Action in Mental Health

Action in Mental Health National Programme for Innovations in Adult Mental Health Final Report 2004 2006 National Leadership and Innovation Agency for Healthcare Asiantaeth Genedlaethol Arweiniad ac Arloesoldeb dros Ofal Iechyd

Published by: National Leadership and Innovation Agency for Healthcare Innovation House Bridgend Road Llanharan CF72 9RP Wales Asiantaeth Genedlaethol Arweiniad ac Arloesoldeb dros Ofal Iechyd Ty Arloesedd Ffordd Penybont Llanharan CF72 9RP Cymru Phone (+44) 1443 233 333 Ffôn (+44) 1443 233 333 www.nliah.wales.nhs.uk www.agaaoi.cymru.nhs.uk In association with the Welsh Assembly Government Llywodraeth Cynulliad Cymru ISBN 1-905456-07-7 Crown Copyright 2006 Design: Ridler Webster Limited, Swansea October 2006

Contents Foreword 3 Acknowledgments 4 Summary 5 Introduction 6 Political context 6 National priorities and targets 7 Collaborative methodology 8 Developing a shared purpose 8 Goal and aims 8 Participating health communities 8 Design of collaborative programme 10 National structure 10 Steering group 10 Expert reference group 10 Local structure 11 Collaborative events 11 Project manager training 11 Additional training and support 11 National learning workshops 12 Programme evaluation 12 Achieving High Impact Change 13 Health community improvement activity 13 High impact change 1 13 High impact change 2 13 High impact change 3 14 High impact change 4 15 High impact change 5 16 High impact change 6 19 High impact change 7 19 High impact change 8 21 High impact change 9 22 High impact change 10 23 Measurement of Improvement 24 Key performance indicators 24 Development 24 Data entry and analysis training 24 Anomalies in KPI 1 data collection 24 Internal communication 25 Definitions 25 National Data Analysis 26 KPI 1 26 Length of stay 26 Admissions 28 KPI 2 29 Waiting times 30 Outcomes 31 Improvements in data collection 33 The Improvement Journey 34 Audit questionnaires 34 Results - Improvement teams 34 - Project managers 36 - Senior managers 37 Conclusions 38 Next Steps 39 Appendices 40 1 - Steering group membership 40 2 - Expert reference group 41 membership 3 - Project managers 43 4 - National project team contact 44 National Leadership and Innovation Agency for Healthcare 1

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Foreword In order to realise the Welsh Assembly Government s strategic intent of developing more equitable, effective, efficient and empowering mental health services there is a need for mental health services to modernise through innovation, service remodelling and improving the connectivity of services. In order to assist in achieving this ambition, Action in Mental Health worked with mental health services in Wales. The programme was steered by a multi-agency steering group including statutory and non statutory health and social care agencies and importantly service user involvement. Ten local projects ran across Wales focused upon improving mental health care pathways and reducing blockages within mental health care systems. Steps were taken to measure progress made using two key performance indicators. These measures focused upon length of time between referral and assessment in community services and length of stay in acute mental health hospital beds. During the 18months of this programme there have been significant achievements including: Improvements to local service systems The dissemination of learning from local projects at all Wales events Improvements in the standardisation of data collection as a result of KPI development Development of service improvement methodology in the mental health service planning workforce Improvements in service user involvement This final report provides a summary of the projects, their key findings and improvements realised at a local level. The report provides vital learning opportunities for service commissioners and planners throughout Wales. Many of the projects demonstrated significant improvements in the efficiency and effectiveness of care and the empowerment of service users. The projects achieved localised improvements in selected discreet areas of mental health systems many of which have made significant improvements to local services. However, if the learning from the various projects was to be replicated across Wales the aggregate impact of the projects would represent significant service modernisation across the mental health whole system. This report together with the Action in Mental Health Improvement Guide offers a useful set of tools for future service modernisation. It captures and celebrates the output of local schemes where innovators have exercised leadership in finding local solutions to blockages in the care system. Much can be learned from this and I am therefore delighted in commending the AIM project and the Improvement Guide to mental health services within Wales. Phillip Chick Director of Mental Health Wales National Leadership and Innovation Agency for Healthcare 3

