A fragmented health service too often sends patients with mental illnesses far from home or for ‘treatment’ in locked wards in private facilities. It doesn’t have to be this way, as Keith Cooper finds in a close-knit, comprehensive and highly effective NHS service
Hopewood Park, on Waterworks Road, Sunderland, is a rare thing in an NHS where beds for people with mental ill health are more likely axed than opened. Built to replace Cherry Knowle Hospital, the old Sunderland Borough Asylum, it opened five years ago with 120 beds.
The Doctor is on a visit to meet the mental health rehabilitation team working with patients with chronic mental illnesses, of NTW (Northumberland, Tyne and Wear) NHS Foundation Trust, led by consultant psychiatrist Priya Khanna.
It’s the sort of service badly needed elsewhere in England where ‘treatment’ is reduced to a room in a locked ward in a private hospital, far from home. Such stays last twice as long as in the NHS, the Care Quality Commission reported last year, doubling the expense and pain of separation from families and friends.
‘We want to catch people earlier and provide the right level of support’
So what sets it apart, marking it out as a template for other corners of the NHS?
There is the obvious advantage of the modern hospital. It’s ward blocks squat among grassy banks, gardens and covered paths, a far cry from the gothic spires of Cherry Knowle.
There is a café and gym. There are the staff, the psychiatrist, psychologists, nurses, and occupational therapists, from the wards and the community. Each one plays an essential supporting role in the long road to rehabilitation for the severely ill.
At NTW, they seem close-knit. All chip in, ending and adding to each other’s anecdotes, telling us how they help people, disabled by ill health, to get their lives back.
Closer to home
Before Hopewood opened, the trust had large numbers of patients in out-of-area beds, as far away as Scotland. Now it has very few, Dr Khanna (pictured below) says.
‘When we opened our HDU [high dependency unit] we were able to repatriate people.’ She recalls one man was brought back to the HDU before being ‘stepped down’ to the ‘move-on’ ward, then into a home in the community.
‘He’s now more in contact with his family and there is still lots of ongoing rehab work with the community team,’ Dr Khanna adds.
Such is the pattern of rehab working well. ‘Our job is to try to stabilise patients, work on their life skills, start the process to move them on from hospital. Give them hope,’ is how Andy Severs, ward manager of the male HDU sums it up – mental health rehab for people with severe and complex illness.
They often have more than one diagnosis. Most suffer psychosis, such as hearing voices or hallucinating. A lot of them may misuse alcohol or drugs and have difficult family relationships. They struggle with daily life. They’re in and out of emergency care, caught in the ‘revolving doors’ of short-term admissions to acute wards, then discharged to free up a bed for the next crisis case.
Freeing patients from the revolving doors of so-called ‘patch-up’ admissions is an important role for the team.
‘We want to identify people earlier, provide the right level of support, medication and psychosocial support to prevent multiple admissions,’ Dr Khanna says. ‘There may be one admission, which is longer, but their quality of life improves and they can move towards more independent accommodation.’
For what is called ‘in-reach’ work, staff go looking in the acute wards for people in need of rehab.
‘The sooner you get into it, the better the outcomes,’ consultant community psychiatrist Sunil Nodiyal (pictured below) says.
‘Before, people were coming to rehab after 22 years. We are trying to cut that down.’ Such transfers entail longer stays than acute ones, which usually last weeks. Rehab stays range from six months to two years at NTW. These could sometimes be longer if necessary.
The prospect of longer stays in hospital isn’t always welcomed by patients, consultant nurse Lisa Strong says.
‘But if we can get the treatment right, we can build up that trust, hopefully improve insight, function and quality of life.
‘In the long term the benefits can outweigh the sense of frustration and coercion that may be there in the shorter term.’ Such decisions can be ‘angst-ridden’, she adds.
‘There’s the benefits of a rehab admission versus the costs and distress of being detained. We look at the option of rehab in the community too.’
A close working relationship between staff in the community and those on the wards seems another key to the success of mental health rehab.
Its absence is a major flaw in services elsewhere in the NHS, where patients are ‘dislocated’ through admission to unfamiliar hospitals, far from home.
NTW’s rehab community team is called the ‘step-up hub’ in the South locality and starts working with patients on wards some six months before they leave hospital.
‘Traditionally, when someone went into an HDU or equivalent ward, the community team stepped back to focus on more acute work,’ says its team leader, Michael Dingwall.
‘But we engage early on, get them used to the community, so it’s less traumatic when discharge day comes.’
‘There may be one admission, which is longer, but their quality of life improves’
It has also removed time limits for treatment in the community.
Dr Khanna says, ‘we realised it wasn’t right for patients. If two years are needed, it’s two years. It’s needs-led.’
The hub runs groups in the community. They’re open to anyone on the wards, in any part of NTW’s patch, which stretches from Sunderland to Northumberland. While some sound more social, they are designed to be therapeutic.
‘On the surface, a group might be about music, but underneath it is about tolerating other people,’ says Katrina Mason, its occupational therapist.
A camera club helped one anxious man focus on photography rather than worry about who was watching him on a bus. ‘People learn coping strategies from each other,’ Ms Mason says. ‘It makes a difference.’
The difference this rehab team makes is thanks to every bit of what’s officially known as the ‘care pathway’ for patients. The logic seems so simple. It’s the right care, in the right place, with no gaps to fall through. Yet pathways are full of holes across much of the NHS.
Read next month’s issue of The Doctor, for an investigation into the financial and human costs when there’s barely a trace of a pathway of care at all.
Serenity meets safety
This is a rehabilitation service with strong clinical leadership and which gives back hope to patients. There should be many more like it
Visiting the staff and patients at the rehabilitation service in Sunderland (Northumberland, Tyne and Wear NHS Foundation Trust) with the BMA was an uplifting and sobering experience in equal measure.
We arrived frazzled after getting lost in the middle of a busy Friday but arrived at what seemed like (and was!) an oasis of calm. We wondered if we were at the right place, as large mental health units do not normally have such tranquillity; ducks were even waddling around the car park.
The physical environment of the recently built architect-designed unit is spacious and light with good privacy for all. However, it was the staff we met that made the place and the care and support special.
Meeting staff from various disciplines talking about a whole pathway was really heartening.
This has become lost in many of our fragmented systems and commissioning arrangements but has been built and preserved here by strong, passionate and coordinated professionals backed by senior management who respect them. Patients have been able to be returned from out-of-area placements far away and there are schemes to allow even those detained under the act to take part in community activities such as gardening.
To hear Andy Severs, the manager of the HDU, talk about ‘working on skills and … giving back hope’ was amazing and an illustration of how a positive and caring approach can make such a difference.
It was sobering because of the time we spend seeing other services and hearing other stories where things don’t work, people fall through the gaps, and bad things happen. Nothing is ever perfect of course but what we saw in Sunderland – a passionate, hard-working, patient-centred group of staff with decent resources (nothing fancy) working together for patients through a whole-recovery pathway – is not that common. It could and should be.
Andrew Molodynski is the BMA consultants committee mental health policy lead (pictured above)
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