The 15th National NAPICU conference, entitled Improving the Patient Experience, was held at the University of York, England. The theme for the two days was therapeutic and managerial interventions, actions and processes that positively contribute to the patient’s experiences in the context of financial challenges and aversion to risk.
The conference was organised by a dedicated planning committee and was led by Dr Faisil Sethi (NAPICU Director of Scientific Programmes and Consultant Psychiatrist, East London).
DAY 1
Welcome and introductions
We were introduced and welcomed to the conference by Dr Faisil Sethi and Dr Stephen Pereira (NAPICU Chairman and Consultant Psychiatrist, North East London). Dr Sethi introduced us to the theme of this year’s conference and the aim to improve both PICU and low secure care services.
Figure 1. Lecture room
Honorary Fellowship Award
The first ever Honorary Fellowship Award was presented to Malcolm Rae (former Joint Strategic Lead for the Acute Care Programme of The National Mental Health Development Unit), by Dr Pereira. He handed over to Dr Colin Dale (Chief Executive of Caring Solutions (UK) Ltd.), who gave a professional and personal account of Malcolm’s ‘road to stardom’ and his achievements and expertise in PICU services.
Malcolm followed this with his thanks and felt this award was a ‘badge of honour’. He ended with words of encouragement and reflections on how to ‘play to our strengths as staff working on PICUs’.
Keynote lecture: the future of low secure services
Ged McCann (Associate Director of Commissioning Secure and Specialist Mental Health) presented the keynote lecture. This looked at how we can reduce costs within services but still maintain quality patient experiences.
Ged discussed the use of The Quality Innovation Productivity Prevention programme (QIPP) to help services reduce length of stay, admissions and cost, improve outcomes and increase patient responsibility. The key aims of this programme focus on a model pathway which looks at how services can move patients to the next stage of their care, and providing a patient portfolio, to allow patients to take ownership of their care. Ged ended his lecture by stating that we, as providers of care, are key to this agenda.
Service user experiences of intensive mental health care
Deborah Wildgoose (Deputy Director of Nursing, Rotherham, Doncaster & South Humber) began with an overview of key publications and policies that are relevant to obtaining service user experiences in adult mental health services. She highlighted research that suggests that there is a lack of service user’s views about the care they receive on PICUs and their satisfaction with this care. As service providers, we are ‘morally obligated to get service user perspectives for accountability and help identify ways to provide cost effective services’.
Deborah gave advice and suggested ways to gather service user experiences by initially establishing what we want to find out and the best approach to ‘enable freedom of expression’.
From discussions at the end of her lecture, other suggestions included focus groups and observations of service users in PICUs to obtain the relevant feedback.
AIMS/PICU
Jo Cresswell (Senior Programme Manager, Accreditation for Acute Inpatient Mental Health Services (AIMS), College Centre for Quality Improvement (CCQI), Royal College of Psychiatry (RCPsych)) and Sarah Bleksley (Deputy Programme Manager AIMS, CCQI, RCPsych) provided an overview of the AIMS/PICU standards. They informed us that there are currently 12 PICUs undergoing the pilot phase of this accreditation. The process is spread over a four year cycle and includes self review, peer review and accreditation by the Advisory Committee, which consists of core representatives from RCPsych, the Royal College of Nursing (RCN), the College of Occupational Therapists (COT), the British Psychological Society (BPS) and service users/carers.
The cost implications of completing this accreditation are approximately £2,400 per year with a 10% reduction after four years. However, services were encouraged to join in the programme which in turn would help to lower costs for services.
We were informed that currently this accreditation process is not available for Low Secure Units; however the team is keen to work with NAPICU in the future.
Breakout sessions
During the course of the first day, there were eight breakout sessions looking at:
• Leadership in the PICU led by Dr Steve Choong (Consultant Psychiatrist, Worcestershire)
• NAPICU Team of the Year
• Service User/Carers Session: Good, Bad and Ugly led by Dr Stephen Dye (Acute Inpatient Consultant, Suffolk) and Mr Bernard Fox (NAPICU Service User Representative)
• Prescribing Trends in Secure Services Based on Gender led by Michele Sie (Consultant Pharmacist, West London)
• Mental Health Law: Community Treatment Orders led by Andrew Parsons (Specialist Mental Health Law Solicitor, RadcliffesLeBrasseur, London)
• ‘Doing’ Recovery led by Kate Wadsworth (Senior Occupational Therapist, Partnerships in Care) and Louise Stevenson (Lead Occupational Therapist, Partnerships in Care)
• The Experience of Being ‘AIMSed’ led by Mr Paul Deacon (Ward Manager, Bodmin Hospital, Cornwall)
• Improving the Patient Experience – The Dutch Way led by Dennis Sarkol and Jeroen van de Sande (Registered Nurses, Crisis Intensieve Behandel Unit, The Netherlands)
The authors were unable to attend all eight workshops. The sessions that were attended are summarised below.
