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VVI-STUDIEREIS BIRMINGHAM 8-10 OKTOBER 2008. Programma Dag 1: - Uitleg over GGZ systeem en organisatie (universiteit + trust) - bezoek aan twee recent.

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Presentatie over: "VVI-STUDIEREIS BIRMINGHAM 8-10 OKTOBER 2008. Programma Dag 1: - Uitleg over GGZ systeem en organisatie (universiteit + trust) - bezoek aan twee recent."— Transcript van de presentatie:

1 VVI-STUDIEREIS BIRMINGHAM 8-10 OKTOBER 2008

2 Programma Dag 1: - Uitleg over GGZ systeem en organisatie (universiteit + trust) - bezoek aan twee recent gebouwde psychiatrische ziekenhuizen Dag 2: veldwerk: naar 18 verschillende teams Dag 3: debriefing en vraagstelling

3 SITUERING BIRMINGHAM  Population is 1.2million  40 % ethnic people (will be majority in 2020)  Single population is high  Higher levels of deprivation against England average  Less mobile population than England average  Inflow of workers from the Black Country  Unemployment rates significantly higher than England (high levels in the Pakistani population)

4 Historische context (1) Jaren 80 en 90 = Periode Thatcher: = periode van zware besparingen, ook in de gezondheidszorg Gevolgen voor de GGZ - NHS: poging tot ombouw naar marktwerking in de zorg - Sluiten van psychiatrische ziekenhuisbedden zonder opbouw van alternatieven

5 Historische context (2) Eind jaren ‘90 en jaren 2000 = periode van nieuwe opbouw, meer geld naar gezondheidszorg Gevolgen voor de GGZ - NHS: gecontroleerde marktwerking: commissioning vanuit eerstelijn - Opbouw van alternatieven in de maatschappij onder stimulans van nationale standaarden en monitoring => Geen vooraf vastgestelde zorgvormen

6 KENMERKEN NHS Aansturing van zorg (1) Parliament Secretary of State for Health/DH Strategic Health Authorities NHS Trusts PCT/Care Trusts Independent Sector Foundation Trusts Monitor

7 KENMERKEN NHS Aansturing van zorg (2)  Based on top down mechanisms  NSF, National Institute for Clinical Excellence targets and performance management processes  Period of extra spending on staff capacity and equipment  Based on a quasi managed market  Demand side: patient choice and commissioning  Supply side: Foundation Trusts and IS  Incentives: Payment by Results (related to activity)  Regulation: Monitor and Care Quality Commission

8 KENMERKEN NHS Organisatie Algemene geneeskunde (inreach voor psychiatrische functie in spoedgevallen & ICU) Geestelijke gezondheidszorg= 95% NHS en enkel voor korte duur privaat verzekerden Geen vrije keuze van huisarts of ziekenhuis Huisarts is de centrale figuur van de eerste lijnszorg, ook voor psychiatrie Geen rechtstreekse toegang naar tweede/derde lijn (in elke spoed is een HA aanwezig) Healthcare (regio), Social care & Welfare (lokale overheden) Vrijwilligers: charities

9 KENMERKEN NHS Toekomstige ontwikkelingen  Moving from input to outcome measures  Emphasis on strengthening of commissioning  Greater choice  Clinical Leadership  Payment of services based on quality and not only on activities

10 KENMERKEN NHS Verhouding NHS – andere sectoren NHS: Nationaal - Primary Care - GGZ -Verslavingszorg Sociaal Care Regionaal = tegemoet- komingen Welfare Lokaal o.a. Huisvesting

11 CONTEXT NHS Verhouding NHS – Huisvesting Welfare –Huisvesting -Zowel charities als private, commerciële organisaties - Soort erkenning door lokale overheid (stad) -Erkenning => Sociale en gezondheidsorganisaties kunnen er cliënten onderbrengen - Erkenning volgens 1 of meer types klanten: Fysiek gehandicapten / bejaarden / daklozen / GGZ / … - Huisvesting met gradaties in uren I(ADL)-ondersteuning per week met /zonder toezicht => serviceflat- achtig ? - Uren ondersteuning door klant zelf in te vullen

12 KENMERKEN NHS PATIENT BIJDRAGEN -Primary Care: gratis behoudens medicatie - GGZ -Medicatie gratis -Zorg: beperkt persoonlijk aandeel Welfare Huisvesting + I(ADL)-ondersteuning: persoonlijk aandeel PERSOONLIJK AANDEEL IN FUNCTIE VAN INKOMEN, LOS VAN DE ZORGVORM !!!! => Geen financiële barrières om patiënt door te schuiven van ene naar andere zorgvorm

