ANNUAL REPORT 2012/13

Transcription

1 NHS Collaborative Commissioning Programme for Mental Health and Learning Disabilities National Framework for Secure Services ANNUAL REPORT 212/13 Mae copïau papur ar gael o Adroddiad Blynyddol y Fframwaith Cenedlaethol Dros Wasanaethau Diogel ar gyfer 212/13 (yn Saesneg neu Gymraeg, neu mewn print bras)

2 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 Report author Shane Mills Clinical Lead Acknowledgments Special thanks for the following colleagues for their support; Dawn Painter for collating and analysing the majority of data Carl Shortland for analysing the financial data Gareth Jones for developing and maintaining the Secure Services Database Jonathan Jones for maintaining the Secure File Sharing Portal Julian Baker for Project Leadership, and development of the National Framework Nic Cowley for procurement support throughout the year Karen Howell for leadership and personal support The SSCT for all the hard work in the first year If there are any questions or clarifications required in connection with this report you can contact the Secure Care Contract Team using the details below By telephone on By at Or in person by visiting our offices at West 3a, Whitchurch Hospital, Cardiff CF14 7XB 2

3 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 Contents Contents... 3 Foreword... 5 Executive Summary... 7 Background What are services? About this report... 9 Section A Overview and activity Snapshot of care for adult patients of NHS Wales Gender of patients in care Age profiles of adult patients in care Patients in learning disabilities hospitals Patients placed in Wales/England Secure care provision by LHB High care patient population by LHB Medium care patient population by LHB Low care patient population by LHB Secure care per each LHB population per tier Pathway into and out of care Delayed Transfers of care in medium care Patients with care coordinators registered on the Database Attendance at care and treatment planning reviews Length of stay in care Section B The National Framework What is the National Framework for Secure Services? Use of the Independent Sector Location of providers & NHS Secure units Activity on Framework Placement patterns Communication, Connectivity and Information Key performance indicators Section C Improving the Quality of Care What is the Secure Services Contract Team? Secure Services Contract Team Activities Hear Me! Project Section D Financial Activity Daily rate price decreases through price refresh mechanism National Framework cost reductions Cost benefit analysis Activity savings Total spend on care Appendix A Pathways by Local Health Board ABMU HB Pathway AB HB Pathway BCU HB Pathway C&VU HB Pathway CT HB Pathway HDda HB Pathway PT HB Pathway

4 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 Copies of the National Framework for Secure Services Annual Report 212/13 (either in English, large print or Welsh language) are available in hard copy. Please request a copy from the Secure Services Contract Team Office at Ward West 3A, Whitchurch Hospital, Park Road, Whitchurch, Cardiff. CF14 7XB. Or telephone Mae copïau papur ar gael o Adroddiad Blynyddol y Fframwaith Cenedlaethol Dros Wasanaethau Diogel ar gyfer 212/13 (yn Saesneg neu Gymraeg, neu mewn print bras) Mynnwch eich copi o Swyddfa Tîm Cytundebu r Gwasanaethau Diogel yn Ward Gorllewin 3A, Ysbyty r Eglwys Newydd, Heol y Parc, Yr Eglwys Newydd, Caerdydd CF14 7XB. Neu ffoniwch

5 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 5 Foreword Mrs Karen Howell Deputy Chief Executive, Hywel Dda Health Board Chair - NHS Collaborative Commissioning for Mental Health Group On behalf of Welsh Local Health Boards External We are now into the second year of this successful collaborative commissioning initiative for Secure Services. The 51 million National Contract was approved by the Minister for Health in January 212 and March 212 saw the establishment of the NHS Wales Collaborative Commissioning Group to oversee the delivery and the implementation of the National Framework. It was always hoped that should this initiative prove successful, consideration should be given to other collaborative commissioning work streams for Wales. Our operational team; The Secure Care Contract Team continues to deliver the benefits of the National Framework for this challenging and vulnerable group of patients; ensuring service providers maintain safe, high quality services within effective environments and deliver patient focused, evidence based outcomes whilst realising best value for money. The Secure Care Contract Team has worked assiduously with each provider to improve the quality of care provided, ensure the promotion of hope and recovery and enhance the patient experience whilst vigorously challenging providers on lack of performance. Further, I am encouraged that whilst there has been a demonstrable improvement in patient treatment and care, the cash released savings exceeded initial estimates with 3.64 million realised in 212/13 (Full Year Effect 4.2m). In addition, case managed and planned reductions in activity are estimated to have reduced the cost of care by a further 5m from 1 st April 213. This overall reduction in spend of 9.2m is equivalent to a 1% reduction in the total spend since 211/12. During this year a number of issues have become apparent; Collaborative Commissioning of care brings with it a broad range of issues and challenges which, through a Team Wales approach, can be shared, disaggregated if necessary and positively resolved. It is becoming apparent that the Secure Services Contract Team brings an additional and valuable stratum of assurance in relation to ensuring safety and quality of care for patients is monitored and thus sustained for those people in Wales requiring access to these services. The National Framework is a real and demonstrable step forward for improving commissioning from the independent sector in Wales. That for issues of openness and transparency it is vital that the NHS is held to the same standards and performance monitoring mechanisms as National Framework providers through the appropriate mechanisms. The benefits of a National Framework could be delivered for other service areas where NHS Wales commissions care from the independent sector. The establishment of the National Framework and most importantly the national performance management team has already realised benefits for patients, WHSSC and the Health Boards of NHS Wales. I am confident that if we continue to work in partnership we can achieve demonstrable positive health and social outcomes for patients, their families and carers whilst continuing to improve service quality and safety and ensure value for money for NHS Wales. Karen Howell Chair Secure Services Collaborative Commissioning Group

