What does good look like in liaison psychiatry? Developing inspection tools for mental health crisis care Nicola Vick Policy Manager Mental Health October 2014 1
Putting crisis care on the agenda Government attention on crisis care long standing problems Normal Lamb, Minister for Care & Support: national Concordat for improving outcomes for people in mental health crisis Theresa May, Home Secretary: Review of S136 of the Mental Health Act CQC commitment to map S136 places of safety CQC Context A new approach to inspection and regulation of health and social care services CEO/Chair commitment to thematic review on mental health crisis care 2
Taking a thematic approach Our themed review focuses on the experiences and outcomes of people at a time of mental health crisis. A key aim is to develop our approach to monitoring, inspecting and regulating the quality, safety and responsiveness of crisis care. We are taking a care pathway approach to look at how different organisations and agencies work together for three groups of people: Care Pathway 1: People who present to Accident and Emergency (including a focus on those who self-harm) Care Pathway 2: People who requires access to and support from specialist mental health services Care Pathway 3: People who are detained under Section 136 of the Mental Health Act 3
Testing our key hypotheses Our work explores the hypothesis that: responses to people experiencing a mental health crisis are highly variable, that in some places the quality of response is a matter of significant concern and that cross agency working is so fragmented that people are being failed because the risks are not being managed in an effective or safe manner. We are testing whether people s experience is dependent on: Where they live Services commissioned locally Staff training, experience and attitude How well services work together When the crisis takes place We want to explore whether there are: inequalities for different groups of people experiencing a crisis inappropriate uses of the MHA or lack of compliance with the Code of Practice issues relating to the parity of response existing models that allow CQC to establish a baseline of what is good in crisis care 4
Elements of our thematic work Phase 1: building our evidence base Review of national data Public call for evidence Survey to map health-based places of safety Phase 2: local area inspections We are currently developing our tools and methods to carry out 15 local area inspections: November 2014 to January 2015 Evidence-led and will explore where we think there may be issues with the care pathways Areas of good and poor practice 5
National data review Development of local area analysis to inform selection of inspection sites and plans to make analysis available Indicators for pathway 1 include: Admissions to acute hospital via A&E for a mental health condition (and for specific conditions) Acute hospital admissions for people who had multiple attendances at A&E Acute admissions for a mental health condition for people known/not known to specialist mental health services and for people with previous acute hospital admission Grading of liaison psychiatry service (national survey findings) PLAN members accreditation status 6
People who present to Accident & Emergency (including a focus on those who self-harm) What services are most relevant to this pathway? Primary care: GPs often first port of call for people experiencing a mental health crisis, including out of hours Ambulance: may be involved in assessing people s physical and mental health and in transporting people to A&E Accident and Emergency: Assessment and treatment of people who are in crisis Liaison psychiatry services: assessment, brief interventions and/or referral for follow up for people with mental health issues, including people who present after self-harming/with disturbed behaviour/substance misuse problems and people with dementia Meeting national standards means Access to support before a crisis: role of primary care in prevention/early intervention recognising people at risk & providing appropriate interventions Urgent and emergency access to care: timely response on a par with responses to physical health emergencies; people in mental distress should be kept safe and be provided with immediate care; liaison services should provide emergency/urgent assessment and treatment to adults of all ages throughout the hospital Quality of care and treatment: staff should be well equipped to work with people in crisis & treat them with compassion and dignity
People who present to Accident & Emergency (including a focus on those who self-harm) Accident and Emergency Increasing numbers of people are seeking access to crisis care in A&E services. Negative attitudes of general hospital staff to people experiencing a mental health crisis, particularly towards those who self-harm. Lengthy waiting times can mean people wait in environments not suited to prevent crisis escalation or may discharge themselves before being seen by a mental health professional. Wide variability in how liaison psychiatry services are commissioned means capacity and capability of the team will be different from location to location. There is a lack of integrated care and clarity about the care pathway for those who have substance misuse and mental health conditions. Parity Concerns Disparity between access to emergency physical health care and emergency responses for mental health crises including as a consequence of inequity in commissioning. Problems accessing crisis help outside weekdays 9am-5pm particularly specialist help e.g. for children and young people or for people with a learning disability. Equality Concerns Among BME groups, rates of self-harm have been identified as highest in young Black females (16-34 years) but they are also some of the least likely to receive a psychiatric assessment. 8
How will the crisis review help improve how we regulate and inspect? Inspecting specialist services New summary statements of what is good for crisis-relevant services Development of specific lines of enquiry for mental health crisis care that can be used where there is evidence of concerns Further testing of tools that can track a person s journey along a pathway of care with a specific focus on crisis New ways of working Exploring how CQC can inspect areas of multi-agency / cross-sector responsibility Piloting new inspection methods: multi-agency evidence review meetings meetings, increased emphasis on pre-visit evidence-gathering Informing with evidence A national indicator set for mental health crisis (and for each of the three pathways) to give national picture and to inform development of CQC intelligent monitoring An evidence base for future inspections Access to responses from the call for evidence that captures what service users, carers and local groups think about how local services respond to those in crisis 9
CQC s comprehensive inspections: What are we doing differently? Larger inspection teams including specialist inspectors, clinical experts, and experts by experience Intelligent monitoring to inform when and what to inspect Inspections on our five key questions about services Identified core services that we will always assess Key lines of enquiry (KLOEs) as the overall framework for a consistent and comprehensive approach Ratings to compare services and highlight where care is outstanding, good, requires improvement and inadequate 10
CQC s five key questions We ask these questions of all services: Is it Safe? Is it Effective? Is it Caring? Are people protected from abuse and avoidable harm? Does people s care and treatment achieve good outcomes and promote a good quality of life, and is it evidencebased where possible? Do staff involve and treat people with compassion, kindness, dignity and respect? Is it Responsive? Are services organised so that they meet people s needs? Is it Well-led? Does the leadership, management and governance of the organisation assure the delivery of high-quality patientcentred care, support learning and innovation and promote an open and fair culture? 11
Development of summary statements for mental health core services Summary statements of good practice drawn from and mapped to an authoritative sources including current policy, legislation and guidance Starting point is Royal College of Psychiatrists standards for peer-review and accreditation schemes where these are available for mental health core services Statements arranged under domain headings and mapped to the key lines of enquiry Output: set of statements of what good looks like for each core service 12
Crisis review draft statements for liaison psychiatry (key concepts1) Safety Management of risk and risk assessment practices Relationships between the service and other teams Follow up of referrals Effectiveness Meets best practice guidelines on staffing and skill mix Advice, training, development and support of staff Provision of brief, timelimited, evidence based interventions 13
Crisis review draft statements for liaison psychiatry (key concepts 2) Caring Dignity, respect and understanding Carries out assessment in private Support and information for people and their carers to enable decisions about their care/access to support Responsive Commissioning in line with agreed service standards Referral timescales and processes Access to appropriate specialist support Out of hours provision and information sharing arrangements 14
Developing inspection approach and tools We will test out how well our data analysis reflects the local picture of the quality of crisis care: Key question for discussion: What are the key indicators that you would suggest for us to monitor on an ongoing basis? We will test out the service specific statements of good practice as part of the mental health crisis review local area inspections: Key question for discussion: What are the key concepts/areas of practice that we should include? We will scope options for when/how to include a focus on liaison psychiatry within our new model of inspection and regulation: Key questions for discussion: How might this best work? 15