Oct 21, 2013 - The full review report is available on the SA Health website. 5. Consultation ..... extent of changes not
SA Health’s response to the Review of the South Australian Stepped System of Mental Health Care and Capacity to Respond to Emergency Demand
October 2013
Contents 1.
Purpose ................................................................................................................................. 3
2.
SA Health’s Strategic Reform Framework ............................................................................. 3
3.
Scope and Review Process ................................................................................................... 4
4.
Review Recommendations .................................................................................................... 5
5.
Consultation Feedback Submissions ..................................................................................... 6
6.
Overview of Submissions ....................................................................................................... 7
7.
SA Health’s Response ......................................................................................................... 13 Resource Realignment and Governance Changes ............................................................. 13 Cultural Change ................................................................................................................... 13 Clinical Redesign ................................................................................................................. 13
8.
Next Steps ............................................................................................................................ 14
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1.
Purpose
This document provides SA Health’s response to the independent Review of the South Australian Stepped System of Mental Health Care and Capacity to Respond to Emergency Demand undertaken by Ernst and Young in 2013. This response takes into consideration the feedback received during four weeks of public consultation. SA Health wishes to thank all respondents, including staff and interested parties for their contributions to the process.
2.
SA Health’s Strategic Reform Framework
The former Social Inclusion Board was commissioned by Government to examine South Australia’s mental health facilities and services and reported in 2007 with 41 recommendations. The report, Stepping Up: A Social Inclusion Action Plan for Mental Health Reform 2007-2012 found that limited options available for the provision of facility-based care resulted in people with a mental illness being cared for in high-cost hospital beds. The Social Inclusion Board concluded that the problems facing the mental health system were not caused by demand, but rather that the limited mix of services provided did not serve clients’ complex needs. South Australia’s mental health system has undergone major reform to modernise and improve mental health services across the State. At the heart of the reform was the development of a new stepped system of care comprising secure care, acute care, intermediate care, community rehabilitation centres and supported accommodation. For the new stepped model to work effectively, community mental health services were placed at the centre of the system of care. SA Health released South Australia’s Mental Health and Wellbeing Policy 2010-2015 as a framework for the promotion of good mental health and wellbeing in our community and the ongoing reform of our mental health system. The objectives of the Policy are to: > Promote positive mental health and wellbeing in South Australia and prevent mental illness as
far as possible; > Protect the human rights of people with a mental illness and support people who experience
mental illness to live fulfilling lives in our community, without stigma or discrimination; > Prioritise early intervention and facilitate timely access to a range of high quality, integrated
mental health services that are culturally respectful and meet the needs of South Australians regardless of age, disability, cultural background, geographical location or circumstances of life; and > Promote and implement principles and strategies that support recovery across the mental
health care system and the general community. Mental health services are part of an integrated health service. Budgets for mental health programs are included in the budgets of Local Health Networks (LHNs) in accordance with governance structures. The current annual budget for mental health across the State is approximately $342 million.
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3.
Scope and Review Process
In March 2013, the Minister In March 2013, the Minister for Mental Health and Substance Abuse announced an independent review would be undertaken of South Australia’s stepped system of mental health care and how our mental health system responds in times of high demand. With the new stepped system of care at an advanced stage of implementation, the State Government needed to be assured that there is the right mix of services between acute and non acute mental health services and beds and the capacity of the system to manage peak demand. The scope of the review was to be undertaken in two phases. It was subsequently determined that phase one would proceed and the scope of this phase was to undertake: > An assessment of the capacity and processes of the Southern Adelaide Local Health Network
(SALHN) to effectively manage acute demand and examine waiting times in the Flinders Medical Centre Emergency Department; > An assessment of bed coordination and patient flow practices, and examine the practices and
processes underpinning emergency mental health responses across the State; > An assessment of the balance of acute and non- acute mental health services as a result of
the Stepping Up mental health reforms; and > A desktop review of the basis and assumptions of the Stepping Up recommendations and how
they compare with current evidence based practice. The important elements of phase two were considered by the review team and resulted in relevant recommendations. Specifically the issues of resource distribution, workforce capacity, culture and practice, consultation with consumers and carers and management of peak demand will be addressed as part of implementation. It was therefore determined that phase two of the review would not proceed. The review team comprised: > Experts in health systems, process review and design; > Senior Consultant Psychiatrist from another jurisdiction (New South Wales); > Senior Psychiatric Registered Nurse from another jurisdiction (Victoria); > Experienced Consumer Consultant from another jurisdiction (New South Wales); and > Experienced allied health professional from another jurisdictions (New South Wales).