6 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 External project recognition Extract from 212 External Review of the NHS Wales Mental Health & Learning Disability Secure Care Procurement Project In summary, all involved within this innovative programme fully deserve the accolades and awards they have received. They have intuitively addressed the most challenging aims in healthcare, improving quality, patient experience and providing value for money. The collaborative approach is unique and this Team Wales approach should be built upon to further enable NHS Wales to meet the aim of providing healthcare that is comparable with the world s best. Well done! Carrie Marr, Director of Change and Innovation Tayside Centre for Change and Innovation Winner 212 Government Opportunities- Excellence in Public Procurement Award- Health and Social Care Organisations Winner 213 Welsh Public Sector Procurement Awards- Outstanding Leadership Shortlist HSJ Efficiency Awards 213 (Awards on 25 September 213) 6

7 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 Executive Summary With the establishment of the Secure Services Contract Team, NHS Wales has, for the first time, a comprehensive depiction of patients, providers, cost and activity across the sector. The National Collaborative Commissioning Framework for Secure Services has brought together representatives from 7 LHBs, WHSSC, HIW and CSSIW to share intelligence, concerns and share best practice around placements with independent sector providers. Two providers removed from the National Framework in the first year, SSCT supported LHB s to relocate all patients promptly and safely. 2+ hours of provider assurance visits undertaken by SSCT, providing additional assurance about the safety of patients in the Independent Sector. 1+ improvement actions imposed on National Framework providers and monitored for implementation, realising demonstrable improvement in quality of care for patients. National Secure Services Database provides standardised information to assist NHS Wales to proactively case manage patients and performance manage providers. National Secure File Sharing Portal has become the largest file sharing portal managed by NWIS in NHS Wales and enables rapid, safe exchange of clinical information between providers and commissioners. 7% reduction in number of patients in care since start of framework. 82% of patients placed with the top five National Framework ranked providers. 7% decrease in delayed discharges from care. Patients without allocated care coordinators reduced from 18% to 1%. 68% of patients placed within Wales. Real cash savings through cost reductions of over 4.2 million realised. 1% reduction in overall spend on care projected between 211/12 and 213/14. 7

8 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 Annual report limitations This annual report is based on activity from 1 st February 212 (commencement of the National Framework) until 31 st March 213 in order to realign with the standard reporting calendar. The pathway through care can take a number of years and this is the first annual report of the National Framework, therefore caution is advised when using data in this report as longitudinal data is not always available for comparison All savings are based on a snapshot of activity at 31 st March 213. Full year effects assume no further changes in activity, and savings are fully realised as placements reach the 1 year date from refresh date. Price changes are reflected as realised cash savings as they reduce spend for NHS Wales. Activity savings are estimated as savings to care and will be available to offset possible incurred costs in non- settings. No assumptions have been made on any further activity changes from 1 st April 213 in the 213/14 forecasts. Any spend on observations above 1:1 are excluded from both baseline and 31 st March 213 as incurred costs data is not available to SSCT. NHS low provision in ABMU and C&VU reflect activity on the 31 st March 213 census date only. Any admissions/discharges from these services are excluded on the basis they are wholly utilised within the host LHB. 8

9 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 Background 1. What are services? Secure services form part of comprehensive psychiatric services and are part of the care pathway for patients who require care under conditions of environmental, procedural or relational security. In Wales care services are generally divided into; High (special hospitals in NHS England classed as category B prisons) Medium (NHS/Independent sector Hospitals in Wales and England); and Low (NHS/Independent sector Hospitals in Wales and England) 1.1. High services In almost all cases, patients in high hospitals will have committed an offence and present a grave and immediate danger risk to themselves or others, combined with the potential to abscond. The Hospitals are not prisons but the physical security measures are equivalent to Category B prisons Medium services In most cases, patients in medium security will have committed an offence and present a serious risk to themselves or others, combined with the potential to abscond. They provide a level of security suitable for public protection. Access to medium services normally follows a court appearance or from general mental health care, or transfer from high care Low services Low services for adults are provided for those patients who have complex problems and cannot be safely or successfully cared for in acute inpatient wards. These patients are usually detained under the Mental Health Act and present a level of risk greater than general mental health care could safely address. Access to this service is typically from local mental health services (including PICU), from medium services or from the criminal justice system. The key functions of services are the assessment and treatment of patients mental disorder and management of the risk that the patient exhibits to themselves and others. It is this risk of harm that distinguishes care patients from those individuals with mental disorders who present to general psychiatry. 2. About this report Section A will provide an overview of all three tiers of care and provide a snapshot of care for patients of NHS Wales on March 31 st 213. Section B will then describe activity by providers and commissioners of medium and low care in the Independent sector under the National Framework for Secure Care for this reporting period. Section C will then describe the quality improvement activity undertaken by the performance management team of the National Framework (the Secure Service Contract Team). The report will conclude with Section D, the financial activity around services in general and specifically the National Framework. The admission and discharge pathway for each Local Health Boards patient population is outlined in the Appendices. 9

