This project was chosen following several cases where individuals had moved from other regions into the Thames Valley area, with little or no planning resulting in near misses. Likewise, when individuals from the Thames Valley moved to other regions e.g. for University, some regions did not accept the referrals in a timely coordinated manner, thus increasing the risk for the individual and their family. It was therefore agreed that the Thames Valley EIP Best Practice group would review its standard practices for patient transfers to firstly understand the issues and agree on a new standard procedure.

1. Early Intervention in Psychosis (EIP): Improving
Quality & Safety During Patient Transfers
Developed With Thames Valley EIP Best
Practice Group
Case Study Discussion

2. Patient Transfers and Handovers
The transfer of professional responsibility and accountability for some or
all aspects of care for a patient or a group of patients to another person or
professional group on a temporary or permanent basis.
National Patient Safety Agency
“
”

3. Project
Objectives and
Method
1. Objective:
To ensure continuity of care and minimise harm for people with first episode
psychosis through improved handovers between teams
1. Method
Patient harm can occur where people with psychosis move between teams without
proper handovers. These incidents are anecdotally noted with little strategic planning
on their reduction. To reduce these incidents, the Thames Valley EIP Best Practice
Group will:
1. Work with the Oxford AHSN Patient Safety Team to establish a baseline of near
misses and incidents occurring during transfer between teams
2. Agree a new Standard Operating Procedure of transfer of patients between
teams
3. Produce materials to embed new good practice across primary care, education
and secondary mental health teams, and share these at an event
4. Review incidents following project to determine if any changes in types or
frequency of incidents
5. Summarise key findings and share with wider EIP, health and social care
community

4. Delivery Issues
and Risks
4. Issues
The following risks were verified with Thames Valley EIP Clinical Leads as part of a
diagnostic meeting in September 2018:
1. Clinical Leadership - insufficient opportunity for clinical leads to meet to
discuss current pathways in and out of EIP as well as partnerships with other
teams
2. Data – although incidents should be reported internally via Risk Registers such
as Datix, there is little if any shared lessons and learning between teams across
organisational boundaries
3. Commissioning – lack of recognition that the new EIP age expansion has
increased demand on teams by up to 50%, arguably leading to less intensive
support for people moving between teams
4. Workforce – recruitment of staff remains an issue – teams have resorted to
recruiting less experienced band 5 clinicians who need more training in
supporting people to transfer safely between teams
5. Standard Operating Procedure – with teams using different practices across
the Thames Valley e.g. the minimum information required, there is a risk of
patients going without vital treatments/interventions

5. There are
Very Few
Community
Mental Health
Patient Safety
Studies

6. PROJECT UPDATE NOVEMBER 2018 (Q3)
Ref Issue Action Lead person/s or organisation delivering action Completion RAG
3.1 Clinical Leadership Reinstate a Thames Valley EIP Clinical Lead to bring
teams together to re-establish EIP Best Practice
Group
EIP Best Practice Group with support from
Oxford AHSN Patient Safety Team
Q3
3.2 Data Review five near misses and incidents that have
been reported involving transfers, to determine
any common themes
EIP Best Practice Group with support from EIP
Clinical Lead and Oxford AHSN Patient Safety
Team
Q3
3.3 Commissioning All commissioners are currently refreshing their EIP
Service Development and Improvement Plans – we
will endeavour to influence these plans to ensure
there is increased investment to increase capacity
of staff and enable better transfers, particularly in
view of the age expansion
EIP Network Clinical Lead, South EIP Programme
Manager & NHS England Quality Improvement
Leads in DCO Strategic Clinical Networks
Q3
3.4 Consistency Identify best practice and embed in new Standard
Operating Procedure (SOP) for EIP transfers and
induction for new staff
EIP Best Practice Group with support from EIP
Clinical Lead and Patient Safety Team
Q4
3.5 Embedding Best
Practice
Develop SOP and teaching materials for adoption
across all EIP teams in the Thames Valley. Host
event to share lessons learnt and learning
materials
EIP Best Practice Group and Oxford AHSN
Patient Safety Team
Q4