13 Birmingham and Solihull Mental Health (Foundation) Trust Quasi de enige GGZ-speler in Birmingham Het resultaat van een fusieproces tussen vroegere trusts (van 6 naar 2 naar 1) One of the largest mental health Trusts in the UK Werkingsgebied Birmingham en Solihull = 276 km² Employ over 3,900 staff Zeer sterke binding met de universiteit train 20% of the Country’s Mental Health nurses Strong R&D base – clinical expertise nationally recognised Achieving Foundation Trust status => grotere financiële vrijheid 3 New Hospitals delivering 21 st Century MH Care

14 Total income = 267 miljoen euro Contact with 50,000 people a year Operating out of 106 sites 779 inpatient beds GGZ 53 wards 130 Clinical teams Nu bezig met herstructurering om aantal sites in te krimpen Veelal community teams op zelfde locatie als inpatient wards (gedeelde gebouwen) Birmingham and Solihull Mental Health (Foundation) Trust

15 Huidig zorgaanbod = aanbod in functie van commissioning met primary care trusts   Onderhandelingen als basis voor het zorgaanbod   De zorg die niet in het onderhandelde pakket zit, wordt ook niet gegeven vb persoonlijkheidsstoornissen Birmingham and Solihull Mental Health (Foundation) Trust

16 Duidelijk onderscheiden aanbod volgens leeftijdsdoelgroepen Kinderen en jongeren: opdracht van andere (somatische) trust => hele aanbod voor kinderen zit samen De BSMHFT: afzonderlijk aanbod voor working age (18-65 jaar) Elderly people (65+) Maar soepele grenzen tussen aanbod Birmingham and Solihull Mental Health (Foundation) Trust

17 UITBOUW VAN COMMUNITY MENTAL HEALTH Randvoorwaarden Development of effective individual community teams requires consideration of the impact on the whole system. Development of effective individual community teams requires consideration of the impact on the whole system. => uitbouw van slechts 1 element uit het systeem werkt niet There was an intentional shift of the centre of the service away from hospital into the community. This has had a significant impact on the function of the hospital too. There was an intentional shift of the centre of the service away from hospital into the community. This has had a significant impact on the function of the hospital too. => uitbouw van CMH heeft ook gevolgen voor het functioneren van de residentiële setting

18 UITBOUW VAN COMMUNITY MENTAL HEALTH Randvoorwaarden Functionalise community in same way that hospital was/is ‘functionalised’, i.e. separate specialised service or team Functionalise community in same way that hospital was/is ‘functionalised’, i.e. separate specialised service or team Drie onderscheiden functies  Primary Care Liaison  Short term Care: Crisis/ Home Treatment Service Community mental health team Residential Services; hospital etc.  Continuing Care: Rehabilitation/ Recovery Assertive Outreach Service

19  Emphasis on multi-disciplinary team working; social care integrated  Identifying clear roles and boundaries between functions i.e. teams A systems of filters and gateways A systems of filters and gateways Modeltrouw Modeltrouw Opleiding en vorming van medewerkers: alle medewerkers moeten individueel kunnen handelen tav cliënten Opleiding en vorming van medewerkers: alle medewerkers moeten individueel kunnen handelen tav cliënten UITBOUW VAN COMMUNITY MENTAL HEALTH Randvoorwaarden

20 VISIE OP ZORG Assessment gericht op functioneren van de cliënt en risicotaxatie, niet op diagnose Diagnose enkel belangrijk voor medicatie Weinig gericht op “therapie-Behandeling” Indien behandeling = Cognitieve gedragstherapie Veel aandacht voor de vragen / noden van de cliënten en hun familie   Individuele aanpak   veel inspraak van clïënten en hun familie ook in de bestuurlijke organen van de trust !

21 GGZ doet gespecialiseerde zorg en zorgt er voor dat cliënt elders de nodige ondersteuning krijgt => teamleden = zorgcoördinatoren (enkel gekwalificeerd personeel heeft caseload, vooral community psychiatric nurses niet-gekwalificeerden werken voor alle cl van het team   Continuïteit van de zorg:   Elk team volgt zijn cliënten, ook als deze intussen door een ander team wordt in zorg genomen   Elk team blijft ex-cliënten minstens 3 à 6 maanden verder opvolgen VISIE OP ZORG

22 GEVOLGEN CMH voor residentiële zorg Kleine eenheden 10 à 15 patiënten Eenheden unisex ( ethniciteit? ) Zeer hoge personeelsbestaffing: 5/5/4 Weinig tot geen afzondering, incidenten Verblijfsduur van dagen tot enkele weken

23 HOSPITAL Continuing needs: REHABILITATION wards LONG STAY wards ACUTE/ admission wards Out-patients department COMMUNITY PRIMARY CARE & AFTERCARE SERVICE Counselling &Depot injections PsychotherapyResidential care support Once upon a time.. Is dit België ?