10 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 Section A Overview and activity 3. Snapshot of care for adult patients of NHS Wales 1 On 31 st March 213 there were 418 patients of NHS Wales in care (on the National Framework and including patients in NHS England high and NHS Wales Medium and Low facilities 2 ), the majority (53%) were in low facilities. This represents a 7.3% overall decline since the start of the National framework in February 212 when there were 451 patients of NHS Wales in care. The decrease in the number of patients in care has been uneven across the tiers with; 14% decrease in high patients (49 to 42) 1% increase in medium patients (155 to 156), and 11% decrease in low patients (247 to 22) High Secure 42 patients 1% Low Secure 22 patients 53% Medium Secure 156 patients 37% Fig. 3 Total patients of NHS Wales in services on March 31 st % Decrease in number of patients in care Fig 3.1 % and number of patients in care on March 31 st 213 by Local Health Board High % of high Medium % of medium Low % of low Total % of Secure Services ABMU AB BCU C&VU CT HDda Powys Total Excludes patients under 18 (5 patients were under 18 and in care on March 31 st 213) 2 Assumes full occupancy of facilities in NHS Wales 1

11 Number of patients Number of Patients NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/ Gender of patients in care In terms of the gender of Welsh patients in care the overwhelming majority (79%) are male, with the minority (21%) being female. This gender differential is in line with the UK average of 2% of women constituting the patient population of care Fig. 4 Gender of welsh patients in care across all tiers care on March 31 st Age profiles of adult patients in care The average age of adults in care is 34 years old. Men (37 years old) have a higher average age than women (31 years old). Men tend to be younger in high (35 years old) than either medium (37 years old) or low (4 years old).91% of patients are between 2-59 years old with 58% being 2-39 years old Fig. 5 Age ranges of adult patients in care on March 31 st 213 Under High Medium Low High Medium Low Male Female 6. Patients in learning disabilities hospitals Patients in mental health hospitals make up 91% of the total, whilst patients in learning disabilities hospitals make up the remaining 9%. Patients in learning disabilities facilities make up 5% of high, 12% medium and 8% of low care population LD MH 2 4 Low Secure Medium Secure High Secure Fig. 6 Patients in mental health /learning disabilities hospital on March 31 st Advances in psychiatric Treatment (21) 7: Not patients with primary or secondary diagnosis of learning disabilities 11

12 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/ Patients placed in Wales/England 3 Overall 68% of patients in care were placed in Wales, this increases to 75% if we exclude high (of which there is currently no provision in Wales). 73% of medium and 78% of low patients were placed in Wales. 69% of males and 66% of female patients in care were placed in Wales. England 32% Fig. 7 % of patients placed in Wales on March 31 st 213 Wales 68% 68% Patients placed in Wales Figure 7.1 below displays the percentage of patients placed in Wales by LHB, as expected those LHBs bordering England have lower percentages of patients placed in Wales (BCU 6%, Powys 6% and AB 71%) with C&VU (89%) and ABMU (85%) having the highest number of patients placed in Wales. Fig 7.1 % of patients placed in Wales on March 31 st 213 by LHB Powys HDDda CT C&VU BCU AB ABMU % 1% 2% 3% 4% 5% 6% 7% 8% 9% 1% ABMU AB BCU C&VU CT HDDda Powys England Wales Excludes CAMHS, of which there were 25 placed in England on March 31 st

13 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/ Secure care provision by LHB From the start of the National Framework (February 1 st 212) to March 31 st 213 an analysis of the total patient population profiles in high, medium and low care is shown below. Whilst Figure 8 demonstrates an overall small decrease in the number of patients in care, activity per each Local Health Board (shown in sections 9-11) demonstrates a considerable variation within each tier of care. Fig 8 Overall number of patients in care at Feb 212 and Mar ABMU AB BCU C&VU CT HDda Powys Jan Mar Figure 8.1, shows the percentage change in the number of patients in care per LHB with Powys and AB demonstrating substantial decreases in the use of care and other LHBs showing small decreases or small increases in the number of patients Fig 8.1 Change in total patient population in care (Feb 12 to Mar 13) listed by % change LHB Change in overall activity (- means less patients in care and + means more patients) Powys -27.3% AB -24.5% CT -4.1% C&VU -3.1% BCU -2.6% HDda +2.6% ABMU +2.7% 13