Acknowledgements Action in Mental Health (AIM) is a quality improvement collaborative that introduced the National Leadership and Innovation Agency for Healthcare (NLIAH) to mental health services in Wales. This introduction came at a time of substantial review for adult mental health services and was welcomed as a vehicle to enable and drive the anticipated recommendations. AIM owes its success to the leadership and vision of particularly the programme Chair Phillip Chick, Clinical Lead Dr Jonathan Bisson and Primary Care Champion Dr Huw Lloyd. Thanks must also be extended to all those who supported and worked with us. The steering group and expert reference panel for their guidance and advice in ensuring that the programme remained receptive and relevant to the improvement needs of the service. The AIM project managers, improvement teams and wider health communities who through their commitment and continuous determination, have secured the principles of service improvement methodology, as a foundation for future work in process and system redesign. The Wales adult mental health networks who have helped NLIAH in spreading the messages of AIM and provided a credible knowledge base for this initiative: Wales Alliance for Mental Health especially HAFAL & MIND CYMRU WaMHinPC (Wales Mental Health in Primary Care) network Wales Collaboration for Mental Health Wales Centre for Mental Health And also our colleagues throughout the UK who have contributed to the planning design and delivery of AIM. We would like to especially acknowledge the support and assistance provided by Malcolm King, Sainsbury Centre for Mental Health. 4 Final Report

Summary This report is a reference source for organisations and teams who have participated in AIM. It has been written for all those, within the NHS, social care, local government, voluntary agencies and for the service users and carers who are the focus for our work. AIM was an 18 month initiative directed by NLIAH. It was initiated and supported by the Welsh Assembly Government to provide a co-ordinated approach to supporting the capacity and capability for improvement in the delivery of adult mental health services in Wales. The overall goal of the programme was the development of systems, to ensure the delivery of timely, effective care and support in a setting appropriate to need, as part of a clear, agreed pathway. AIM was underpinned by a proven improvement method that relies on the spread and adaptation of existing knowledge about better practice. National improvement measures were used to suggest the changes required to achieve improvement. Key performance indicators (KPIs) were collected in all local health communities. These measured demand, at identified bottlenecks in the pathway of care, in order to provide meaningful information to support the achievement of the AIM goal and objectives. They focused on improved flow and quality of care with timely and appropriate access to secondary care services, thereby facilitating the implementation of the National Service Framework for Adults of Working Age 1 (NSF) specifically standards 6 and 7. Health communities agreed local action plans to support achievement of the national goal and acted on the data they collected to produce evidence of their own improvements and provide monthly reports to track national progress. Local activity was supported by a structured programme of training and shared learning providing an opportunity to learn about the improvement methodology as well as leading implementation at practice level. The Plan, Do, Study, Act (PDSA) model was used to test change ideas. Participating teams were committed to making improvements in several key areas: Development of effective assessment processes and care planning Improved access to information on services Meaningful engagement of service users and carers Introduction of care pathways Implementation of NICE guidance This report details selected high impact outcomes, an analysis of the national data collected during AIM and an evaluation of the improvement journey. 1 NSF for Adults of Working Age - Welsh Assembly Government- (WAG) 2002 National Leadership and Innovation Agency for Healthcare 5

