Mental Health Services Monthly Statistics Exploratory Analysis: Response times between referral for urgent or emergency treatment up until the time of the first face to face contact with crisis resolution teams, February to April 2017, experimental statistics Published 23 August 2017 As part of publishing new statistics from the Mental Health Services Dataset (MHSDS), exploratory analysis is completed to understand the quality and completeness of the relevant data items. This month we present exploratory analysis into median response times for people referred for emergency treatment. Author: Community and Mental Health Team, NHS Digital Responsible Statistician: Dan Collinson Copyright 2017, Health and Social Care Information Centre. Copyright The Health 2017 Health and Social and Care Social Information Care Information Centre is a non-departmental Centre. body created by statute, also known as NHS Digital. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital.
Contents Introduction 4 Identifying the crisis care pathway 5 Results 7 Data quality 8 Time recording 10 Author: Community and Mental Health Team, NHS Digital Responsible Statistician: Dan Collinson Copyright 2017, Health and Social Care Information Centre. 2 Copyright 2017 Health and Social Care Information Centre. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital.
This is an Experimental Statistics publication This document is published by NHS Digital, part of the Government Statistical Service Experimental statistics are official statistics which are published in order to involve users and stakeholders in their development and as a means to build in quality at an early stage. It is important that users understand that limitations may apply to the interpretation of this data. More details are given in the report. All official statistics should comply with the UK Statistics Authority s Code of Practice for Official Statistics which promotes the production and dissemination of official statistics that inform decision making. Find out more about the Code of Practice for Official Statistics at www.statistictheysauthority.gov.uk/assessment/code-of-practice Find out more about Experimental Statistics at https://gss.civilservice.gov.uk/wp-content/uploads/2016/02/guidanceon-experimental-statistics_1.0.pdf ISBN 978-1-78734-090-9 This information will support discussions between providers and commissioners of secondary mental health, learning disability and autism services. For patients, researchers, and the wider public it provides up to date information about people using services and to support the monitoring of access to timely, evidence-based care. Copyright 2017, Health and Social Care Information Centre. 3
Introduction A person experiencing a mental health crisis often feels unable to cope or be in control of their situation. They may feel great emotional distress or anxiety, that they can t cope with day-today life or work, think about suicide or self-harm, or experience hallucinations and hearing voices. When a person is experiencing a sudden deterioration of an existing mental health problem, or are experiencing problems for the first time, they need immediate expert assessment to identify the best cause of action and stop you getting worse 1. The guidance on the care and support a person experiencing a mental health crisis should receive and appropriate quality standards have been outlined by the National Institute for Health and Care Excellence (NICE) 2.This defined package of care is referred to in this report as the crisis care pathway. In February 2014, 22 National bodies involved in health, policing, social care, housing, local government and the third sector signed the Crisis Care Concordat 3. The Crisis Care Concordat focuses on four main areas: 1. Access to support before crisis point 2. Urgent and emergency access to crisis care 3. Quality of treatment and care when in crisis 4. Recovery and staying well This exploratory analysis focuses on the second area of the Concordat; urgent and emergency access to crisis care. This exploratory analysis focuses on response times for people who are referred to mental health crisis resolution teams in need of an urgent or emergency clinical response. The care pathway is described in detail later in this report. The Five Year Forward View for Mental Health 4 also sets out initiatives to improve crisis care. As part of our role in supporting these initiatives NHS Digital are publishing new analysis exploring how the Mental Health Services Dataset (MHSDS) can be used to support this work. This report includes the first analysis of: The average (median) response times for people accessing crisis care The percentage of care contacts within 4 hours for emergency access to crisis care and within 24 hours for urgent access to crisis care The results of this exploratory analysis are published here in order to involve users of these statistics and data providers in the development of new statistics at an early stage, including assessing the quality and completeness of the supporting data. 1 More information on mental health crises, including what to do if you or someone you know is experiencing a crisis, can be found at http://www.nhs.uk/nhsengland/aboutnhsservices/mental-health-servicesexplained/pages/mental-health-emergencies.aspx 2 Available at http://pathways.nice.org.uk/pathways/service-user-experience-in-adult-mental-healthservices/service-user-experience-in-adult-mental-health-services-overview#content=view-node:nodesassessment-and-referral-in-crisis 3 Available at http://www.crisiscareconcordat.org.uk/ 4 Available at https://www.england.nhs.uk/wp-content/uploads/2016/02/mental-health-taskforce-fyfv-final.pdf Copyright 2017, Health and Social Care Information Centre. 4