14 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/ High care patient population by LHB The normal stay in high is 5-6 years so the throughput in a given year is small and the small numbers can make the percentages appear exaggerated. Powys, BCU and ABMU demonstrated substantial decreases whilst C&VU and AB demonstrated a small increase in the number of patients in high within the reporting period Overall there was a 14% decrease in the number of patients in high 14 Fig. 9 Number of patients in high care at Feb 212 and Mar 213) ABMU AB BCU C&VU CT HDda Powys High Secure Jan High Secure Mar Medium care patient population by LHB Within the reporting period there was little change overall in the number of patients in medium care. Powys, CT, AB and HDda demonstrated substantial decreases and ABMU demonstrated a substantial increase in the number of patients in medium care within the reporting period 4 35 Fig 1 Number of patients in medium care at Feb 212 and Mar ABMU AB BCU C&VU CT HDda Powys Medium Secure Jan Medium Secure Mar

15 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/ Low care patient population by LHB Within the reporting period there was an overall a significant decrease (11%) in the number of patients in low care. AB, Powys and ABMU demonstrating substantial decreases in the use of low care, C&VU showing a small decrease, CT showing no change and HDda and BCU showing a moderate increase in the number of patients in low care within the reporting period 6 Fig 11 Number of patients in Low care at Feb 212 and Mar LHB ABMU AB BCU C&VU CT HDda Powys Low Jan Low Mar Secure care per each LHB population 4 per tier Figure 15 shows an analysis of the numbers of patients in each tier of care per 1, of population Note that the figures do not account for local epidemiological, social or demographical variations or factors. Adjusted figures are for ages 2-69, as they signify 99% of patients in care. Overall for each 1, citizens in Wales there are 14 in care, including only those between 2-69 years old there are 22.3 per 1, in care Fig. 15 Proportion of patients in each tier of care per 1, of population Pop. in 1, Adjusted (2-69 age group only) per 1, pop. High Secure per 1k pop. High Secure per k pop. Medium Secure per 1k pop. Medium Secure per k pop. Low Secure per 1k pop. Low Secure per k pop. Pop. in Secure care per 1k pop. Pop. in care per k pop. ABMU AB BCU CVU CT HDda Powys Total Figures from Public health Observatory, 27 figures (latest available that can be adjusted)

16 Fig. 13 Discharge destination and sources of admission for care High NHS medium Independent sector medium Independent sector low NHS England low Total NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/ Pathway into and out of care There were 28 admissions into, and 236 discharges from, care within the reporting period. Figure 13 illustrates the admission source and discharge destination for each of these patients. Breakdown by LHB available in appendix A. NHS Wales Pathway into and out of care Admission source Discharge destination Total High Secure NHS Medium Secure Independent sector Medium Independent sector Low NHS Low Secure Independent sector Rehab NHS Rehabilitation Psychiatric Intensive Care Unit NHS Acute Unit 24 Hr Supported Accommodation Community Courts/prison/police CAMHS Deceased Other

17 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 Figure 13, on the previous page, highlights some variation in the pathways of individuals moving into, through and out of care a) From February 212 to March 213 there were 28 more discharges than admissions in care. 13% The amount discharges exceeded admissions b) As expected, the principal sources of admission for services was the criminal justice system (courts/prison and police) with 44% of admissions into NHS medium from this source and for the Independent sector 35% of medium and 21% of low admissions were from this source c) Of the 82% discharged from high to medium 64% are discharged into the NHS and 18% into the Independent sector. d) 75% of discharges from NHS medium are stepped down to non- environments compared to 17% from Independent sector medium, this could possibly be a consequence of moving patients under the National Framework, repatriation to NHS, acuity of patients, differing models of care, availability of community outreach, or fiscal incentives to move people to lower tier of security more rapidly in Independent sector. e) 7% of patient discharged from the independent sector low units were stepped down to non- environments with the top three non- discharge destinations being; NHS rehabilitation units (23%), 24 hour accommodation (13%) and directly to community (13%) Figure 13.1, below demonstrates that of all the discharges and admission through care within this reporting period; 41% were stepped down to lower tiers of security 23% were transferred to another unit within the same tier of security, and; 17% were stepped up to a higher tier of security, 19% being discharged to or admitted from criminal justice or other areas. Fig Patients stepped up/down or transferred across tiers from Feb 12 to Mar 13 17% Stepped up 23% Transferred within tier 41% Stepped down 17

18 Number of Delayed Discharges NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/ Delayed Transfers of care in medium care In February 212 there were ten Delayed Transfers of Care (DToC) in NHS or Independent Sector medium units, in December 212 this had decreased to zero, whilst in March 213 it had stood at three Fig. 14 Number of DToCs from medium care Feb 12 to Mar 13 7% Decrease in DTOCs 15. Patients with care coordinators registered on the National Secure Services Database In February 212, across all LHBs, on average 19% of patients in care did not have a care coordinator registered on the National Secure Services Database. Since the commencement of the framework the SSCT liaise with the LHBs to identify a responsible care coordinator (now greatly assisted by the legal requirements of the MH (W) M 21) and the number of patients without a registered care coordinator was 1% on 31 st March Fig. 15 Percentage of patients in care without a care coordinator registered on the National Secure Care Database in Feb 12 and Mar ABMU ABHB BCUHB CVUHB CTHB HDHB PTHB Mar 13 % without recorded care co-ordinator Feb 12 % without recorded care co-ordinator 18% Decrease in patients without care coordinator since Feb 12 18

