Outside‐In and Inside‐Out: Outreach as a Copernican moment in psychiatry?

1. Outside‐In and Inside‐Out:Outreach as a Copernican moment in psychiatry? Prof. Mervyn Morris Birmingham City University presentation 17th March 2011

2. Where is Birmingham?

3. ‘De-institutionalisation’:Birmingham Beds: 722 (pop.1.2 million)

4. Deprivation in Birmingham..

5. The ‘BIRMINGHAM MODEL’ • A defined set of ‘functional’ outreach teams, providing a mobile/ ambulant community service, with different ways of working that reflect the different needs of people; • Strong emphasis on multidisciplinary team-working; • Different teams working in the same community..

6. BIRMINGHAM MODEL ..core teams PRIMARY CARE SERVICES Primary Care interface COMMUNITY MENTAL HEALTH TEAM Primary Care Continuing Need: Liaison Rehab and Recovery HOME TREATMENT TEAM CONTINUING NEED ASSERTIVE OUTREACH TEAM Hospital interface Residential based care: Hospital Beds, Day services, Crisis Homes,

7. ‘Functionalised’ Community Teams KEY CHARACTERISTICS 1 • Same pattern of services found across City; • Each team suited to work with different levels of need; • Multi-disciplinary, integrated with social care; • Depending on deprivation, serve smaller or larger populations..

8. BIRMINGHAM MODEL PRIMARY CARE SERVICES Primary Care interface COMMUNITY MENTAL HEALTH TEAM Primary Care Continuing Need: Liaison Rehab and Recovery X 21 teams CONTINUING NEED ASSERTIVE OUTREACH TEAM HOME TREATMENT TEAM X 7 teams X 5 teams Hospital interface X 17 wards Residential based care: Hospital Beds, Day services, Crisis Homes,

9. ‘Functionalised’ Community Teams KEY CHARACTERISTICS 2 Differences in: • Caseload; staffing ratio/population served/ working hours; • Contact frequency/ location; • Visiting patterns/ length of time on caseload;

10. CORE SERVICE TEAMS

11. ‘Functionalised’ Community Teams KEY CHARACTERISTICS 3 • Integrated into care pathways: Acute and Continuing Care; • Emphasis on avoiding hospital; • Clearly defined boundaries and interface with hospital and primary care; • Some outreach teams more specifically target vulnerable populations, for example; early intervention; homeless team.

12. PRIMARY CARE SERVICES COMMUNITY MENTAL HEALTH TEAM Primary Care Continuing Need: LiaisonRehab and Recovery HOME TREATMENT TEAM CONTINUING NEED ASSERTIVE OUTREACH TEAM Residential based care: Hospital Beds, Day services, Crisis Homes Acute Care pathway

13. PRIMARY CARE SERVICES COMMUNITY MENTAL HEALTH TEAM Primary Care Continuing Need: Liaison Rehab and Recovery HOME TREATMENT TEAM CONTINUING NEED ASSERTIVE OUTREACH TEAM Residential based care: Hospital Beds, Day services, Crisis Homes Continuing Care Pathway

14. Additional teams PRIMARY CARE SERVICES COMMUNITY MENTAL HEALTH TEAM Primary Care Continuing Need: Liaison Rehab and Recovery EARLY INTERVENTION SERVICE HOME TREATMENT TEAM CONTINUING NEED ASSERTIVE OUTREACH TEAM Residential based care: Hospital Beds, Day services, Crisis Houses,

15. Additional teams PRIMARY CARE SERVICES COMMUNITY MENTAL HEALTH TEAM Primary Care Continuing Need: Liaison Rehab and Recovery HOMELESS TEAM HOME TREATMENT TEAM CONTINUING NEED ASSERTIVE OUTREACH TEAM Residential based care: Hospital Beds, Day services, Crisis Houses,

16. The Copernican shift.. The service begins to revolve around the patient The Birmingham Model is not enough! There’s a difference between: “DOING THE RIGHT THING” and “DOING THE THING RIGHT” The Birmingham Model explains DOING THE THING RIGHT, about organising a system; it is then down to the teams to do the ‘right thing’..

17. The Copernican shift.. The service begins to revolve around the patient INSIDE – OUT • Reduces the stigmatisation of • Hospitalisation • Relate to the person and their social network in a different way; • Seeing mental illness in context: understand content of symptoms;

18. The Copernican shift.. The service begins to revolve around the patient OUTSIDE – IN A new model of psychiatric practice emerges: • More personalised intervention: • empowerment through choice and negotiation of meaning; - in vivo, and with social network; • including not excluding people from each other. • Recognise the social context of mental health problems; to be in a position to address directly vulnerability; exploitation, poverty, homelessness.

19. The Copernican shift.. The service begins to revolve around the patient Outreach isnecessary, butnot sufficient.. This is the moment to pause: We can take ‘psychiatry out of the hospital’, but we must also take the ‘hospital out of psychiatry’. If we continue to think and practice community outreach in the same way as we thought and practiced in the hospital, then we are not de-institutionalising, we are re-institutionalising..

20. Thank you for listening.. mervyn.morris@bcu.ac.uk www.hcc.uce.ac.uk/ccmh www.soterianetwork.org.uk

21. OTHER ADULT SERVICES PRIMARY CARE TEAM DRUG & ALCOHOL SERVICES COMMUNITY MENTAL HEALTH TEAM Primary Care Continuing Need: Liaison Rehab and Recovery SOCIAL CARE HOME TREATMENT TEAM CONTINUING NEED ASSERTIVE OUTREACH TEAM LIAISON SERVICES Residential based care: Hospital Beds, Day services, Crisis Homes

22. What made community services work? An integrated service pathway Effective boundary management between teams – ‘system of gateways and filters Integration with social care – housing, employment, benefits and ‘3rd Sector’ Teams with competent team managers Preparation and learning as we go Data – targets and monitoring Continue to innovate and adapt

23. Gaps/ issues/areas for development • Transition from child to adult services • Biological v Social models: i.e. EVIDENCE!! (families, work) • Fidelity (e.g. CRHT) • CMHT’s – function • Shifting/ diversifying provision • Effective commissioning/ contracting

24. Pre-conditions for transformation A vision.. Being ready.. Evidence of effective community models Service user and carer support Existing competence amongst staff in independent community practice An opportunity e.g. psychiatric hospital that needs to close Courage