Leadership in the PICU
Dr Steve Choong presented this interesting workshop. Steve introduced us to theories relating to leadership and how the concept of ‘leadership’ has evolved over time. He suggested that it isn’t really the name that matters, but what you do that counts, commenting that ‘the greatest leaders are those who make things happen, rather than just having the ideas and visions’.
Steve also provided some clinical examples of leadership. He highlighted the importance of patience, thoroughness, self belief and keeping a cool head particularly when a team is in crisis (which can often be the case in a PICU). Most importantly, Steve raised the importance of mutual support and being able to think about, and discuss, issues as a team. He suggested creative ways such as developing care plans to reflect how we can support one another, remaining available to manage stakeholder anxiety and finding ways to involve carers and relatives in managing risk.
Service user/carers session
This was a question and answer session with Dr Stephen Dye and Mr Bernard Fox (a service user representative). Bernard reflected upon his time in a PICU and gave examples of his stay as an inpatient and the feelings he experienced. Bernard explained that ‘poor communication is one of the scariest things and is confusing’ and that if he had been communicated to better and told what was going to happen, then his stay in a PICU would not have been so traumatic. He went on to say that ‘any form of expression is vital’.
Bernard expressed that he now makes light of what happened to him and moves on from this. He stated that he has lots of ideas about how PICUs can be improved and wishes to work with teams to help design future PICUs.
This breakout session was incredibly inspiring!
‘Doing’ recovery
Kate Wadsworth and Louise Stevenson led this session about the use of the outcome tool ‘The Recovery Star’. Kate and Louise explained to the group about how the star works, that there are 10 elements to focus on and each element has a ladder of success for the patient to ‘climb up’. The tool is written using patient friendly language rather than medical terminology. They explained that the Star is patient-led and they can pick where they feel they fit in on the ladder and from this, they build their own action plan.
Kate and Louise further went on to explain a case study in which The Recovery Star was used with a service user from their team and proved to the group just how positive this tool was.
Improving the patient experience – the Dutch way
Dennis Sarkol and Jeroen van de Sande gave us an entertaining insight into their Crisis Intensive Treatment Unit based in Holland, which provided interesting reflections into the differences and similarities between Holland and UK PICU services.
Figure 2. Dennis Sarkol and Jeroen van de Sande
We were informed that in Holland, health insurance companies dictate medical care and there is a belief that quality of care is improved if it is ‘money-based’. As such, there is an emphasis on ‘clients’ rather than ‘patients’. This also raised an interesting discussion as to whether the customer is always right and whilst this may not always be the case, the aim is to provide the ‘highest level of care’ for clients. Indeed, the provision of smaller clinics and treatment at home are regarded as steps towards this aim. There is also a ‘SMAKK’ project which aims to lower seclusion and promote an ‘advancement of competence and expertise’. Guidelines for seclusion and alternatives are currently being suggested by this project.
Dennis and Jeroen provided details of their Crisis Intensive Treatment Unit which consists of a 7 bed ward and 3 seclusion rooms. External admissions are accepted and a range of services are covered. One member of staff is on each night shift for 7 clients and 2 staff members cover 24 clients. Only seclusion rooms are locked on this open ward. If clients require one to one attention then staff are asked to attend from the forensic ward next door. When asked how staff effectively manage clients on night shifts, their response was that ‘most people sleep at night’ which created some discussion and much laughter.
It certainly appeared that there is a lot of interaction between staff and clients and plenty of meaningful activities and choice offered in order to encourage as normal an experience for service users as possible. PMVA is used with clients but the level and incidence of violence is reportedly low. This raised another interesting debate as to the ‘dangerousness’ of clients in Holland compared to the UK.
Finally, in response to the question ‘what works best for you in Holland?’, Dennis and Jeroen concluded that communication is key to improving the client’s experience and outcome along with openness to continued learning, honest dialogue and co-operation.
Depots: improving patient care
Caroline Parker, consultant pharmacist for adult mental health services and NAPICU Executive began her presentation with an overview of some of the depots available and a historical context of their use since the 1960s. She gave some of the reasons why depots are used including promoting compliance, relapse prevention and service user preference. She also suggested some of the disadvantages of using depots which included side effects, stigma and whether it is ethically sound. Caroline highlighted the fact that compliance improved with depots and so the choice of whether to use depots or oral medication lies with the service user. This highlighted the importance of maintaining informed choice but there remains a conundrum as to which is the best method. Caroline postulated whether one depot could be used that is acceptable independently and concluded that a depot is just one route of administration; however, the overall goal is to keep people well, prevent relapse and optimise compliance.
