Crisis Care Safety Initiative: digitalisation of the S136 pathway in London

Background and aims

NHS England and Improvement, Healthy London Partnership, Camden and Islington NHS Foundation Trust and Thalamos worked in partnership on a transformation project to improve the safety, care and efficiency in relation to the Section 136 care pathway across London.

The aims of the project were to:

• Improve the patient and family experience of crisis care, especially processes relating to Section 136 (S136) of the Mental Health Act
• Free up clinical time to care by reducing duplication of processes and data entry
• Improve safety and reduce suicide through better information sharing and communication between services
• Enable accurate data collection through the use of S136 so that London can work with partners to identify all avoidable detentions, especially men from ethnic minority backgrounds
• Streamline pathways including common cross city standard operating processes
• Three year aim is to reduce all avoidable use of S136 (including police use) and to advocate for proven effective NHS mental health crisis outreach and paramedic support to be commissioned

Solution

Working to achieve these aims involved taking five steps:

Step 1: Thalamos used the ZSA Suicide Prevention Resource Map to see how London benchmarked in their use of S136 police crisis powers for a person they identify as at risk in a public place.

The ZSA map showed:

• Over 5,000 Section 136 assessments are undertaken in London each year for a base population of nine million and working population of 12 million
• 50 percent of all S136 in London are brought to emergency departments (EDs) and the remaining 50 percent to mental health trusts S136 suites
• There is major variation in the numbers of S136 assessments and the processes across our nine mental health trusts, 26 acute emergency departments and 32 local authorities areas
• The London multi-agency Urgent and Emergency Care Programme agreed a ‘deep dive’ project to identify the current process and optimal improvement methods
• The ZSA special report that reviewed crisis services across England showed the need for ‘live real time’ S136 incidents to be on a pan London dashboard and for 111 to have digitally searchable local community services crisis alternatives

Step 2: Listened to lived experience

• Used Expert by experience (EbyE) focus groups to ask ‘what is it like now’ and ‘what do we want to change together in partnership’
• 20 EbyE lived experience stories about their S136 crisis experiences: from police assessment in the street to what happened in emergency departments and mental health trust S136 assessment suites
• Five common themes reported by EbyE patients and families:
  • It was not known where to get crisis help when unwell
  • Staff were kind when being assessed but did not often ask ‘what happened to lead to the crisis’ and ‘what do you need now’
  • The most common intervention was to be signposted to another service (for example NHS 111, GP, emergency department, mental health trust)
  • Families and trusted supporters were seldom involved to help
  • Did not have care plans with ‘advance decisions’ of what works to prevent repeat crises
  • Long waits for effective treatments
  • People from ethnic minority communities being more frequently detained under the Mental Health Act including police power of S136

Step 3: Mapped the pathway process across all agencies

Led by Camden and Islington NHS Foundation Trust and partners, a lean quality improvement multi-agency initiative was developed to map:

• Duplications of mental health assessments
• Quality and consistency of data entry from use of S136 forms
• Safety outcomes for patients and staff
• Avoidable delays
• Safeguarding
• Other issues that impact adversely on patient experience, outcomes, NHS trust efficiency and return on investment for the pathway process.

A report is available on this, contact us for more information.

Step 4: Digitalisation of the pathway and S136 paperwork as a major enabler for culture change and improvement  

• Used Thalamos software as service as commissioned by London Metropolitan Police to digitalise the police S136 form (part 1)
• London mental health trusts, NHS England and Improvement with Thalamos worked with a wide group of stakeholders to map the pathways and streamline the NHS handover form (part 2)
• Thalamos training rolled out to every police group, mental health and acute trusts in London

 Step 5: Partnership working with Experts by Experience, families and frontline staff

Developed a three minute promotional video in the voice of patients, families and frontline staff, including the rationale for the digitisation of S136 form (form 434). Signed off by the pan London mental health transformation leadership group/team, this was circulated across every mental health trust and emergency department/liaison psychiatry teams in London.

Watch the YouTube video to learn more.

Outcomes

Numerous outcomes were achieved throughout the project as described including the digitalisation of the S136 pathway in London. Full benefits are yet to be reviewed but will be monitored.

Please contact us if you would like more information or updates on this transformation project