19 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/ Attendance at care and treatment planning reviews Good practice would indicate that every patient has a care and treatment plan (CTP) review at regular intervals. The SSCT encourages all care and treatment planning reviews to be uploaded onto the national Secure Services Database, of which 45% patients had their CTP document uploaded by 31 st March 213. Of the uploaded CTP documents 78% had evidence of attendance by the care coordinator or another representative of the LHB. As an example figure 16 uses data for low only 5 Fig. 16 % attendance at CTP recorded on CTP document uploaded onto the national database by LHB (excluding Cwm Taf HB) LOW SECURE ONLY ABMUHB ABHB BCUHB C&VUHB HDda PTHB No of patients Uploaded onto SSDb Reviews Attended Length of stay in care Ensuring patients stay for the minimum period necessary in care requires proactive discharge planning throughout the whole care pathway. Figure 17 demonstrates a significant reduction in length of stay in high over the last decade. Although caution is advised when using length of stay data in figure 17 as longitudinal data is not available for comparison. Fig. 17 Average Length of stay of completed episodes as at March 213 Tier High Secure NHS Medium Secure Independent Sector Medium Secure Independent Sector Low Secure Number of discharged patients as of 31 March 213 Average Length of stay in Years and Days 11 5 years 323 days 32 3 years 28 days 4 year 362 days year 199 days 5 Cwm Taf HB CTP documentation currently not uploaded onto the National Secure Care Database 19

20 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 Section B The National Framework 18. What is the National Framework for Secure Services? After two years of development the NHS Wales National Collaborative Framework for Low and Medium Secure Services (the National Framework ) was signed by the Minister for Health and launched on 1st February 212. The National Framework combines a unified placement process with national standards and specifications in order to provide assurance about care quality whilst standardising prices and driving down costs. Since its development, the National Framework has won the 212 UK Government Opportunities Award for Best Healthcare Procurement, the 213 Welsh Procurement award for outstanding leadership, shortlisted for the 213 Health Service Journal Efficiency award, publicised as good practice in the invest to save annual report and been held up as an exemplar project by an independent external review by NHS Scotland. 19. Use of the Independent Sector For NHS Wales s the use of the Independent sector for patients requiring care is greater (6%), than the use of NHS 6 provision (4%) with the disparity being greater in within low care (83% independent sector) than medium (45% Independent sector). There has been no change in the NHS provision of low and a 6% increase in the use of NHS medium compared to the independent sector within the reporting period. Fig. 19 Number and % patients in NHS & Independent sector on March 31 st 213 High 42 Medium 86 7 NHS Independent Low % 2% 4% 6% 8% 1% 6 All high hospitals in England counted as NHS

21 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/ Location of providers and NHS Secure units There were 14 providers with 41 sites at the commencement of the Framework, in March 213 this stood at 13 providers with 39 sites 7. There are also 4 NHS Wales s units and 2 high hospitals in England. Figure 2 shows the geographical location of each provider site and the NHS Units used for the provision of care by patients of NHS Wales. Fig. 2 Location of National framework providers (red) and NHS Units (Orange) Key Provider Site Key Provider Site 1 Mental Healthcare Ltd New Hall Independent Hospital 24 Coventry & Warwickshire NHS Trust Brooklands Hospital 2 St Lukes Healthcare Hillside 25 St Andrews Healthcare St Andrews Birmingham 3 Partnerships in Care Llanarth Court 26 Partnerships in Care Calverton Hill 4 Pastoral Cymru Ltd Ty Cwm Rhondda 27 Partnerships in Care Annesley House 5 Ludlow Street Group Heatherwood Court 28 St Andrews Healthcare St Andrews Nottingham 6 Priory Secure Care Ltd Cefn Carnau 29 The Huntercombe Group Ashley House Hospital 7 Pastoral Cymru (Cardiff) Ltd Ty Catrin 3 Lighthouse Recovery Ltd The Woodhouse Hospital 8 Ludlow Street Group Llanbedr Court 31 Partnerships in Care Hazelwood House 9 Cygnet Healthcare Ltd Kewstoke Hospital 32 Partnerships in Care The Spinney 1 Priory Secure Care Ltd Thornford Park 33 Regency Lodge Ltd Regency Lodge 11 Partnerships in Care The Dene 34 Partnerships in Care Arbury Court 12 The Huntercombe Partnership Cedar House 35 St George Healthcare St Mary s Hospital 13 The Huntercombe Partnership Huntercombe Hospital 36 Priory Secure Care The Priory Widnes 14 Partnerships in Care North London Clinic 37 St George Healthcare All Saints Hospital 15 Partnerships in Care Kneesworth House Hospital 38 Cygnet Healthcare Ltd Cygnet Hospital Wyke 16 St Andrews Healthcare St Andrews Healthcare Essex 39 Partnerships in Care Kemple View 17 Partnerships in Care Suttons Manor 4 The Huntercombe Group Linden House 18 Cygnet Healthcare Cygnet Hospital Stevenage 41 Partnerships in Care Stockton Hall 19 Partnerships in Care Oaktree Manor A BCUHB Ty Llywelyn 2 The Huntercombe Partnership Beech House Hospital B ABMUHB Caswell Clinic 21 Partnerships in Care Learning Disability Centre C C&VUHB Low Unit 22 The Huntercombe Partnership Rowan House D Mersey care NHS Trust Ashworth Hospital 23 St Andrews Healthcare St Andrews Northampton E Nottingham Healthcare NHS Rampton Hospital F ABMUHB ISIS Unit provider with 1 unit entered into administration and 1 unit from another provider removed from Framework for quality issues