Seclusion: improving patient care
Roland Dix Consultant Nurse, Editor-In-Chief of the Journal Psychiatric Intensive Care and NAPICU Executive gave an account of the history of the use of seclusion and pointed out that whether seclusion should be used in mental health care is possibly the longest running debate of any issue in the history of health care.
Roland moved on to modern day seclusion use and entered into the ethics. An entertaining ethical dilemma was proposed which involved trying to decide on the best actions to serve the most people, giving appropriate weight to all interests; and crucially, who should decide? Roland then displayed a disturbing news clip covering the story of an 8 year old boy who was held in a seclusion room at a special school wearing only his underpants.
Roland displayed new innovations used in an Extra Care Area, including the installation of an effects unit producing soft colored lighting and music.
He concluded by suggesting that high secure and medium secure units should retain the seclusion option although, in general, PICU and acute services should not.
Inquiry after a homicide: themes, lessons & reflections
Dr Tim Exworthy (Consultant Forensic Psychiatrist, at Oxleas NHS Foundation Trust) provided an interesting presentation on the independent inquiry into the care and treatment of Peter Bryan and Richard Loudwell (September, 2009).
The full report is now available online (http://www.london.nhs.uk). Tim informed us of aspects of the inquiry process which involved looking at the care of the patients involved, looking for safer practices and recommendations for the future. Key themes highlighted from the inquiry centred on legal issues, communication and relapse, and risk. A central finding highlighted the importance of sharing key, sophisticated assessments. Unfortunately, in this case, some detailed reports highlighting subtle markers in the patients’ behaviour, personality, cognitive and mental health state had become lost in the system. The inquiry therefore concluded that better communication is required within teams in order to successfully manage risk and identify future stressors and signs of relapse or dangerous behaviour. The report also concluded that implementing recommendations sooner, professional development and constant reflection and review of working practices is essential in ensuring good standards of care in forensic inpatient settings.
NAPICU Annual General Meeting
Dr Steven Pereira chaired the NAPICU AGM at the end of the first day. Next year’s conference will be held at Gloucestershire University followed by Manchester University in 2012 and then Keele University in 2013.
Steven then discussed finances and expenditure for the year as well as membership and fees, highlighting that if NAPICU members pay fees before the annual conference they will be offered a reduced rate. Attendance of quarterly meetings is increasingly popular and is free to NAPICU members. Details of quarterly meetings can be found on the NAPICU website (http://napicu.org.uk). These are held all over the UK, and the first international quarterly meeting was held in Bruge in February 2011.
The website continues to be successful and the plan is to make it more interactive and faster at uploading information. There are also new responsibilities for the administration of the NAPICU international journal that the team are enjoying.
Gala dinner
After the Annual General Meeting and a bit of rest and relaxation, the delegates were invited to the conference dinner held at The Galleria. We had a three course dinner provided by the University of York and served by some comedy waiters who provided much entertainment throughout the evening. Delegates enjoyed a disco and a night of singing and laughter.
DAY 2
We were welcomed back to day two of the conference and were due to start the day with the Team of the Year 2010 award. However, Dr Sethi announced that this year the award was not to be provided as the evidence needed to support how well the team was doing, was not produced. Dr Sethi encouraged all teams to apply for next year’s award.
Figure 3. Serenading comedy waiters at the Gala dinner
Team of the year
The team of the year from 2009, Woodlands Hospital, was asked to give a talk on how their service had been doing since winning the award. They explained that winning had boosted team morale and that there is a good level of self-belief amongst team members. They explained how the service users felt included in the process and had pride in the staff and hospital. They believe the team has grown since winning in 2009 and gave them a sense of validation.
The award for the best stall set up for the duration of the conference was also awarded and was given to South West London and St George’s.
Figure 4. Exhibition area
Dragon’s den: 2009 & 2010
The winners of Dragon’s Den 2009, Fairoak in Portsmouth, explained to the delegates what their programme was and what has been done with the £1,000 they received for winning. Their winning idea was called Life Music Project. £500 of the money received was used for 10 sessions of ‘Life Music’. The rest of the money was used to train a member of staff and a service user to become trainers, who could then go on to teach others, and on percussion instruments.
Dragon’s den: 2010
Three teams of contestants for this year’s Dragon’s Den award gave their presentations in an attempt to win £1,000 courtesy of NAPICU to set up a new initiative in their hospital.
The first application was from Hooper Ward, Cygnet Hospital in Beckton. Their initiative was to have a computer with internet access for their patients to use on the ward. This initiative was suggested by the patients themselves, who would like to see this happen.
The second presentation was from Haven Unit from St Ann’s Hospital in Poole with their initiative to transform their current lounge into a therapy and relaxation room for the patients to use.