The review team consulted a wide range of groups including senior clinicians, consumers and carers, non -government organisations, (NGOs), the Mental Health Coalition of South Australia, the Public Advocate, Medicare Locals, the Community Visitor Scheme and other government agencies and industrial organisations.
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4.
Review Recommendations
The review was completed in August 2013 and delivered a number of key findings. These were: > There are sufficient resources and capacity across the system; > SA spent above the national average per capita on mental health; > There were sufficient resources, but imbalances across LHNs. Northern Local Health
Network (NALHN) has significantly less resources than the SALHN; > There are sufficient acute and non acute beds, but there will be no bed closures for up to 12
months to ensure that the balance between the care types is right; > The review supported the reforms set out in Stepping Up; > Some LHNs have resources skewed towards inpatient services. The spread of medical
resources was highlighted as an issue for further analysis; > Improvements are possible in Emergency Departments (EDs), including the use of nurse
practitioners and having clear ED protocols; > Mental Health population boundaries were not aligned to the LHN boundaries, for example
Unley and the Hills differ from health boundaries; > Cultural and change management training and development were a gap in the implementation
of the Stepping Up report; > Clinical risk management confidence in acute and community services needs support; and > Governance and accountability were unclear for mental health services.
The review team made 15 recommendations to address the issues identified: 1.
Design and deliver a comprehensive change management program to implement the remaining reform focussing on the priority recommendations in this review.
2.
Develop a new function in EDs delivered by Mental Health nurse practitioners to optimise timely admission/discharges through changes to the acute care pathway and medical/nursing delegations. This recommendation along with other measures outlined in recommendations 7, 8 and 9 should also reduce seclusion and restraint rates.
3.
Design and deliver a training and development program for Mental Health staff in acute, non acute and in support areas such as Ambulance, Police and Correctional Services to improve workforce capability. Workforce capability is considered to be a critical success factor in the Alfred Mental Health service in Victoria.
4.
Consider how the content from third parties (such as the Victorian Department of Health and in particular the Alfred Health) can be leveraged in designing the training and development programs. Some adaption may be required however this is likely to be minimal.
5.
Close no further adult acute inpatient beds in the Mental Health system until a greater acute/non acute balance is achieved and the ‘flexing’ of SALHN Mental Health inpatient beds is stabilised. This should be achieved within 12 months.
6.
Re-assess the bed capacity once the review recommendations are underway (including the introduction of further planned and funded Stepping Up initiatives) with the intent of further shifts in resources to non acute services and to better balance resources between LHNs. This process should take up to 12 months at which point a migration plan can be finalised with the appropriate Department of Health and Ageing (Department) resource support.
7.
Develop and apply a consistent ED/Mental Health team set of triage criteria and protocols.
8.
Design and implement a system within EDs to alert Mental Health teams of repeat
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consumers so they can be more actively managed to reduce incidence of ED contact in the future. This system should include the development of procedures to support and escalation of a case review for known clients re-presenting multiple times e.g. 3 times in a month; 6 times in 6 months. 9.
Reference to monitor the advancement of practice development, practice change and outcome monitoring.
10.
Consider the development of local telephone triage assessment with an underpinning competency framework connected to Community Mental Health Teams (CMHTs).
11.
Align the LHN and Mental Health catchment areas. The Department should run a population and needs resource reallocation model to rebalance resources between LHNs based upon their population coverage and service need.