7. Survey of Thames Valley EIP Teams

8. Referral Sources

9. Use of Referral Templates

10. Information
Not at all satisfied Very satisfied

11. Joint Working Period

12. Comments

13. Other Thoughts
Q9 Is there anything else about patient transfers you would like to tell us?
Answered: 4 Skipped: 0
# RESPONSES DATE
1 Pressure and low capacity Pressure on the systems generally do mean that there is an increase
in last minute transfers of care, poor follow up and at time refusal from services to collaborate.
11/29/2018 3:43 PM
2 Different Trust Policies Different Trust policies regarding transfers of care can lead to risks in
transfer process
11/29/2018 9:08 AM
3 Transfer Protocol -formalised protocol would be helpful. Internally we have been looking at this 11/20/2018 2:31 PM
4 GP Registration Clients do not always register with a local GP in a timely manner. A recent
transferred client has not been seen by previous team for a number of months.
11/20/2018 1:23 PM
Early Intervention in Psychosis - Patient Safety During Transfers

14. Example Standard Letters to External Referrers
Dear XXXX
Thank you for referring XXXX to the XXXX team. Please note that all our CMHT's and EIP request a period of joint
working for up to six months, whereby we ask that you support your client with us to settle in their new
placement and local area; this will help to ensure all their health needs are catered for, including their
medication.
From our experience it takes time for a patient to settle into a new home and area. The familiarity of a known
care coordinator can help this settling down period and allow the client to feel supported during the transition
and any problems that might materialise can be effectively dealt with.
Once the client has had this period of stability, then we would be happy to hold the CPA transfer meeting to
discuss further and arrange a transfer CPA if appropriate, we ask that you retain responsibility for the care of the
client until this formal handover takes place. We also require the following up to date documentation:
1. Risk assessment and management plan
2. Crisis contingency/safety plan
3. CPA documentation/care plan
Please note, if your client is subject to 117 then you would still have responsibility for funding and monitoring the
appropriateness of the placement.
We look forward to receiving the above information and working with you to safely transfer XXXX and settling
them in their new home.
“
”

15. EIP Transfer Case Study Summary Timeline
15th September
• Referral received from EIP Team in a South West region Trust for young man with first episode psychosis
• He lives in the South West, but his University is in the South East
• He became unwell whilst home in April, treated by EIP and home treatment team and was detained under Mental Health Act in May
17th September
• Following triage by Single Point of Access, referral is passed on to EIP team
• Information on referral states client is a student who is returning to Uni in neighboring Trust’s locality
• He has a GP on campus where he will be living for the term
18th September
• EIP team assessor contacts referrer to confirm details of current residence (Uni Campus) and GP (GP is also on campus)
• EIP assessor also confirms that client is back at Uni in neighboring Trust’s locality
• Neighboring Trust had initially accepted referral in August, but changed their mind in previous week and declined referral
18th September – 31st September
• Negotiations with neighboring Trust’s EIP team ensue
• Neighboring Trust’s EIP team states they are not commissioned to treat individuals at this University even though it is in their locality
1st October
• Following further calls, emails and discussions with management - neighboring Trust’s generic CMHT accepts referral
• Offers appointment to young man for 2nd October
Please note that this is a fictitious case example which amalgamates several anonymized near miss cases. Any resemblance to a real case are purely by coincidence.

16. Discussion
5. Discussion
Questions for EIP Best Practice Group Clinical Leads
1. What are the main issues with the sequence of events in the case example?
2. Should the South West EIP team referrer have done anything differently?
3. Should the neighbouring Trust’s EIP team done anything differently?
4. Should the Thames Valley EIP team assessor done anything differently?
5. What are the pros and cons of the suggested different actions for point 3?
6. Do you have any other thoughts or comments about this patient transfer case
example?