Identifying the crisis care pathway The service standard reports response times on the crisis care pathway in hours. As a result of this the response times are calculated in hours and minutes between the start of the referral to a crisis resolution team and the first face to face contact with the team. This is to ensure that the calculations are precise enough to ensure targets have been met. The analysis reports on people who are 18 or over when the referral was received. In the future it is likely that analysis will be undertaken to produce response times for the Children and Young People (CYP) crisis pathway. This analysis focuses on patients whose first face to face care contact occurred between 1 February and April 30 2017: Clock start The patient must have the following to start the clock: The patient must either have an emergency or urgent Clinical Response Priority Type 5 for the referral. The patient must have been referred to either the Crisis Resolution Team/Home Treatment Service or the Crisis Resolution Team (community based crisis response teams hereafter). The clock start is the date and time that the referral request was received. Clock stop The clock stops after the following criteria is met: The patient must have had a face to face contact and must have attended the contact following the referral being received. The clock stops at the first instance of this. The time and date of the care contact is used as the clock stop. Figure 1 shows this pathway: 5 Full details of the fields used can be found in the Technical Output Specification which is available at: http://content.digital.nhs.uk/mhsds/spec Copyright 2017, Health and Social Care Information Centre. 5
Figure 1: The Crisis Care pathway Calculating the response time The response time is calculated in hours from the date and time of the referral to the community based crisis response teams (clock start) to the date and time of the first face to face contact following the referral which was attended (clock stop). The initial count of people includes all people who had a first face to face contact with the community based crisis response teams in the period. In some cases these people had a date of referral or contact recorded but no the time that the referral or contact took place. As such it was possible to know that they had a face to face contact following the referral but it was not possible to calculate the response times for these people. In these cases they are included in the initial count but excluded from later counts used to calculate the median response times and percentages of response times within 4 hours for emergency referrals and within 24 hours for urgent referrals. Copyright 2017, Health and Social Care Information Centre. 6
Results Between 1 February 2017 and 30 April 2017 there were 10,127 emergency referrals that had a face to face contact with the community based crisis response teams, of these 9,685 had sufficient data recorded in order to calculate the response time. In the same period there were 19,037 urgent referrals that had a face to face contact with the crisis resolution team, of these 17,055 had sufficient data recorded to calculate the response time. Data relating to emergency referrals with a care contact with community based crisis response teams between 1 February and 30 April 2017 can be seen in Table 1 below. Table 1: Emergency referrals with a care contact with community based crisis response teams between 1 February and 30 April 2017 1. Median response time is calculated from the referrals with a face to face contact with the community based crisis response teams with valid referral and care contact times. 2. Percentage of care contacts occurring within 4 hours is calculated from the referrals with a face to face contact with the community based crisis response teams with valid referral and care contact times. Table 2 provides data relating to urgent referrals with a care contact with community based crisis response teams between 1 February and 30 April 2017. Table 2: Urgent referrals with a care contact with community based crisis response teams between 1 February and 30 April 2017 1. Median response time is calculated from the referrals with a face to face contact with the community based crisis response teams with valid referral and care contact times. 2. Percentage of care contacts occurring within 4 hours is calculated from the referrals with a face to face contact with the community based crisis response teams with valid referral and care contact times. Copyright 2017, Health and Social Care Information Centre. 7
