MENTAL HEALTH PRIMARY CARE SUPPORT SERVICE (PART 1 MENTAL HEALTH MEASURE) PERFORMANCE REVIEW

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Belinda Murphy
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1 AGNDA ITM May 2014 MNTAL HALTH PRIMARY CAR UPPORT RVIC (PART 1 MNTAL HALTH MAUR) PRFORMANC RVIW xecutive Lead: Chief Operating Officer Author: Head of Operations and Delivery Mental Health Clinical Board Contact Details for further information: Whitchurch Hospital 6502 ITUATION The Mental Health (Wales) Measure 2010, is a National Assembly for Wales (Welsh Government) law that has similar legal status to an Act of Parliament. The Measure introduces a number of important changes to the assessment and treatment of people with mental health problems in Wales. Parts 1 to 4 of the Measure set the main legislative requirements relating to mental health service provision and are supported by subordinate legislation and guidance. The Mental Health Measure UHB performance is reported to, and monitored by, the Welsh Government on a monthly basis, with reports back to the UHB Performance Monitoring Committee. In addition, the Mental Health Legislation Committee within Cardiff and Vale Health Board require a report on the operational performance arrangements and performance for all Parts of the Mental Health Measure. Part 1 of the Measure is the Primary Mental Health upport ervice (PMH) introduced 12 months ago following 0.5 million investment. Part 1 of the Measure has a number of functions. One of these includes the 28 day assessment target as a Tier 1 target. Demand has increased over the first 12 months of the measure to, currently, 550/600 referrals per month; as a consequence, compliance with this target has declined to a single figure percentage. The Mental Health Clinical Board has developed the following plan to return this performance to the 80% compliance target by mid June 2014 if current demand remains the same. BACKGROUND Part 1 of The Mental Health (Wales) Measure 2010 seeks to strengthen the role of primary care in delivering effective mental health care and treatment. Local Primary Mental Health upport ervices (PMH) will broadly provide the following 5 functions: Mental Health Primary Care ervice Page 1 of 9 People, Performance & Delivery Committee

2 1. identification and assessment assessment within 28 days of GP referral (Tier 1 target) 2. short-term treatment 3. referral on to an appropriate service 4. information and advice to individuals and their carers about interventions and care 5. support and advice to GPs and other primary care providers 0r more succinctly - ATRIL; Assessment, Treatment, Referral, Information, and Liaison. This new Primary Mental Health Team (PMH) is now 15 members strong; it is currently based in the Hamadryad CMHT and works within three locality teams mirroring the PCIC locality boundaries. The PMH provides a range of psychological interventions to people with mild to moderate mental health problems and is additional to the already established secondary care mental health service. The following diagram (Fig 1) is the integrated/tiered mental health service which provides a step-up and step-out filtering system consistent with the Mental Health (Wales) Measure and the Welsh Government Psychological Therapies in Wales Policy Implementation Guidance (PIG). This model has attracted national recognition. Fig 1. CARDIFF & VAL UHB INTGRATD COMMUNITY MNTAL HALTH RVIC Referral Pathway under Part 3 of the Measure only Foundation Level Psycho-education and Information CLINT GP O P N A C C Bibliotherapy ccbt Mental Health Promotion elf Help Groups L I A I O N Third ector ervices Benefits Advice Housing Advice Carers Groups Tier One LOW INTNITY C INTRVNTION R MDIUM INTNITY INTRVNTION L I A I O N N I N G PRIMARY MNTAL HALTH UPPORT RVIC HIGH INTNITY INTRVNTION A M N T Tier Two econdary Mental L I A I O N Health ervices Development of Information Hub R e f e r r a l P a t h w a y D i s c h a r g e P a t h w a y Mental Health Primary Care ervice Page 2 of 9 People, Performance & Delivery Committee

3 There are four methods by which an individual can access the various parts of the service: 1. directly into the open access Foundation level only, 2. into Tier One by GP referral or by secondary care, 3. into Tier Two by GP referral or referral following assessment by a member of the PMH, 4. directly into Tier Two for assessment under Part 3 of the Measure. ach pathway will be described in more detail when the model is deconstructed into its three Tiers as follows. The PMH provides a psychological model of care and it has been very successful in its 1 st year with the 28 day assessment element being only one of the 5 components of the service. Other elements include liaison and education support to primary care practices as well as therapeutic interventions provided without necessarily an assessment first it was agreed at an early stage that the usefulness of this model to service users had to remain a central focus with the nonassessment elements of the service delivered having equal importance. It was also agreed that the clinical model should not be compromised to meet the Tier 1 target so as to avoid a reduction in the general usefulness of the service to high numbers of users. However, all short term efforts will now focus to improve the position with respect to the Tier 1 target. Importantly, due to the success of the service, referrals have increased markedly through the 1 st year with 550/600 per month now exceeding the numbers of referrals per month into all of the CMHTs put together. With a limited resource, there are significant challenges regarding service sustainability Fig 2. Fig 2 LPMH Referrals Mental Health Primary Care ervice Page 3 of 9 People, Performance & Delivery Committee