22 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/ Activity on Framework There are currently 266 patients placed under the National Framework, the number of patients placed with each of the National Framework providers is shown in Figure There have been 169 admissions and 18 discharges in total from National Framework between February 212 and March 213 with Figure 21, below, showing the number of admissions and discharges from each provider between February 212 and March 213. Comparing the number of discharges and the number of admissions for providers is indicative of usage under the National Framework. Fig. 21 Number of patients with each National Framework provider on March 31 st 213 (Providers in volume order, alongside number of admissions and discharges between Feb 12 and Mar 13) 65 admissions 13 admissions 24 admissions 1 admissions 11 admissions 13 admissions 23 admissions 5 admissions 5 admissions 1 admission 1 admission Partnerships in care 98 pts Ludlow Street Healthcare 42 pts Priory Secure Services Limited 27pts Pastoral Cymru (Cardiff) Limited 19 pts St Andrews Healthcare 16 pts Pastoral Cymru Limited 14 pts Cygnet Healthcare 13 pts Mental Healthcare UK Limited 11 pts Regency Hospitals 6 pts St Georges Health Care 3 pts The Huntercombe group 3 pts 73 discharges 28 discharges 15 discharges 7 discharges 6 discharges 14 discharges 13 discharges 2 discharges 1 discharges discharges 7 discharges 8 Two providers with zero NHS Wales patients on March 31 st 213 excluded from table 22

23 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/ Placement patterns The National Framework uses a ranked provider model where for each specific area (called Lots) service providers are ranked with others able to provide this same service within their units (for example: Lot 4 is medium female mental health). There are 8 Lots in total with at least 6 providers in each Lot, with the uppermost number being 11 providers. In order to ensure that providers are incentivized offer best value to achieve, the process of the National Framework encourages LHBs, where clinically appropriate to do so, to place patients with the highest ranked provider. It is an encouraging sign that 82% of patients have been placed with the top 5 ranked providers, with over 5% placed with the top 3 ranked providers. Fig. 22 % of patients placed with ranked providers between Feb 12 and Mar 13 82% Patients placed with top 5 providers in each lot 18% Patients placed with provider ranked below 5th 23. Communication, Connectivity and Information The Secure Services Contract Team has been working in partnership NHS Wales Informatics Service to promote, develop and maintain systems to support contractual rigour and performance management of the National Framework. Two systems in use by the SSCT are; National Secure Services Database This intranet system provides standardised information and multiple functionality (figure 23) to assist NHS Wales with the proactive performance management of providers Demonstrates activity volumes and costings News Page Rapid access to clinical information Bed availability for Framework Providers National, regional and local planning data Fig. 23 Functionality of the National Secure Services database Downloadabl e Framework Documents Patient level performance indicator measurement Comparable consistent performance monitoring information Follows a patients journey through their pathway 23

24 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 Secure File Sharing Portal The Secure File Sharing Portal is a way of sharing information through an online application. The SSCT is a paperless team so ensures all National Framework providers and Local Health Boards utilise the Secure File Sharing Portal, as it ensures the instantaneous safe transfer and distribution of sensitive, confidential information The main objectives of the Secure File Sharing Portal Service are to; Enable the sharing of sensitive information such as Person Identifiable Information and commercially sensitive information and ensures this data cannot be intercepted, corrupted or misplaced The sharing of large volume information Enables information to be shared instantly Enables communication between SSCT, providers, Local Health Boards and 3 rd Party organisations inside and outside of NHS Wales Eliminate postage costs The Secure File Sharing Portal currently has over 2 users coordinated by the Secure Care Contract Team Currently, the Secure Services Contract Team has the largest file structure managed by NWIS within NHS Wales with a total of 9,121 folders. Figure 23.1 demonstrates the information types flowing through the portal Fig Exchanges through the National Secure File Sharing Portal Performance reports Clinical reviews Termination Notices Care and Treatment Plans Observation forms Key Performance Indicators Patient Placement Agreements Remedial Action Plans Serious incident reports DToC notices 24

