Measuring and monitoring quality in mental health: preparing to implement the new access & waiting time standards Sarah Khan Deputy Head of Mental Health NHS England
This presentation 1. Context for the introduction of access and waiting time standards for mental health services 2. The standards to be introduced from 15/16 3. The data challenge: What data do we want? What data do we have? What are we doing about it? 4. Measurement challenges, opportunities and hopes for the future
1. Context for the introduction of access and waiting time standards for mental health services
MH 5YP: rebalancing the system Prevention Early intervention Effective care Recovery Right care Right time Right setting
The system is currently not in balance
There is a 15-20 year gap in the life expectancy of individuals with serious mental illness compared with the rest of the population Health promotion activity, physical health assessments and interventions need to be integrated at every level if the 15-20 year mortality gap is to be closed.
We are also missing opportunities to deliver better and higher value care to individuals receiving treatment for a physical health condition If we are to improve outcomes and quality of life for individuals with physical health needs, then: a. Promotion of positive mental health as part of condition management b. Recognition of mental health needs c. Timely access to expert assessment and evidence based mental health care Will need to be integrated at every level of the physical healthcare system. a + b + c = reduced demand from repeat attendances in primary care, UEC and outpatient clinics = reduced acute length of stay = better outcomes at lower cost for individuals with long term conditions
2. The standards to be introduced from 2015/16
The October announcement From 1 April 2016: More than 50% of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral. 75% of people referred to the Improving Access to Psychological Therapies programme will be treated within 6 weeks of referral, and 95% will be treated within 18 weeks of referral. 30m investment is to be targeted on effective models of liaison psychiatry in a greater number of acute hospitals.
The Autumn Statement The Autumn Statement 2014 outlined the provision of additional funding of 30million recurrently for 5 years to be invested in a central NHS England programme to improve access for children and young people to specialist evidence-based community CAMHS eating disorder services. Part of this programme funding will be used to develop an access and waiting time standard.
The Spring Budget The Spring Budget 2015 included an announcement of 1.25bn new mental health funding over the next 5 years ( 250m per year) to improve access to mental health services for children and young people and for mothers experiencing perinatal mental illness.
We need standards for access to mental health treatment for people of all ages that balance the equivalent standards for physical health. We need the same quality of data and transparency about performance for mental health services for people of all ages so that long waits for effective treatment are visible and have to be tackled. Rt. Hon. Norman Lamb Minister of State for Care and Support
3. The data challenge
The EIP standard The new access and waiting time standard requires that, by 1 April 2016, more than 50% of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral. The standard is two-pronged and both conditions must be met for the standard to be deemed to have been achieved, i.e. A maximum wait of two weeks from referral to treatment; and Treatment delivered in accordance with NICE guidelines for psychosis and schizophrenia - either in children and young people CG155 (2013) or in adults CG178 (2014). Most initial episodes of psychosis occur between early adolescence and age 25 but the standard applies to people of all ages in line with NICE guidance.
What are we aiming to do? In 2011, No Health Without Mental Health, highlighted the effectiveness of EIP services. When delivered in accordance with NICE standards they help people to recover from a first episode of psychosis and gain a good quality of life. We want to ensure that: Duration of untreated psychosis is reduced and anyone with an emerging psychosis and their families and key supporters can have timely access to specialist early intervention services which provide interventions suited to age and phase of illness. Individuals experiencing first episode psychosis have consistent access to a range of evidence-based biological, psychological and social interventions as recommended by NICE.
What data do we want from national datasets to support implementation? We want to be able to understand: Referral to treatment times in a way that makes sense for the FEP pathway; Whether people experiencing FEP are accessing the full range of interventions recommended by NICE; The outcomes people with FEP are achieving as a result of treatment; The nature, size and skills of the EIP workforce wte, profession, competency to deliver interventions recommended by NICE.