Introduction AIM commenced in March 2005 to support Health and Social Care in addressing: Improvement of information and signposting in primary care settings Development of community based services to offer alternatives to hospital admission and support prompt discharge Modernisation of inpatient care with a focus on recovery The programme provided the environment and service improvement methodology to enable local teams to review existing pathways of care, identify pressure points in delivery and create local solutions to address capacity and demand whilst improving quality of access and care. All health communities signed up to the collection and analysis of 2 national measures to: Provide an accurate picture of national activity Demonstrate the effect of ongoing improvement The goal and objectives focused on achievement of the NSF by adopting a vision that required a shift towards prevention, improving access and better designed and delivered services, as described subsequently in Designed for Life 2. Models of good practice can be found in Wales but there is inequity of provision. The programme sought to encourage the sharing of existing good practice models in order that local teams could learn from these to assist them in developing and implementing models of excellence. Political Context The Wanless Review 3 detailed that Wales does not get as much out of its health spending as it should and made a number of recommendations to improve NHS service provision in Wales. It identified the necessity of building capacity in Primary Care to reduce the increasing burden on acute services. For this reason AIM adopted a partnership approach to service improvement encouraging the development of interface services across the primary and secondary and health and social care boundaries. Activity within AIM focused on the implementation of standards 6 and 7 of the NSF and adapted activity to respond to the findings of the revised NSF 4 and baseline review of service provision conducted by the Wales Audit Office 5. 2 Designed for Life WAG - 2005 3 The review of health and social care in Wales - Derek Wanless WAG 2003 4 Raising the Standard revised NSF- WAG October 2005 5 A Baseline Review of Service Provision Adult mental health services in Wales. Wales Audit Office September 2005 6 Final Report

Both these reviews asked for a change in working practices and culture to target significant gaps in key elements of service delivery. AIM, supported by the Welsh Assembly Government offered additional support to improve capacity within the service to achieve full implementation of the NSF. National Priorities and Targets supported by AIM Local activity also targeted delivery of the SaFF Targets 2005-2006 6 : Introduction of crisis resolution and home treatment services. Improvement of therapeutic outcomes and implementation of the Tidal or Refocusing model of care in adult acute wards And the SaFF targets for 2006/07 7 : Make available Gateway workers to GP surgeries and provide training for GP s and practice staff in diagnosis and management of mental health problems. Improve access to specialist psychological therapy to 3 months Reduction in delayed transfers of care in mental health Long Term Care target Development of self-management training schemes Collaborative Methodology The collaborative methodology originates from work of the Institute for Health Improvement in 1996 in the USA that has been used to develop service improvement programmes throughout the UK via the NHS Modernisation Agency in England and NLIAH in Wales. A collaborative is an evidence based, service improvement methodology, which delivers systems wide engagement and demonstrable improvements in care, offered to service users and their carers. The improvement teams brought together in a collaborative use a simple but tightly defined improvement method that has been demonstrated to achieve accelerated change in some complex systems. It enables organisations and their partners in care to achieve pre-existing objectives more rapidly and more effectively through a number of steps or inputs: Develop a set of principles, ideas and actions that would, if replicated across those involved in delivery of that care, secure greatest gain Present the ideas in conjunction with change management methods to the participating health communities Enable these communities to apply learning to their own situation through rapid and inclusive change management approaches Share the learning, both achievements and failures Share and encourage the adoption of change management approaches across the wider Health and Social Care arenas Improvement journeys based on these steps provide learning opportunities that allow an essential sharing across collaborative teams, to seek new and innovative experiences. 6 Strategic and Financial Framework Targets - WAG 2004 7 Strategic and Financial Framework Targets - WAG 2005 National Leadership and Innovation Agency for Healthcare 7

Developing a Shared Purpose The critically important aspect of collaboratives is that they allow health communities to set their own improvement projects that will achieve agreed performance indicators. They are not about imposing new priorities. However in order that the collaborative has a shared purpose, a hierarchy is established to link local objectives to the overall project goal. Goal: set by the sponsor (Steering Group) Aims: agreed by stakeholders (Expert Reference Group) Key Performance indicators: agreed by all groups Improvement projects identified locally to achieve overall goal, aims and specitic key performance indicators Goal and Aims The overall goal and aims of the programme provided a framework from which local objectives for service improvement were agreed. Goal Development of systems to ensure that people receive timely, effective care and support in a setting appropriate to need, as part of a clear, agreed pathway. Aims to improve: Effective assessment processes and care planning Access to information on services Meaningful engagement of service user and carer Delivery of the most appropriate care by the most appropriate person at the most appropriate time in the most appropriate place Implementation of NICE guidance Participating Health Communities North Wales North West Wales (NWW) Gwynedd Local Health Board (LHB) and Social Services Angelsey LHB and Social Services NWW NHS Trust Voluntary Agencies Conwy and Denbighshire Conwy LHB and Social Services Denbighshire LHB and Social Services Conwy and Denbighshire NHS Trust Voluntary Agencies North East Wales (NEW) Wrexham LHB and Social Services Flint LHB and Social Services NEW NHS Trust Voluntary Agencies 8 Final Report