25 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/ Key performance indicators Key Performance Indicators (KPIs) are used by SSCT to examine and compare performance across providers on the National Framework in order to: Provide a comprehensive picture of the providers progress towards achieving its performance targets Provide an early indication of emerging issues that may require remedial action Indicate where there is potential to improve the cost effectiveness of care through comparison with other providers These KPI are reported on quarterly by providers, there are currently four KPIs in place as set out below: KPI 1 - Care Plan The Service User will have an up to date care plan in place All Service Users will have an individual care plan in place that meets CPA requirements (and where applicable requirements of the Mental Health (Wales) Measures) and sets out plans to address and manage their needs by identifying admission objectives and therapeutic requirements to achieve identifiable outcomes. The care plan will state the anticipated length of stay. At a maximum interval of 1 month the care plan will be reviewed and updated. KPI 2 - Physical Health Care The provider will ensure that the improvement in the physical health of all Service User s is an integral part of their care and treatment plan. After a physical health check within 2 weeks of admission Service User s will have in place a physical health and health promotion plan (or specified within the overall care plan) that identifies physical health and health promotion needs and set out plans to meet those needs. The physical health and health promotion needs will be reviewed at a maximum interval of 3 months. KPI 3 - Therapeutic Activities The Service User will be enabled to receive a minimum of 25 hours specific individual and group therapeutic activities per week (including but not limited to rehabilitation programmes, occupational therapy, relapse prevention, psychological therapies and addressing offending behaviour). The Service User s activity programme will be based on multi-disciplinary assessment, formulation and personalised planning. These therapeutic activities will be based on sound research using a model that has measurable outcomes and delivered by appropriately qualified and experienced Staff trained in their use. KPI 4 - Risk Management All Service User s will have in place an individual risk management plan developed from comprehensive, multidisciplinary clinical formulations and assessments, the risk management plan will be reviewed at a maximum period of 3 months. Individual risk management plans will include types of Interventions (medical and psychosocial), Supervision (on leave or on unit) and Prevention (including utilising the Service User s own internal/external positive coping strategies). 25 The target rate for the Key performance is 75% or over, the SSCT validate all returns during reviews. The majority of providers self report 1% compliance, however a number of providers have reported less than the target rate and these providers are being performance managed.

26 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 Section C Improving the Quality of Care 25. What is the Secure Services Contract Team? The NHS Wales Secure Services Contract Team is a new national specialist team serving the seven Local Health Boards (LHB) and WHSSC. The team performance manages the National Framework providers and supports WHSSC in the performance management of NHS specialist high and regional medium care. It is also available for comparable reviews of NHS Wales s facilities. The team ensures providers of care are doing so in safe and high quality environments that promote rehabilitation and recovery and with experienced staff using treatments that are evidence-based and effective, whilst ensuring public protection and value for money. 26. Secure Services Contract Team Activities The Secure Services Contract Team has been fully established since September 212. The team consists of a clinical Lead, WHSSC Lead, Senior Nurse, 4 Nurse Reviewers, Performance Manager, Team Coordinator and Administration support. The SSCT performance manages providers by; Collecting and analysing performance management information on providers in line with national specifications, standards or contracts Challenging providers on lack of performance Ensuring providers reduce risk and promote hope, recovery and rehabilitation Ensuring all procured care are provided and provide value for money Ensuring quality and safety concerns about providers are raised, discussed, collated and disseminated by statutory agencies, Local authorities and LHB s Facilitate collaborative working between providers and commissioners to ensure safe and effective care The team had 51 clinical hours at its disposal, of which 44% (2242 hours) were spent with providers undertaking the activity outlined in figure 19. The remaining 56% of the hours was spent liaising with and supporting LHBs, gathering intelligence on providers, preparing for and writing reviews or team development Fig. 26 SSCT deployed clinical activity in hours Independent sector provider reviews 1762hrs High provider reviews 144.5hrs NHS Medium support 51hrs CAMHS support 37hrs Action Plan compliance 247hrs 26

27 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 Within the reporting period the Secures Services Contract Team undertook the following actions; Issued 1+ improvement actions. Issued 3 remedial Action plans with a total of 34 actions. Suspended 1 provider. Terminated 2 providers (One for financial reasons and the other for poor quality). There are areas of good practice in many providers; mainly good quality environments of care and reasonable nursing and medical staffing levels The principle areas of for quality improvement were: Making care plans person centred, comprehensive and based on multiprofessional assessment with clear outcomes. Ensuring risk assessments were based on robust formulation with a clear indication of current and historical risks and accompanied by a clear management plan. Ensuring patients receive at least 25 hours of therapeutic activity. Ensure every provider has robust safeguarding procedures in place. On completion of every review the SSCT issues a review report and improvement action plan, which is then monitored. These are all available through the national Secure Services Database. 27. Hear Me! Project Although person-centred care, participation and empowerment characterise national policy priorities, these were alien to the experiences of Winterbourne View Hospital patients and their families. Their silencing was scandalous 9 The SSCT is developing a number of initiatives to ensure that the views of service users are central to the quality monitoring of National framework Providers. The five aims of the project are; i. To ensure that the voices of care users in care are listened to and acted upon by NHS Wales. ii. To provide an opportunity for commissioners of care to ensure that physical interventions are not used as a means of intimidation or punishment. iii. To ensure that the views of advocates are directly conveyed to the commissioners of care. iv. To ensure that the views of carers are directly conveyed to the commissioners of care South Gloucestershire Safeguarding Adults Board, Winterbourne View Serious Case Review