12.
Change the nursing skill mix for acute services at SALHN in order to accommodate nurse practitioners.
13.
Reallocate approximately 3-5 full time equivalents (FTE) from hospital based medical staff at SALHN to community Mental Health services within SALHN.
14.
The LHNs should operate the Mental Health Services. Redefine the role and accountability of the Department and the LHNs such that LHNs have full operational accountability and responsibility for the Mental Health service delivery.
15.
Review the required change in FTE for the Mental Health Unit of the Department in light of the changes in LHN accountabilities.
The full review report is available on the SA Health website.
5.
Consultation Feedback Submissions
The independent review report was released for a four week period of public consultation, closing on 4 September 2013. At the close of the consultation period, SA Health received a total of 31 letters, emails and responses. These submissions included feedback from individuals and peak bodies, including unions, professional associations, health consumer alliance, NGOs, consumers and carers, a consumer and carer advisory group, advocates, and staff from within the Department for Health and Ageing and LHNs. Response Group Staff Unions Professional Associations Peaks Consumer and Carers Advocates University Veterans TOTAL
Number of submissions 15 3 2 3 5 1 1 1 31
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6.
Overview of Submissions
The submissions demonstrated general support for the recommendations contained in the review. Some of the feedback received highlighted areas for further investigation and focus, which will be undertaken when planning for implementation. The majority of submissions were structured in response to the eight questions raised in the review along with the accompanying recommendations under each question. The key points from submissions are noted in the table that follows. It should be noted that the views expressed are those provided by the respondents and may not necessarily be supported or rejected by SA Health.
GENERAL • There was general support for the recommendations contained in the review however there were specific groups that questioned some of the findings and this will be detailed as follows where relevant to the review’s scope and recommendations. • There was criticism of the scope of the review being too narrow and not taking into consideration special populations such as veterans, defence force, intellectual disability, older persons and research activities. • The focus on metropolitan mental health services and limited consideration of country mental health services was questioned given that the resourcing issues faced by Country Health SA Local Health Network (CHSALHN) mental health services were similar to those identified for NALHN mental health services. • There was strong support for consumer and carer input into the implementation of the report’s recommendations and specifically into performance frameworks, benchmarking and accountability processes. • The specific focus on SALHN was questioned along with a concern that the review report was biased against SALHN and containing un-evidenced statements, inaccurate and simplistic data and therefore lacked integrity. Question 1: Does the EY Review support current Government MH policy as documented in the Stepping Up report and recommendations? • Consumers, carers, advocacy groups and peak bodies indicated that it was pleasing that the directions of Stepping Up had been confirmed as appropriate and relevant. • Furthermore it was felt to be disappointing that it appeared there was resistance in implementing the recommendations of the Stepping Up report. • Professional groups and representative bodies were critical of the investment in intermediate care and sub-acute care and suggested alternative uses for these facilities or resources. • There was general agreement that the stepped system of care as implemented did not currently address the issue of emergency demand. • Supported accommodation options and access to rehabilitation and forensic care were reported as ongoing obstacles to more efficient acute mental health bed management. • The new model of support offered by intermediate care centres was applauded by consumers however it was felt that the rules around access and length of stay were felt to be unrealistic and in need of review.
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Question 2: Are there problems with the way in which the Stepping Up report has been implemented? • There was broad support for the recognition of the specialist skills within the community mental health team, better care pathways and a learning and development program. The importance of close collaboration between community teams, inpatient teams and ED staff was broadly recognised. • There was some criticism of the finding of a risk averse culture being in contrast to the realities of clinical work on a day to day basis and the system response to adverse incidents. • Consumer feedback indicated that balanced risk was necessary to provide an opportunity for people to learn and acquire new skills. • There was broad acknowledgement of a requirement for a cultural and change management process to be undertaken. • Some respondents felt that there was no cultural problem in services and that the challenges faced by mental health reform would be addressed by a shift to a medically led mental health governance model, with specialist psychiatrist (Clinical Directors) leading mental health services and directly reporting to LHN CEOs. Recommendation 1 Design and deliver a comprehensive change management program to implement the remaining reform focussing on the priority recommendations in this review.