South East Wales Gwent Bleanau Gwent LHB and Social Services Caerphilly LHB and Social Services Newport LHB and Social Services Monmouth LHB and Social Services Torfaen LHB and Social Services Gwent Healthcare NHS Trust Voluntary Agencies Cardiff and East Vale Cardiff LHB and Social Services Vale LHB and Social Services Cardiff and Vale NHS Trust Pontypridd and Rhondda Rhondda Cynon Taff LHB and Social Services Pontypridd and Rhonda NHS Trust Voluntary Agencies South West and Mid Wales South West Wales Ceredigion LHB and Social Services Carmarthen LHB and Social Services Pembrokeshire LHB and Social Services Pembrokeshire and Derwen NHS Trust Voluntary Agencies Swansea Swansea LHB and Social Services Swansea NHS Trust Voluntary Agencies Bridgend and West Vale Bridgend LHB and Social Services Neath Port Talbot LHB and Social Services Vale LHB and Social Services Bro Morgannwg NHS Trust Voluntary Agencies Powys Powys LHB & NHS Trust Powys Social Services Voluntary Agencies Prior to AIM, local multi agency planning was dependent on 22 Mental Health Strategic Planning Groups (MHSPG). These groups reconfigured for the duration of AIM, reducing the number to 10 health communities. National Leadership and Innovation Agency for Healthcare 9

Design of the Collaborative Programme The framework of the programme is illustrated below. The Collaborative Programme Framework National Steering Group 1 National Events 2 & 3 Regional Events 4 National Events Celebration Events Local Improvement Teams Local Actions Local Actions Support from NLIAH, Sainsbury Centre and Project Managers The NLIAH programme management team, senior manager, service development manager, clinical lead and data analyst, coordinated the delivery, agenda of events and support to local teams. Advice and direction was provided by a steering group, and an expert reference group. National Structure Steering Group The steering group was chaired by the director of mental health and consisted of representation from health and social care, the voluntary sector and service users. This group provided strategic leadership and advised on the goal, objectives, expected programme outcomes and configuration of the health communities. Regular meetings shaped the development of the programme delivery ensuring that it took account and adapted to respond to the mental health reviews that reported in October 2005. Expert Reference Group An invited panel of professionals and service users provided advice on the initial programme design and identified a set of measures for consideration as key performance indicators. Membership included representation from mental health strategic groups, Wales adult mental health managers network, Wales collaboration for mental health, Wales mental health in primary care network. AIM integrated with the mental health stakeholder community to strengthen further the partnership approach to service development, forge sustainable networks and avoid duplication of effort. Collaborative Structure Steering Group Expert Reference Group National Programme Team Local project managers leading local teams 10 Final Report

Local Structure Locally determined organisation structures were responsible for recruiting a local project manager and building the local service improvement team. In total there were 14 improvement teams based in the 10 communities each facilitated by an AIM project manager. Each team had representation from health and social care, the voluntary sector and carer and service user involvement. Local structures mirrored the national structure with professional direction provided by the mental health strategic planning groups and health and well being partnership boards. Collaborative Events Project Manager Training A training and development programme was provided for the project managers. This consisted of two 3 day residential workshops followed by monthly one day workshops. The purpose was to develop the knowledge and skills of service improvement tools and techniques and to build confidence in application. Time was safeguarded to: Shape the vision of the programme Identify with the steering group the key performance indicators Clarify specific collaborative improvement programme arrangements Learn collaborative improvement methodology, the model for improvement and use of PDSA cycles Focus on personal development and interpersonal skills Knowledge and skills development and the improvement of capability and capacity locally were essential to the success of the programme. Monthly workshops focused on improvement methodology and provided the opportunity for the project managers to learn from each other and establish a network of contacts. An electronic smart group facilitated continual learning and sharing nationally between each of the health communities. Additional Training and Support To assist in improving information knowledge and skills, further training events were provided regionally and locally. These events focused on building the capability and knowledge of the improvement teams and their parent organisations. Special attention was given to identification of capacity, demand, flow and data analysis, and implementation of service improvement methodology. Support information including a workbook and CD were developed and made available. Training was provided flexibly to meet the needs of local communities: National/ regional workshops for programme managers and local improvement teams Quarterly site visits by the NLIAH team to support ongoing progress Topic specific workshops to address learning deficits Individual sessions as required Telephone advice and information National Leadership and Innovation Agency for Healthcare 11