What are we doing about it? 1. We commissioned the National Collaborating Centre for Mental Health to support the programme and establish a reference group of EIP experts to: Design the RTT pathway; Specify the interventions that would need to be captured; Specify the outcomes dataset. 2. We worked with the HSCIC and provider information experts to agree the associated changes required to the MHLDDS and the timeframe for delivery. 3. We established 4 Regional EIP Preparedness Programmes and tasked them with undertaking workforce surveys that would provide granular data regarding skill-mix and competencies. 4. We are working with HQIP to commission a national clinical audit of EIP services to understand the current level of NICE concordance. 5. We are working with the RCPsych (CCQI) to establish an accreditation scheme for EIP services.
4. Measurement challenges, opportunities and hopes for the future
Referrer suspects first episode psychosis (FEP) Urgent / emergency referral made flagged as suspected FEP Central triage point? Y Clock starts when central triage point receives referral Onward referral to EIP service A relatively complex pathway N Clock starts when EIP service receives referral Patient invited for EIP assessment DNA? Y N EIP assessment commences DNA Y N EIP assessment completed FEP? N Y Clock stops when: 1. Accepted on to EIP caseload 2. EIP care coordinator allocated 3. NICE concordant package of care commenced. Active monitoring / watch and wait Active monitoring / watch and wait Clock stops when: 1. Accepted on to EIP caseload 2. EIP care coordinator allocated 3. Specialist ARMS assessment commenced. ARMS? N Y Commence NICE concordant package of care Onward referral to appropriate service or discharge 19
Referral to clock start 1. Referrer suspects first episode psychosis (FEP) 2. Urgent / emergency referral made flagged as suspected FEP Central triage point? Y 3a. Clock starts when central triage point receives referral Onward referral to EIP service N 3b. Clock starts when EIP service receives referral Patient invited for EIP assessment 20
Assessment 1. Patient invited for EIP assessment 2a. DNA or cancella tion? N EIP assessment commences 2b. DNA or cancell ation? N EIP assessment completed Y Y 3a. Active monitoring / watch and wait 3b. Active monitoring / watch and wait 21
Assessment to clock stop 1. EIP assessment completed FEP? N Y 2a. Clock stops when: 1. Accepted on to EIP caseload 2. EIP care coordinator allocated 3. NICE concordant package of care commenced. 2b. Clock stops when: 1. Accepted on to EIP caseload 2. EIP care coordinator allocated 3. Specialist ARMS assessment commenced. 3. ARMS? N Y Commence NICE concordant package of care Onward referral to appropriate service or discharge 22
Other measurement challenges Risk of increased administrative burden for clinicians High variation in incidence of psychosis need to be careful not to penalise unjustly areas with low incidence when we start to measure the standard Will we be able to go higher than 50% in future given the DNAs rule? How can we ensure that the second prong of the standard (NICE concordance) is afforded just as much priority as the 2-week wait? How can we guard against perverse incentives (e.g. what about the people already receiving care for psychosis?) Routine clinical outcome measurement is not yet well embedded in many places
Measurement opportunities The changes to the dataset will support the introduction of A&W standards across the piece (not just EIP). There is an opportunity to improve radically our intelligence on mental health care and make this transparent: How long do people wait? For effective care? How good are their outcomes? Opportunity to improve the information available to people accessing services to enable them to make choices. Opportunity to learn from the acute sector (who have been measuring waiting times since the 1950s!) Opportunity with new ECRs and improved technology to get smarter about how we collect data. Opportunities for regulators to have far improved data on quality and outcomes CQC, TDA, Monitor Opportunity to use the new dataset to support the design of more effective payment, lever and incentive systems (e.g. a best practice tariff for EIP?)
Reflections and hopes for the future We want to get the EIP standard right. This standard has the potential to improve the lives of thousands of people and their life opportunities. The way that we measure the standard is critical it can t just be a waiting time standard. It must also be about the quality of care that people access after the clock stops. We hope (subject to future spending review decisions) to take a very similar approach to the introduction of other access and waiting time standards: A clinically informed maximum waiting time (RTT) For access to NICE-concordant care. This approach has the potential to support transform care, improve outcomes and have a significant impact on rebalancing the system. There is an awful lot to do and collaboration is essential!
sarah.khan@nhs.net