Recommendation 2 Develop a new function in ED delivered by Mental Health (MH) nurse practitioners to optimise timely admission/discharges through changes to the acute care pathway and medical/nursing delegations. This recommendation along with other measures outlined in recommendations 7, 8 and 9 should also reduce seclusion and restraint rates.
• There was broad support and commitment to implementing the recommendation. • There was criticism that over time mental health services have introduced excellent policies however these have not been translated into actual practice. • There was agreement that there was a slower than expected change to cultural and clinical practice and addressing this should be a priority. • There was a call for a continued focus on reducing stigma and particularly stigma that exists in health services. • There was support for the notion that services were still very much crisis driven with an emphasis on acute beds and that as a result of this imbalance, people remain neglected and marginalised in the community. • This recommendation was broadly supported. • Some respondents commented that consideration needed to be given to enhanced roles for allied health practitioners also. • The focus on reduction of seclusion and restraint was applauded.
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Recommendation 3 Design and deliver a training and development program for MH staff in acute, nonacute and in support areas such as Ambulance, Police and Correctional Services to improve workforce capability. Workforce capability is considered to be a critical success factor in the Alfred MH service in Victoria
• The majority of respondents and particularly consumers and carers supported this recommendation and the inclusion of broader staff groups in the process. • It was felt critical that the process was appropriately resourced and supported. • Integration with undergraduate vocational programs was recommended. • There was criticism that the training recommendation did not include specific reference to ensuring a recovery orientation. • Respondents indicated areas were some elements of recommended training and professional development programs were already occurring and could be developed further.
Recommendation 4 Consider how the content from third parties (such as the Victorian Department of Health and in particular the Alfred Health) can be leveraged in designing the training and development programs. Some adaption may be required however this is likely to be minimal.
• There was broad support for exploring opportunities available in other jurisdictions. • There was criticism about the focus on Victoria and the Alfred as there were other examples of highly effective evidenced based practices across Australia.
Question 3: Are there sufficient adult acute inpatient beds available in the SA Mental Health system? Recommendation 5 • Majority of respondents were supportive of the Close no further adult acute recommendation to closing no further acute mental health inpatient beds in the MH beds. system until a greater • Consumer and carer feedback indicated that many acute/non acute balance is admissions to the acute sector could be avoided by achieved and the ‘flexing’ of supporting the person in the community. SALHN MH inpatient beds is • It was recommended that future bed planning and stabilised. This should be consolidation incorporate the integrated mental health achieved within 12 months. inpatient units in country. • There was criticism that the report did not address the limited number of Psychiatric Intensive Care Unit/High Dependency Unit beds available in NALHN in comparison to the other metropolitan networks. • There was criticism regarding the data contained in the report to support the conclusions that there were sufficient beds. • There was criticism that the report did not address the chronic underfunding on mental health which was an issue at the national level and affecting all jurisdictions, drawing into question the validity of inter jurisdictional comparisons.
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Recommendation 6 Re-assess the bed capacity once the review recommendations are underway (including the introduction of further planned and funded Stepping Up initiatives outlined herein) with the intent of further shifts in resources to non acute services and to better balance resources between LHNs. This process should take up to 12 months at which point a migration plan can be finalised with the appropriate Departmental resource support.
• This recommendation received general support with the caveat that a full data analysis is undertaken, taking into consideration the accurate evaluation of service utilisation and population needs analysis. • There was criticism that the 12 month timeframe was arbitrary and there would need to be demonstrated achievement of demand reduction targets over a sustained period before further resource redistribution was undertaken. • There was strong support from NALHN for the further development of intermediate care centre beds in the northern area as planned and for resource redistribution to allow equitable staffing of the north eastern team. • Concern was raised that there be no reduction to service provided by Veterans Mental Health Services particularly at Ward 17, Repatriation General Hospital.