Data quality Data quality issues affecting the MHSDS are descibed in the Executive Summary for this publication, with specific metrics for individual months presented in the Data Quality Reports which accompany the monthly release. Data quality issues specifically relating to the crisis care pathway are detailed below. Across England 102 providers submitted data to MHSDS in the period between 1 February and 30 April 2017, of these 38 had data relating to emergency or urgent referrals to the community based crisis response teams. Whilst some providers in scope for MHSDS do not have crisis response teams and so not all providers will submit data relevant to the pathway, this does give some indication as to the use and completeness of fields related to the crisis care pathway across providers. Further information on the data that providers have submitted can be found in the Data Quality reports for each of the months used here. Of particular interest to this analysis is Data Quality measure MHS-DQM11. This relates to Service Team Type Referred To and provides information on Validity for each provider. Data Quality measure MHS-DQM20 provides information on the Clinical Response Priority Type but the measure is limited to patients with eating disorders under the age of 19 and as such cannot be used to inform data quality on the use of the field in this analysis. The Clinical Care Response Priority field which is used to determine whether a referral is urgent or emergency was also investigated. Of the 779,823 referrals which started between 1 February and 30 April 2017, 170,845 (22%) of these had no Clinical Response Priority recorded. Of the 779,823 referrals, 96,189 were to the community based crisis response teams. Of these referrals relating to the crisis care pathway, 15,037 (16%) had no Clinical Response Priority type. A further 4,110 could not be categorised as the codes submitted were valid. This can be seen in Table 3: Table 3: Referrals to community based crisis response teams starting between 1 February and 30 April 2017 by Clinical Response Priority Type. 1. Invalid includes submitted values which were not listed in Technical Output Specification for MHSDS as accepted values for this field. 2. Missing is a count of records where there was no Clinical Response Priority Type recorded. Whilst this analysis was limited to included only referrals for people aged 18 and over, it should be noted that of the 779,823 referrals in the period 123,436 were for people aged under 18. For people aged under 18, 2,966 of the 123,436 referrals were to the community based crisis response teams. These have not been included in this analysis as the NICE guidance and quality standards apply to adult services only. These figures do provide some understanding of the number of young people in contact with the community based crisis response teams in the period. Copyright 2017, Health and Social Care Information Centre. 8
For the purposes of this analysis data was only included in response time calculations if there was both a valid referral received time and a valid face to face contact time. Some records in the analysis were missing one or both of these times and as such they were removed from the response calculations. Currently 96% of reported emergency referrals with a face to face contact with the crisis team have valid dates and times reported to allow for response times calculations. Between 1 February and 30 April 2017 there were 10,127 emergency referrals in the period with a face to face care contact. 371 (4%) emergency contacts were removed due to having no referral request received time recorded. 135 (1%) emergency contacts were removed due to having no care contact time recorded 6. For urgent referrals the percentage of reported urgent referrals with a face to face contact with the community based crisis response teams that have valid dates and times reported to allow for response times calculations was 90%. Between 1 February and 30 April 2017 there were 19,037 urgent referrals in the period with a face to face care contact. 1,264 (7%) urgent contacts were removed due to having no referral request received time recorded. 843 (4%) urgent contacts were removed due to having no care contact time recorded. Current crisis care pathway response time calculations are based on the first care contact following the referral request received date regardless of the team type of the care contact team. Analysis was carried out to explore which teams these first contacts were taking place with. 95% of emergency and 94% of urgent referrals had a first face to face contact with the community based crisis response team (either recorded as a crisis resolution team or a combined crisis resolution/home treatment team). Details of the team types of the care contact can be found below in Table 4: Table 4: Team type of the first care contact by emergency and urgent referrals 1. Some unique care contact team IDs had multiple team types associated with them during the reporting period. In these cases the breakdowns will not sum back to the total. 2. Unknown includes care contacts where the team type was not recorded. 6 Some records had neither time recorded. These records are included in the figures shown here for contacts removed due to having no referral request received time recorded, and for contacts removed due to having no care contact time recorded. As such the total number of records removed is less than the sum of the two figures shown here. Copyright 2017, Health and Social Care Information Centre. 9
