LCA Mental Health & Psychological Support Mapping

Transcription

1 LCA Mental Health & Psychological Support Mapping November 2013

2 Contents 1 Introduction Method Results Information Centres Training and Education Level Two Supervision User Support Groups Level 3 & 4 professionals Discussion Limitations Information Centres Training and Education Level 2 Supervision User Support Groups Current Level 3 and 4 Provision Emergency Psychiatric Support Recommendations

3 1 Introduction The LCA Mental Health and Psychological Support Pathway Group set out to map the availability of psychological support services for cancer patients in the London Cancer Alliance (LCA). A questionnaire was designed which asked questions about the support services available in all Trusts at levels one to four, as defined in the NICE Supportive and Palliative Care Improving Outcomes Guidance, The purpose of the survey was two-fold: to identify what types of services were available where; and what current education, training and supervision was being provided to underpin these services. These data have been used to provide the rationale for suggested service models and level 3 and 4 staffing requirements for the LCA. ( Developing a pathway for mental health and psychological support services, LCA Mental Health & Psychological Support Pathway Group 2013) 2 Method A questionnaire was developed to capture the information described above. The content was agreed by the pathway group, and then circulated for completion to representatives of each Trust, which were most often the Group members themselves. This generated a significant volume of information from some Trusts, but due to the group membership, which was still being developed, there were significant gaps. The questionnaire was then circulated to the lead cancer nurses and to the lead liaison psychiatrists for Central and North West London NHS Foundation Trust (CNWL) and West London Mental Health NHS Trust (WLMNT). This gathered more information about the level 4 services, but still left a gap for levels 1-3. Finally, an on-line survey tool was used to further develop the questionnaire to enable easier completion by those who weren t specialist psychological support professionals and it was recirculated. The method of circulation means that the results are from the LCA Trusts only, with one exception (a third sector service). Existing palliative care service mapping will be used to identify LCA-allied hospice provision. 3 Results Results were received from 14 Trusts. However, the completeness of the questionnaire varied. Where more than one questionnaire was completed per Trust, this was indicative of different people completing different sections, and any duplication was removed. 3.1 Information Centres All 14 Trusts reported having on-site information centres. These were situated within the same unit as the oncology clinics in three Trusts and within easy walking distance at another five Trusts. All information centres reported having quiet space available for consultations. Nine information centres reported being actively involved with information prescriptions and six were being used for purposes over and above information provision. This included holding yoga classes, education and support groups and wig-fitting services. 3

4 LCA MENTAL HEALTH & PSYCHOLOGICAL SUPPORT MAPPING The following charts show the annual footfall of the centres and their staffing levels. A vast majority of staff were nurses by profession, with social workers, allied health professionals (AHPs), counsellors and complementary therapists accounting for the rest. 4

5 RESULTS 3.2 Training and Education Sage and Thyme Sage and Thyme is a basic communication skills training package aimed at level one staff, i.e. anyone who may come into contact with cancer patients. It was being used in nine Trusts. The number of facilitators and attendees varied widely, depending on how long it had been running, but all nine had clear plans for further roll-out Advanced Communication Skills Training (ACST) Nine Trusts responded to this question. The numbers of core multidisciplinary team (MDT) members and non-core MDT members who had completed ACST varied considerably, as shown in the graphs below. 5

6 3.2.3 Level 2 Psychological Assessment Skills Training LCA MENTAL HEALTH & PSYCHOLOGICAL SUPPORT MAPPING All 14 Trusts responded to this question, with 12 reporting that this was available to staff in their Trust. Four were using the Jenkins model, three sent their staffs to The Royal Marsden NHS Foundation Trust s training and the others were using on-site Jenkins adaptations. The numbers of staff who had completed training was not provided. 3.3 Level Two Supervision The table below shows which MDTs are currently attended by a level 3 or 4 practitioner. The other category includes inpatient MDT, as requested, attendance possible but never requested, and not available at all. 12 Trusts reported monthly group supervision being available; two Trusts reported it wasn t available.. The same 12 Trusts said that one-to-one supervision was also available, but this was largely dependent on having completed the level two psychological assessment skills training. In seven of these Trusts, anyone could access this supervision. 3.4 User Support Groups User support groups were available in eight Trusts, with seven of these reporting being able to signpost users to other groups if necessary. The following chart shows which tumour types had user support groups. The other category most commonly specified open access for all patients, irrespective of tumour type, but also included mesothelioma and bladder cancers. 6