4 These increasing volumes of referrals since the introduction of the LPMH team in January 2013 are creating increasing difficulties in meeting the Tier 1 standard for part 1 of the Mental Health Measures. In October 2013, the target reduced from 56 days to 28 days which served to increase the challenge in meeting it. This change, coupled to increased referrals and 4.6 whole time equivalent vacancies, have impacted dramatically on achievement of the target. In January, fewer than 4% of patients received an assessment within 28 days against an 80% target, and only 7% within 56 days. The residual demand and new referrals in February and March mean that it is likely that there will be no patients meeting the target before the end of the financial year Fig 3 Fig 3 first 12 month performance against tier 1 target in Wales. Mental Health Primary Care ervice Page 4 of 9 People, Performance & Delivery Committee

5 AMNT PMH recovery plan to meet Welsh Government assessment targets Projected figures for Quarter /14 indicate the PMH will receive approximately 550/600 referrals per month and under Part 1 of the Measure, the PMH is obliged to offer an assessment to those not self referring into a psychoeducation class. Based on this figure, to be within the Welsh Government target of assessing 80% of referrals within 28 days, the PMH would need to complete approximately 380 assessments per month or just under 100 assessments per week. This assumes that referrals will plateau at around about this figure but it is too early to say this with any certainty as the service has only been fully operational since April The current model being utilised, i.e., all referrals are offered a full assessment which is arranged via an appointment letter, is proving to be unsustainable because demand is outweighing capacity causing longer and longer waiting times for assessment. The PMH has also not been at full establishment since 'going live' in April '13 and the imminent appointment of a number of crucial posts will increase capacity to carry out Part 1 assessments, although this alone will not be significant enough to bring Part 1 assessment performance to the 28-day target. Therefore, there needs to be a period of over performance on assessment activity as well as service model itself needs to be redesigned for sustainability. In early March 2014, 4 possible scenarios were considered by the Mental Health Clinical Board and the Health Board through the MHCB performance meeting. The following scenario was chosen and Fig 4 plots the impact on performance. The scenario assumes full recruitment with average levels of absence of staff through sickness, and the capacity of the team being allocated to the 5 elements of the model. Actions Agreed to Improve Performance As of 1st April 2014 the PMH will operate a different system whereby all referrals will be contacted within two weeks of receipt of referral. Based on the findings of Dr. Jim White, Consultant Clinical Psychologist at Glasgow TP, namely that two thirds of referrals into the TP service did not want a full assessment but preferred a brief assessment with a view to quickly accessing an intervention, the PMH will offer a solution-focused first contact (which will include a risk assessment) whereby appropriate patients can be quickly fed into the low/medium/high intensity interventions or signposted/referred to other services. Those wanting a more comprehensive assessment will either have the assessment there and then, or will be offered the assessment at a later date. ufficient sessional time will be re-allocated from other components of the PMH model within the team temporarily in order to over-perform to recover to the 28 day target. If the findings in Glasgow TP are replicated here in Mental Health Primary Care ervice Page 5 of 9 People, Performance & Delivery Committee

6 Cardiff & Vale, the PMH will very likely be compliant with the Welsh Government target by mid June Those currently on the waiting list are being prioritised ahead of the new referrals. Indeed, these people are already being contacted using this new system. This revised model maintains the PMH commitment to delivering on all five functions of Part 1 of the Measure so capacity to deliver the interventions mentioned above is only partially affected in the short term. With regard to recruitment, a full time assessor commenced in April and a final clinical appointment is due in May 2014 completing the appointment of clinical staff. The service is currently looking to appoint an additional two full time junior admin staff to reduce the administrative burden on assessors. The first is due to start imminently with a final appointment to be made as soon as possible. The team will then be at full recruitment. In order to over perform for a number of weeks to return the performance to 80% compliance with the Tier 1 target, an additional Band 6 assessor has been temporarily placed in the team to undertake an assessment only service, and team staff have been requested to work additional hours up to vacancy resources again to undertake assessments only. The CNA and DNA policy in line with MHCB will be implemented stringently. All those referred will be initially contacted by phone to assess depth of assessment required. If the referred individual is not contactable, the PHM team worker will forward an appropriate self help pack and an opt-in letter. The Opt-in letter will explain purpose of contact and will ask for a response within three weeks from date of letter otherwise patient will be discharged. Opt-in letter will include a self-help pack specific to the needs of the patient as stipulated by the referrer in the referral. The person may answer and only require initial assessment in which case the assessor should complete assessment on PARI, write and send the assessment letter, allocate to the appropriate group mailing lists and so on, and leave then in tray with cover sheet instructions. Thirdly the referral may answer and require subsequent assessment in which case the assessor should complete full assessment at that time if able to and appropriate. If unable to at that time the assessor should book in their next available assessment slot and make a casenote on PARI. In the case of opt ins, the administrator will record the referral on the opt in spreadsheet if they do not contact the team within four weeks they are sent another DNA letter and discharged. Generally the one DNA and discharge policy applies to all DNAs. Mental Health Primary Care ervice Page 6 of 9 People, Performance & Delivery Committee