The third and final contestants were from Ward One, in Springfield University Hospital. Their initiative was to introduce the use of iPod shuffles onto the ward for patients to upload and listen to their own choice of music without disrupting the rest of the ward.
All three groups made an excellent attempt to ensure that their service won the award, however, there could only be one winner and this was Ward One from Springfield University Hospital. They were delighted to have won and will attend the conference next year to update delegates on how well the initiative has been working.
The other applicants were thanked for their presentations and hard work and the rest of the delegates were urged to apply for next year’s Dragon’s Den.
Ethnicity and pathways to psychiatric intensive care
Dr Paul Birkett (Clinical Lecturer, University of Sheffield, Honorary Consultant Psychiatrist, Sheffield Health & Social Care NHS Foundation Trust) spoke about ethnicity and the pathways to psychiatric intensive care.
He spoke about the inquiry into the death of a patient called David Bennett where racism was at the forefront of the inquiry. Paul explained how there was institutional racism in the service where this death occurred and that they may have failed to meet the cultural or ethnic demands that this man required to provide an appropriate service.
The many faces of PICU
The John Howard Centre in East London
The first lecture on PICU in medium secure services was presented by Dr Gerard Waldron (Consultant Forensic Psychiatrist at the John Howard Centre in East London NHS Foundation Trust). Gerard provided an interesting and insightful account of their brand of this service, beginning with an evolution of the medium secure unit’s speciality criteria. This service covers both East and North London and a population of approximately 1.5 million people, and is described as an area of high deprivation. The MSU consists of 210 beds covering various types of wards and multi-disciplinary teams. Procedures and ward practices typically involve drug screening, off-ward leave, assessment of risk and use of seclusion. Pre- and post-clinical assessments are offered and incorporated into care plans and weekly ward rounds.
Adolescent PICU
The second lecture on adolescent PICU was presented by Dr Sasha Hvidsten (Consultant Child and Adolescent Psychiatrist at Huntercombe Hospital). Sasha began with an overview of adolescent development and pointed out the frequency of inappropriate referrals to adult psychiatric wards. Sasha noted that inpatient care for adolescents is predominantly offered in private care and geographically far from an individual’s home, thus demonstrating insufficient levels of provision. There is a hope that development of tier three services will address this gap.
At Huntercombe, there are 12 beds offered to both males and females with complex and mixed diagnoses and the average length of stay is 76 days. An overview of autism and attachment disorders was provided along with associated co-morbid mental health problems observed in individuals with these difficulties, and possible interventions that can be implemented. Sasha also gave an overview of adolescent schizophrenia, and conduct disorder, highlighting the lack of clarity and problems associated with these diagnoses.
Women’s PICU
The third lecture on women’s PICU was presented by Linda Holbrook (Modern Matron from Avon and Wiltshire Mental Health Partnership NHS Trust). Linda provided an introduction to the Elizabeth Casson House which opened in January 2007 and was one of the first female PICUs to open in the NHS. The unit consists of 10 beds and offers service users up to 12 weeks stay. There is flexibility around the admission criteria and Linda stressed the importance of working collaboratively with community services. Linda also highlighted the fact that the culture is changing in terms of staff recruitment and stressed that it is important to retain staff who understand and want to work with this client group, particularly due to issues relating to increased risk and deliberate self harm. Good training and service user involvement appear to be key factors that help to maintain the privacy and dignity of service users.
PICUs in high secure services
The final split lecture on PICUs in high secure services was presented by Dr Shaun Bhattacherjee (Consultant Forensic Psychiatrist from Broadmoor Hospital, West London Mental Health NHS Trust). Shaun provided an interesting overview of pathways at Broadmoor for patients who come from the criminal justice system and NHS services. Service users spend 6 months on the admissions ward and then either leave or move to the Assertive Rehabilitation, High Dependency or PICU ward. Approximately 9% of service users go to the PICU with an average length of stay of 230 days. Service users are classed as: i) acute high dependency/high risk, ii) chronic high dependency or iii) chronic high risk. Shaun described the spectrum of these classifications and the processes involved. He then showed us photographs of the wards and rooms which are ‘destruction proof’ and highly specified. Shaun highlighted that engagement and interaction are key factors that make a difference to patients’ lives as well as the importance of trust and feeling safe in order for service users to start taking responsibility and moving towards recovery.
Closing remarks
There were some closing statements from Dr Faisil Sethi, along with Andy Johnston who thanked applicants for the Dragon’s Den award with a presentation to the winners and a plea for more entries for next year. Dr Paul Birkett then summarised the main themes of the workshops at the conference centering on the theme of Improving the Patient Experience, illustrating that it had been an enjoyable and useful conference with the help and support of all involved.
For 2011 NAPICU conference details and to view 2010 conference videos online visit http://www.napicu.org.uk