7 RESULTS 3.5 Level 3 & 4 professionals Access to Psychological Support and Mental Health Services 12 trusts answered this question. The availability of level 3 and 4 professionals to assess and treat cancer patients was inconsistent across the LCA. This was especially true when subdivided by profession and WTE (working time equivalent). The professionals (absolute number, not WTE) available were: Profession Cancer-specific Not cancer specific Counsellor 6 1 Psychologist 3 Clinical psychologist 5 Psychiatric liaison nurse 2 3 Psychiatric SpR 1 Psychiatric consultant 2 2 Psychotherapist 1 These professionals were mostly based at Guys and St. Thomas NHS Foundation Trust, The Royal Marsden NHS Foundation Trust and St George s Healthcare NHS Trust. Nine trusts reported that these professionals were able to provide supervision and support, but in seven of these Trusts, this was of less than 10 hours per month and only five had dedicated space to carry out this role. The number of consultations provided 7

8 LCA MENTAL HEALTH & PSYCHOLOGICAL SUPPORT MAPPING by the respondents varied. However, due to the way the original questionnaire was worded, the answers provided may not be comparable. The graph below shows which interventions were most commonly being undertaken by level 3 and 4 practitioners Emergency Psychiatric Support The graph below shows how the Trusts were able to access support in event of a psychiatric emergency. This varied hugely across the LCA, though in-hour provision, i.e. Monday-Friday, 9am-5pm was generally better than out-of-hour provision. 8

9 DISCUSSION 4 Discussion 4.1 Limitations A vast majority of the responses to this survey came from LCA Trusts, rather than any other providers across the LCA such as hospices, and so recommendations can only be applied to this group. Results were received from 14 Trusts, but the full questionnaire wasn t completed by every respondent. The results came from cancer centres, cancer units and district general hospitals, so can be considered representative of the LCA landscape. The LCA Palliative Care Group undertook a detailed mapping of palliative care services during 2012, and use of this data to calculate level three and four palliative care staffing may be possible. The availability of other third sector services needs further consideration and mapping; this may be usefully done collaboratively by Mental Health & Psychological Support Pathway Group and the LCA Survivorship Pathway Group given the duality of agenda at levels one and two. 4.2 Information Centres All respondents reported having an information centre. Most reported being within easy walking distance of the oncology clinics, though five skipped that question and one respondent was a third sector centre. The centres were reported as having a wide range of uses; they were going beyond just providing information and seemed to be acting more as a central place for providing supportive care aimed at meeting the holistic needs of cancer patients and their carers. They were staffed by trained professionals, though often used volunteers. When considering the psychological supervision needs of the Trusts, the centre staff should be included in calculations for WTE requirements. This has implications for advanced communications and level two psychological assessment skills training. 4.3 Training and Education Sage and Thyme Sage and Thyme is a basic communication skills training package, which has been widely promoted by Macmillan Cancer Support over the last two years. It is aimed at level one staff, i.e. anyone who may come into contact with cancer patients. It is a self-sustaining model,as staff are trained to become facilitators of future courses. This may be a financial incentive to Trusts, as once they ve paid for staff to be trained as facilitators, there are no further costs, particularly if the facilitator s places are funded externally. However, there may be a danger that replacements for the previously nationally funded advanced communications skills training are not sought. Communication training courses have been shown to be effective in supporting senior clinicians to have difficult conversations, such as when breaking bad news. There is a concern that implementation of nationally agreed best-practice, such a holistic needs assessment (HNA), could fail without high level communication training to support these complex discussions Advanced Communications Skills Training (ACST) Advanced communication skills training has been completed by % of core MDT members at five responding Trusts, and by 50-90% at another four. It is a peer review requirement that all core MDT members complete ACST, so it is worrying that in some trusts this has dropped to as little as 50%.This peer review requirement does not extend to non-core MDT members: AHPs are not core members for most tumour groups and this requirement also does not apply to information centre staff, even when these groups of professionals are cancer specialists, i.e. treating cancer patients at least 50% of their time. To date, custom and practice has been that non-core MDT members can attend courses in the event of cancellations by others, but the reality is that in small teams, late notice of planned absence is rarely agreed by line managers. Ensuring staff have access to advanced communication skills training needs 9

