorder.  There has also been considerable reduction in admissions to acute inpatient settings.  

The team has become embedded within the area’s mental health services, with demand for its expertise in considering the need for referrals and providing input into clinical meetings about other patients.  Service users have come to trust the programme and understand how they can benefit from engaging with it.

Overcoming obstacles

The team faced resistance from other mental health teams about bringing a large number of patients back to the area. Many of these patients were well known after multiple, challenging episodes of crisis and there was scepticism about managing them in a community setting, along with nervousness about their impact on local resources given their history of intensive needs. This required significant management of internal relationships, but by year three, the recovery team was able to demonstrate that demand had not gone up, and by years four to five, these other mental health teams had begun to seek input and support from the recovery team.

Patients’ families were also nervous about their relatives returning from the safety of locked rehabilitation, so the team developed approaches to supporting them. This included training staff in family therapy and facilitating a carers’ support group.

Takeaway tips

• Perseverance may be required initially, with the first one or two years likely to be challenging while teams establish what works locally through trial and error.
• Protect the clinical team from the question of finance and empower them to focus on patient outcomes.
• It is vital to choose staff wisely, focusing on people who (1) have the core value of placing the client at the centre of everything, and (2) are able to maintain a professional boundary in the context of close relationships with clients.
• Provide staff with dedicated operational and psychological support, plus regular case reviews.
• Ensure budgetary delegation is meaningful, with only a small number of KPIs about the key outcomes.
• Invest in training providers of supported accommodation to help avoid breakdown in the community.
• Patients benefit from their drug and alcohol misuse being treated as part of their mental health problem rather than as a separate issue, hence the addition to the team of a specialist drug and alcohol worker has been beneficial.