7 Fig 4: Note: Row 2 in 1 shows the figure for those already awaiting assessment. 1 May 2 June 3 July 4 August 5 ept 1 Refs req asst (approx) to keep within WG target of % of referrals being assessed within 28 days 2 Refs rolled over from previous month (as 7) Oct 3 Total number of referrals for the month (1 + 2) a Brief asst per month - core team hours b Brief asst per month additional hours a Full asst (1.5 assts/session) per month core team hrs 5b Full asst per month additional hours Total assts (4 + 5) No. of referrals rolled over into following month (3-6) Assessed this month Not assessed this month Waiting 28 days or less 0% 0% 37% 80% 100% 100% Waiting between 29 and 56 days 0% 37% 50% 20% 0% 0% Waiting more than 57 days 100% 63% 13% 0% 0% 0% Comments This Fig 4 trajectory of a return to 80% compliance by end of August 2014 is based on only 1 month s data collection related to the revised model. It dependant on at least 4 team members completing an additional day a week to undertake assessments, the over- establishment by a whole time Band 6 dedicated solely to undertaking assessments and the inclusion of two additional Band 2 administration assistants. The projection has been made factoring in average sickness levels, 42 weeks of capacity, variations for periods including Bank Holidays and traditional periods of high annual leave. The Mental Health Clinical Board is meeting with the directorate and the team weekly to monitor performance against this trajectory deviation from the expected performance will be escalated immediately. The Mental Health Measure reports into the Mental Health Legislation Committee. The Clinical Board has also met with the performance department prior to the submission of this report and agreed to overlay a standard UHB waiting list demand/capacity template onto these manually collated and calculated figures as assurance on the accuracy of the recovery projections. It is anticipated that the recalibration of the trajectory will show some in month variation but not impact on the planned trajectory overall. Mental Health Primary Care ervice Page 7 of 9 People, Performance & Delivery Committee

8 Performance Risk Log Risk Mitigation The PHM is a small team already exceeding all other referral numbers into MH - unexpected workforce issues such as sickness or staff turnover can have a disproportionate impact. The PHM team will be prioritized for recruitment and staff deployment where necessary The team has benefited from April by having an additional Band 6 assessor redeployed from elsewhere temporarily. The trajectory to recover performance depends on this post holder remaining. Within workforce guidance, the Band 6 redeployment will continue until the position is recovered or the MHCB will consider additional funding within the business plan for this post. The Tier 1 performance recovery in Fig 4 depends on the current total referral numbers remaining static at 550/600 per month. The new service has been in place for 12 months and the referral activity has remained static for 2 months. The MHCB does not yet have a performance dashboard all stages of performance activity reporting are undertaken manually, using resources within the team to undertake and rendering the MHCB slower in responding to changes in performance. It is not know in this will increase. This is a national issue. Following the changes described in this paper, the team will be running at full or close to full efficiency. The MHCB will consider redeployment of resources into this team or seek further WG funding alongside other UHBs The clinical teams are responding to the requests for the development of a dashboard which is underway. RCOMMNDATION The committee is asked to: APPROV the approach recommended by the Mental Health Clinical Board Financial Impact Quality, afety and The approach is making use of additional staff time resourced out of vacancies within the team. The additional demand management will be resource neutral within the budget for the Primary Mental Health upport ervice. Adopted, for reasons given within the report is to maintain the integrity of the PMH model in delivering its 5 component parts but also to adhere Mental Health Primary Care ervice Page 8 of 9 People, Performance & Delivery Committee

9 xperience to the routine target for assessment waiting times of 80% by 28 days. This will ensure a consistent standard is met for people waiting for a service. tandards for Health ervices Please summarise the impact of this report of the delivery of the tandards for Health ervices [tandards can be obtained on the following link Risks and Assurance quality and diversity Tier 1 Target for Mental Health supported by specific legislation under the Mental Health Measure. ee risk log A new service development which increases access to primary care services for mild to moderate common mental health problems, which did not exist previously. The model is based on an open access, locality basis and has improved age blind access to services for all groups. QIA completed nationally and locally. Mental Health Primary Care ervice Page 9 of 9 People, Performance & Delivery Committee

Implementing the Mental Health (Wales) Measure 2010

Implementing the Mental Health (Wales) Measure 2010 Guidance for Local Health Boards and Local Authorities on the Establishment of Joint Schemes for the Delivery of Local Primary Mental Health Support