24 COMMUNITY MENTAL HEALTH TEAM Primary CareContinuing Need: Liaison CONTINUING NEED ASSERTIVE OUTREACH TEAM Rehab and Recovery HOME TREATMENT TEAM Residential based care: Hospital Beds, Day services, Crisis Homes, PRIMARY CARE TEAM Model 2

25  PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, NOT the whole picture.. NOT the whole picture..

26  PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, NOT the whole picture.. NOT the whole picture.. EARLY INTERVENTION SERVICE SPECIALIST SERVICES

27  PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, Functional map Functional map

28 Primary Care Liaison Interface between primary care and specialist service Interface between primary care and specialist service Gateway to specialist services Gateway to specialist services Manage all new referrals from Primary Care Manage all new referrals from Primary Care Key workers with variable case load Key workers with variable case load Clinics, groups, home based intervention Clinics, groups, home based intervention Multidisciplinary team Multidisciplinary team

29 Primary Care Liaison Working hours service Working hours service Varies across city in terms of delivery because; Varies across city in terms of delivery because; Integration of a continuing needs service: ‘Community Mental Health Teams’ Integration of a continuing needs service: ‘Community Mental Health Teams’ Some Teams have a base with a day hospital-like facility Some Teams have a base with a day hospital-like facility GP’s prefer to provide part of a service themselves e.g. health promotion GP’s prefer to provide part of a service themselves e.g. health promotion Some GP’s commission a service within their surgeries Some GP’s commission a service within their surgeries Different development of Gateway workers Different development of Gateway workers

30  PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, Functional map Functional map

31 Home Treatment and Crisis Resolution ‘Acute’ psychiatric care at home ‘Acute’ psychiatric care at home Mobile, 24 hour 7 days a week service Mobile, 24 hour 7 days a week service Crisis resolution and Home Treatment Crisis resolution and Home Treatment Access to hospital beds Access to hospital beds Alternative to psychiatric hospitalisation Alternative to psychiatric hospitalisation Multidisciplinary team Multidisciplinary team Shared caseload ≤ 2:1 Shared caseload ≤ 2:1 Utilise home and community resources Utilise home and community resources

32 Crisis Resolution/ Home Treatment (CR/HT) Rapid response following referral Rapid response following referral Assertive approach to engagement Assertive approach to engagement Intensive intervention and support in the early stages of the crisis Intensive intervention and support in the early stages of the crisis Active involvement of the service user, family and carers Active involvement of the service user, family and carers Time-limited intervention that has sufficient flexibility to respond to differing service user needs Time-limited intervention that has sufficient flexibility to respond to differing service user needs Learning from the crisis Learning from the crisis

33  PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, Functional map Functional map

34 COMMUNITY MENTAL HEALTH TEAM Primary CareContinuing Need: Liaison Rehab and Recovery CONTINUING NEED ASSERTIVE OUTREACH TEAM HOME TREATMENT TEAM Residential based care: Hospital Beds, Day services, Crisis Homes, PRIMARY CARE TEAM Model 2

35 Rehabilitation and Recovery (Community Mental Health Teams) People predominantly with ‘severe/ enduring’ illness experience People predominantly with ‘severe/ enduring’ illness experience Complex social and health care needs Complex social and health care needs Long term service use Long term service use Need for community based support Need for community based support Recovery and social integration Recovery and social integration Individual case management but access to team resources Individual case management but access to team resources

36  PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, Functional map Functional map

37 Assertive Outreach Team based approach with key worker Team based approach with key worker Team responsible for meeting all needs Team responsible for meeting all needs Assistance in obtaining basic needs Assistance in obtaining basic needs Primary goal of improved client functioning Primary goal of improved client functioning Assistance with symptom management Assistance with symptom management

38 Assertive Outreach One team member is care coordinator One team member is care coordinator Smaller case load ( ≤ 15:1) Smaller case load ( ≤ 15:1) Treatment is individualised Treatment is individualised Services provided “out of office” Services provided “out of office” Assertive “can do” approach Assertive “can do” approach

39 Maintaining a framework Key issues: A system of filters and gateways A system of filters and gateways Fidelity Fidelity Early and later development problems Early and later development problems Staff training Staff training


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