10 LCA MENTAL HEALTH & PSYCHOLOGICAL SUPPORT MAPPING careful consideration by the LCA. The national programme and funding ended in March 2013 and a locally agreed solution to on-going provision needs to be decided. Level 2 Psychological Assessment Skills Training Another peer review requirement is that all core MDT members have level 2 psychological assessment skills training. An important component of this training is that attendees are then able to access monthly supervision from a level three or four training professional. Of the 14 responding Trusts, 12 said that their staff could access this training. This was being provided either on-site, or through The Royal Marsden School of Cancer Nursing and Rehabilitation. This training is another area which the LCA needs to consider, including how this is accessed, by whom, and how it is commissioned and funded. 4.4 Level 2 Supervision This mapping survey suggests that the on-going monthly supervision required following level 2 psychological assessment skills training is accessible in a majority of Trusts. However, it is not known how many staff had completed the training, so it is impossible to assume that, if all those who need training completed it, the capacity currently exists to meet demand. Results suggest that level 3 and 4 practitioners attendance at MDTs occurs most often in specialist palliative care. Again, peer review mandated input from level 3 psychological support practitioners for several tumours and includes them as extended members for all others. Capacity to meet these recommendations is unclear, though this was not cited as rational for current non-attendance. This should be further investigated as part of the concurrent service design work. 4.5 User Support Groups Recommendations from the National Cancer Survivorship Initiative (NCSI) suggest that all those living with and beyond cancer should have access to user support groups. They don t specify where these should be situated or by whom they should be run. However, evidence suggests that co-facilitation by a professional and a service user works best. Opinion is mixed as to where tumour specific or generic groups are most efficacious. This mapping identifies user support groups at eight trusts, with seven being able to signpost to outside organisations. The LCA may wish to consider how to respond to the apparent gap in user support group access, in order to best ensure equitable access to, at minimum, information on how to access user support groups. 4.6 Current Level 3 and 4 Provision This questionnaire identified clear inconsistency in the numbers of level 3 and 4 practitioners across the LCA. Where these posts were available their exact profession, type of intervention provided and ability to provide supervision within their job roles varied considerably. This issue, as well as caseload and postutilisation, is addressed more fully in the service design paper. 4.7 Emergency Psychiatric Support Access to 24-hour psychiatric assessment is an essential part of the care pathway. Psychiatric emergency, such as acute psychosis or immediate risk of harm to oneself or others, is a rare consequence of cancer and its treatment. When it does occur, the outcome can be catastrophic. This mapping shows wide variation in the current management of psychiatric emergency in the LCA. The LCA Mental Health and Psychological Support Group will need to consider whether current practice meets best evidence, or at the very least, constitutes safe practice. 10

11 RECOMMENDATIONS 5 Recommendations In light of the above findings, the following recommendations are made: The LCA MH & PS Pathway group will work collaboratively with the Survivorship Pathway group on areas of dual interest or responsibility The LCA MH & PS Pathway group should promote the use of Sage and Thyme as a communication training appropriate for level 1 staff The LCA MH & PS Pathway group will lead work to develop plans for future ACST, taking into account past successes and lessons learnt The LCA Clinical Board is asked to support the explicit inclusion of level two supervision in level three and four professionals job descriptions in LCA trusts The LCA MH & PS Pathway group will liaise with the LCA patient experience project to discuss the support group findings and to jointly develop an action plan if appropriate The LCA MH & PS Pathway group will further investigate 24-hour psychiatric emergency access 11