28 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 v. To ensure that the views and recommendations of the advocates, carers and care users are clearly articulated to, and acted upon by the Independent Sector Provider. The initiatives include; strengthening the role of the general advocate, confidential meetings with service user representatives, debrief of service users after physical interventions, joint work with service user charities and service user surveys. Figure 3 shows the results of a pilot questionnaire undertaken with 57 service users in care to ascertain whether they perceived themselves valued by the provider. The results show that service users knew how to raise a complaint and that they are valued by staff but less than 5% felt the organisation changed its practice in light of concerns (question 7)and a majority thought the organisation could do better to listen to the voice of the service user (question 8). Fig. 3 Response to service user questionnaire Question Yes No 1 Do you feel that your issues, when raised are valued by staff? 2 Do you feel that your views are being valued by the organisation? 71% 29% 61% 25% 3 Do you receive feedback when you raise a concern or make your views known? 68% 29% 4 Do you know how to make a complaint? 71% 21% 5 Do you know how to raise an issue regarding your treatment (not complaint)? 68% 18% 6 If your issues cannot be resolved at ward level, are you aware of the process to raise them at a more senior level? 62% 27% 7 Do you feel that the organisation is changing their practices in light of concerns / complaints? 43% 46% 8 Do you think that the organisation could do better to listen to the voice of the patient? 65% 27% 9 Would you know what to do if you saw something untoward happening on the ward (eg a nurse shouting at a patient)? 61% 25% 1 How would you raise an issue if someone was behaving in a threatening manner towards you (if it was a fellow patient, or member of staff)? 82% % 11 Do you know who you patient representatives are on the ward 68% 21% 12 Do you feel that your service user representatives take your views forward to the patient council meetings? 57% 14% 13 Do you receive regular feedback from the ward meetings via the ward representatives? 54% 35% 14 Do you feel that the weekly ward/staff meetings promote freedom to air views and seek resolutions? 72% 2% 28

29 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/213 Section D Financial Activity 28. Daily rate price decreases through price refresh mechanism The price structure of the National Framework is based on a daily price for a specified service under a specific Lot (Lot defines different care). The National Framework incorporates quarterly price refresh points, where providers have the opportunity to move prices downward in order to increase standing on the provider rankings. Through 212/13 there were 4 price refresh points and the decrease in the daily price ranged from.6% to 6.6% across the eight Lots. Fig. 28 Decrease in average daily price through price refresh mechanism Lot 1 Medium Male LD Lot 2 Medium Female LD Lot 3 Medium Male MH Lot 4 Medium Female MH Lot 5 Low Male LD Lot 6 Low Female LD Lot 7 Low Male MH Lot 8 Low Female MH Average price on 1st February Average price on 31st March % drop National Framework cost reductions The National Framework has as one of its aims the reduction in the per capita cost of care. This has been achieved in 212/13 by; Cost reductions across providers at commencement of contract (by reducing daily rates) resulted in cash savings of 2.9m in 212/13 Four price refresh points realised further cash savings of.7m in 212/13 (Full Year Effect 1.25m). Fig. 29 Realised savings by LHB LHB Initial framework savings Price refreshes (Part Year Effect) Total Realised cash savings of 4.19m Cash Savings 12/13 Price refreshes (Full Year Effect) Total Cash Savings ABMU 416,22 132, , ,6 649,82 AB 361, , , ,325 69,879 BCU 897,272 12,947 1,, ,935 1,46,27 C&VU 217,883 97, , ,47 392,353 CT 357,517 78,96 436, ,4 488,917 HDda 132,86 53,83 186,663 13, ,155 Powys - 2,845 3,332 9,487 55,48 34,635 WHSSC 577,34 16, ,976 79, ,591 Total NHS Wales 2,939, ,784 3,636,567 1,255,756 4,195,539

30 NHS Wales Collaborative Commissioning for Mental Health and Learning Disabilities Annual Report 212/ Cost benefit analysis The cost of procurement exercise was met by 169, of Welsh Government Invest to Save funding with additional project leadership costs met by a collaborative Team Wales approach. 5, annual budget for SSCT met by funding released through WHSSC 169,+ 5,= 669, Procurement and first year costs 212/13 Attributable realised cash savings = 4,195, Resultant cost benefit of every 1 invested into National Framework realised 6 Fig. 3 National Framework cost benefit analysis for 212/ Activity savings Reductions in activity and movements through the care pathway have led to spend being reduced by a further 5m. The major factors have been; SSCT encouraging discharges and price reduction in high care leading to reduction in cost from 16.11m to 14.35m. Of these savings 1.28m has been released from high contracts in 213/14. Medium costs have increased slightly by.2m partly due to the increased level of step down from high care. However the initial medium savings from the framework have been utilised to fund the ongoing costs of the care contract team of.5m. Discharges, changes to placement practice and lateral transfers to higher ranked providers in have led to a reduction in cost in low from 37.53m to 3.1m. It is estimated that 3.98m of the total 7.52m savings in low is due to activity changes. Fig.31 Projected savings from care through activity for 213/14 LHB Projected Full year 13/14 Activity ABMU 838,187 AB 3,352,747 BCU - 419,93 C&VU 628,64 CT - 29,547 HDda - 628,64 Powys 419,93 WHSSC 1 1,44,152 Total NHS Wales 5,25, Figure includes SSCT team costs, high savings and projected overspend on medium