Question 4: How can ED function better for Mental Health consumers? • Support for recommendation to place competent, specifically trained staff in ED to assess and triage the needs of those presenting with mental health problems. • Support for the finding of lack of communication between mental health services and others involved in the person’s care outside of ED. • Some respondents highlighted that treatment and care plans were mandatory and that in reality many people do not have these in place. • Delays in bed access from the ED at the same time as vacant beds in intermediate care centres was highlighted as an issue requiring urgent consideration. Recommendation 7 • This recommendation was broadly supported. Develop and apply a • Consistency between mental health and other ED consistent ED/MH team set presentations around the 4 hour target was supported. of triage criteria and protocols. Recommendation 8 Design and implement a system within ED to alert MH teams of repeat consumers so they can be more actively managed to reduce incidence of ED contact in the future. This system should include the development of procedures to support and escalation of a case review for known clients re-presenting multiple times e.g. 3 times in a month; 6 times in 6 months.
• There was general support for the development of customised care programs for people who presented frequently and that this should be done in conjunction with community mental health services. • The reports findings were questioned in that this process was already in place at SALHN EDs at Flinders Medical Centre and Noarlunga.
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Recommendation 9 Establish an ED/MH team liaison meeting withmeeting with a Terms of Reference to monitor the advancement of practice development, practice change and outcome monitoring.
• This recommendation was supported. • Respondents from SALHN indicated that this process is already occurring in Flinders Medical Centre and Noarlunga ED.
Recommendation 10 Consider the development of local telephone triage assessment with an underpinning competency framework connected to CMHTs.
• There was general support for localised triage and localised management of service delivery. • Concern was raised about the resource implications for community teams and that the centralisation of triage allowed emergency response functions to develop within CMHTs that may be lost under a devolved triage model.
Question 5: Should the catchment areas for LHNs and MH system catchment areas be the same? Recommendation 11 • There was broad support for this recommendation leading Align the LHN and MH to local, regional, clinical and financial accountability. catchment areas. The • A call for more sophisticated and balanced analysis prior Department should run a to any redistribution of resources. population and needs • NALHN respondents highlighted the need for the urgently resource reallocation model prioritising of the resourcing of the North Eastern CMHT. to rebalance resources • There needed to be acknowledgement of socioeconomic between LHNs based upon disadvantage in any population analysis. their population coverage • Respondents from CHSALHN highlighted the need for and service need. consideration of the resource needs of country SA. Question 6: Is there a need to reallocate staff within SALHN? Recommendation 12 Change the nursing skill mix for acute services at SALHN in order to accommodate nurse practitioners.
• There was general support for this recommendation but caution that any change in practitioner redistribution needed to be carefully thought out and take into consideration the broader functions of the service. • There was some criticism of the proportional number of nursing positions given that the work within mental health differed from traditional nursing practice. • Some respondents called for additional staffing to be provided and rejected the finding that SA mental health services were adequately resourced.
Recommendation 13 Reallocate approximately 35 FTE from hospital based medical staff at SALHN to community MH services within SALHN.
• Many respondents did not feel they were in a position to provide comment. • SALHN respondents felt that any firm decision regarding resource translocation was premature and required further analysis. • Some respondents supported the general notion of moving resources from acute inpatient services to community services and the use of community based service models as a means of providing more preventative approaches to health and wellbeing.
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Question 7: Who should operationally manage Mental Health services including bed triage and allocation of patients to LHNs? • Some respondents attributed the systemic issues in mental health services to the lack of a clear clinically led management model. Recommendation 14 The LHNs should operate the MH Services. Redefine the role an accountability of the Department and the LHN’s such that LHNs have full operational accountability and responsibility for the MH service delivery.
• There was strong support for LHNs operating and integrating mental health services. • There was support for centralised bed management to cease and the responsibility for this to be integrated into LHN based mental health services. • There was concern however that a process for cross network coordination be established and for the Department to set a clear performance management framework and key performance indicators for mental health services in LHN service agreements.