Time recording A further analysis of the times used for both the referral and care contacts to calculate response times was carried out in order to check the accuracy of the response times reporting. Accurate reporting is essential to the calculation of response times. In order to determine if a person has received a contact within a certain number of hours, the recording of both the referral time and the contact time must be precise to the unit of time below that, i.e. to a number of minutes. If it is not precise to that level then some cases may be reported as receiving a contact within a certain number of hours when this was not the actual experience of the person referred. This is explained in more detail in the example below. Example A person has an emergency referral which starts at 10:09. This referral is submitted as starting at 10:00. The care contact takes place at 14:04. This care contact is submitted as taking place at 14:00. The calculated response time for this referral based on the actual times is 4 hours 5 minutes. The time calculated based on submitted times is 4 hours. For the purposes of the calculation of number of contacts within 4 hours this referral and contact would be included in that percentage despite the response time actually being over 4 hours. Figure 2: Percentage of Recorded referral start times for both emergency and urgent referrals on the crisis care pathway, February to April 2017 1. Only the referrals used for the calculation of a response time on the crisis care pathway are displayed. Copyright 2017, Health and Social Care Information Centre. 10
When considering the referral request received times, it is possible to see that a large percentage of referrals are recorded as beginning at midnight. The number of referrals starting at midnight is also proportionally higher than other times overnight (between 18:00 and 08:00). As a result response times for referrals with a midnight start time are unlikely to be fully accurate. Some times will inevitably fall at midnight or midday however the submitted data would appear to be higher than expected, especially when compared with other percentages around these times. Figure 2 shows the distribution of response times for both emergency and urgent referrals. The recording of default times of midnight or midday is less of a problem for the care contact time. For care contacts the majority of the times recorded are between 09:00 and 19:00. Figure 3 shows the percentage of recorded care contact times for both emergency and urgent referrals. Figure 3: Percentage of recorded care contact times for both emergency and urgent referrals on the crisis care pathway, February to April 2017 1. Only the care contacts used for the calculation of a response time on the crisis care pathway are displayed. Further analysis into the minute of the time that the referral was received and the care contact minute was also carried out. Results for both referral received time and care contact time both show that submitted times tend to be recorded to the nearest 5 minute interval. There are also larger spikes in recording of times on the hour, 15 minutes, 30 minutes and 45 minutes past the hour. Copyright 2017, Health and Social Care Information Centre. 11
For both the referral start time and the care contact time there are a large number of times recorded as being on the hour. Of the referral start time, between 25 and 30% of referrals on the crisis care pathway start on the hour for both urgent and emergency referrals. For the care contact times around 30% of emergency referrals start on the hour, for urgent referrals this figure is around 42%. There is a similar spike for half past the hour. For the referral start time around 10% of referrals start at 30 minutes past the hour. For care contacts this number is around 22% for emergency referrals and just over 25% for urgent referrals. Despite this tendency for times to be clustered around these minutes it is worth noting that some of these times will be valid. Also for care contacts it is likely that these are scheduled before the contact occurs and as such it is potentially more likely for these times to fall on 5 minute intervals, and on major intervals in particular. Figures 4 shows the percentage of referral times by minute for both emergency and urgent referrals whilst figure 5 shows the percentage of care contact times by minute for both emergency and urgent referrals. Figure 4: Percentage of recorded care contact minutes for both emergency and urgent referrals on the crisis care pathway, February to April 2017 1. Only the referrals used for the calculation of a response time on the crisis care pathway are displayed. Copyright 2017, Health and Social Care Information Centre. 12
Figure 5: Percentage of recorded care contact minutes for both emergency and urgent referrals on the crisis care pathway, February to April 2017 1. Only the care contacts used for the calculation of a response time on the crisis care pathway are displayed. NHS Digital will work with service providers to further understand how the information used in the creation of these new statistics should be interpreted, and any limitations they have in recording any part of this activity. Any feedback gathered will be published alongside future reporting of crisis care activity. Copyright 2017, Health and Social Care Information Centre. 13
www.digital.nhs.uk 0300 303 5678 enquiries@nhsdigital.nhs.uk @nhsdigital ISBN 978-1-78734-090-9 This publication may be requested in large print or other formats. Published by NHS Digital, part of the Government Statistical Service Copyright 2017 Health and Social Care Information Centre. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. You may re-use this document/publication (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence v3.0. To view this licence visit www.nationalarchives.gov.uk/doc/open-government-licence or write to the Information Policy Team, The National Archives, Kew, Richmond, Surrey, TW9 4DU; or email: psi@nationalarchives.gsi.gov.uk Copyright 2017, Health and Social Care Information Centre. 14