Recommendation 15 Review the required change in FTE for the MH Unit of the Department in light of the changes in LHN accountabilities.
• There was strong support for reduction in the FTE of the Mental Health Unit. • Support was expressed for the maintenance of centrally led processes for developing NGO models of service that has resulted in improved quality and contracting and procurement processes over recent years. • There was criticism that the review team did not really understand system wide policy and system wide operational planning and implementation. • Some respondents expressed caution regarding the extent of changes not mirroring the previous Building a Better Organisation (BABO) process of 2004 that resulted in fragmentation of mental health services that ultimately led to the need to establish a centralised structure to drive reform.
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7.
SA Health’s Response
The feedback was reviewed and considered by SA Health and has shaped the final response to the review report and recommendations. SA Health would like to thank all respondents for their comments and suggestions. Following the consultation process, all recommendations of the review were accepted inprinciple by the South Australian Government. While the scope of the review was necessarily tight in order to urgently address problems experienced by mental health consumers in EDs, it has provided specific recommendations and a way forward to progress the reforms set out in the Stepping Up report. The review team’s endorsement of the Government’s mental health policies documented in the Stepping Up report and recommendations provided reassurance that SA Health mental health strategies remain relevant and received strong support from respondents. Whether due to the pace of reforms or the method of implementation, the system issues that have resulted in the current challenges faced by mental health consumers seeking acute care must be addressed. All work on the Report’s recommendations will be undertaken under three broad categories set out below.
Resource Realignment and Governance Changes In response to the consultation submissions the Department will undertake a detailed analysis of existing mental health resources and a population needs analysis using relevant indices. This work will help inform resource realignment planning that will lead to more equitable resourcing of NALHN and CHSALHN mental health services in relation to other LHNs. In addition, this work will inform the planning of staff movements within networks and the realignment of mental health service boundaries to be consistent with those of LHNs. The Department will also be responsible for reviewing the functions of the Mental Health Unit.
Cultural Change In line with the strong support from consultation feedback for LHNs having full operational accountability and responsibility for mental health service delivery, the implementation of recommendations related to cultural change for mental health service staff will be the responsibility of LHNs. The Department will work with LHNs to identify the key components, outcomes and performance targets by which LHN activity in this area will be monitored.
Clinical Redesign Again recognising the role of LHNs in having full operational accountability and responsibility for mental health service delivery, implementation of recommendations regarding the system of care across community and hospital services and redesign of ED mental health services to address the issues of emergency demand and length of stay, will be the responsibility of LHNs. This will allow some flexibility and variation at the local level while recognising that LHNs will collaboratively establish mechanisms to address consumer access across networks. The Department will work with LHNs to develop clear service delivery targets through which LHN performance against these recommendations will be measured. Finally, it is worth noting that the consultation feedback provided comments and recommendations regarding broader mental health service elements and issues that were beyond the scope of the current review and recommendations. This ‘out of scope’ feedback will be retained and considered in the next South Australian Mental Health Strategy. Funding will be allocated to progress recommendations associated with clinical redesign and cultural change. It is not envisaged that any additional funds will be required to operate the mental health system, but that resources are more equitably redistributed across LHNs and care types.
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8.
Next Steps
An executive Steering Committee will oversee the implementation of the review’s recommendations. The Steering Committee will comprise a mix of Department for Health and Ageing executives, LHN Chief Executive Officers and consumer and carer representatives. The implementation of recommendations will be managed through three work streams: > Resource Realignment – managed by the Department for Health and Ageing; > Clinical Redesign – managed by each LHN; and > Cultural Change Management – managed by each LHN.
A detailed implementation plan will be developed and it is anticipated that implementation of the recommendations will be completed by the end of 2014. Ongoing communication and consultation will take place with staff, unions, professional associations, consumers and carers, NGOs, peak bodies and other interested parties throughout the implementation of the review’s recommendation.
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