National Learning Workshops During the 18-month duration of the programme 3 national workshops were delivered plus 2 workshops in each of the regions. These workshops provided the opportunity for teams to come together to learn about the model for improvement and to share ideas amongst their own teams and teams from other locations and to action plan. The workshops took place on the following dates: Learning Workshop 1 - Launch Event 24th - 25th February 2005 Learning Workshop 2 - NW Region 6th June 2005 SWW Region 8th June 2005 SEW Region 9th June 2005 Learning Workshop 3 - NW region 1st November 2005 SWW Region 3rd November 2005 SEW Region 4th November 2005 Learning Workshop 4 - National Event 1st - 2nd March 2006 Learning Workshop 5 - Celebration Event 20th - 21st June 2006 These learning events have been found to be an integral part of the collaborative process and help accelerate the process of learning through social networks. Each workshop was followed by an action period of a couple of months where teams were encouraged to put learning into practice. During these periods local teams tested local implementation plans to achieve the AIM goal, collected KPI data and reported monthly on ongoing progress. The events schedule concluded with a celebration event attended by the Minister of Health and Social Care. Health communities presented their achievements and displayed posters. A service user co-presented with a Medical Director sharing how each had benefited from participation in AIM. Programme evaluation It was agreed from the outset that AIM should be properly evaluated in a way that helped to develop and support rather than dominate the project. The areas of evaluation are outlined in the following sections of this report: Achieving high Impact Change Activity of the improvement teams. Measuring Improvement The development of KPIs and the use of data during AIM. The Improvement journey Analysis of audit questionnaires to consider the performance of AIM in relation to: The aims and objectives of the project Standard aspects of collaborative methodology Factors found to be associated with positive outcomes in other Collaboratives Whole systems approach This section reports elements of the evaluation conducted by Dr Jonathan Bisson, Clinical Senior Lecturer, Cardiff University and Honorary Consultant Psychiatrist, Cardiff and Vale NHS Trust. A copy of this evaluation is available on request. 12 Final Report

Achieving High Impact Change Health Community Improvement Activity Local health communities documented evidence of progress and impact on patient outcomes. The examples included outline some of the high impact improvements that have been achieved in Wales, rather than describe all of the achievements of each health community involved in AIM. Local evaluations are available from Project Managers (appendix 3). Improvement activity has been described in relation to the ten high impact changes matrix as described by Care Services Improvement Partnership (CSIP), National Institute for mental Health in England 8 (NIMHE). High impact change 1 Treat home based care and support as the norm Reconfiguration of Depot clinics - North East Wales Health Community Professionals managing Ty Celyn Depot clinic felt that the environment was not user friendly and at times due to non-attendance at the clinic, time was not efficiently utilised. A questionnaire was sent to service users seeking feedback on the current service. The results of the questionnaire found that 90% of service users preferred home visits, with 10% preferring clinic visits. To provide choice to service users, reduce duplication of contacts and stigma, the clinic was reconfigured to provide physical health checks to all service users and home visits as appropriate. High impact change 2 Improve the flow of service users and carers across health and social care by improving access to screening and assessment Training Package for primary care - South West Wales Health Community A questionnaire for GPs and nurses working in practices, was piloted, to identify the skills and experience for screening and signposting the mentally ill. Survey results indicate that there were gaps in their knowledge and experience and identified training needs. As a consequence of the survey a training package has been developed aimed at improving knowledge and confidence about dealing with mental health problems within primary care. 8 Ten high impact changes CSIP NIMHE 2006 www.nimhe.csip.org.uk National Leadership and Innovation Agency for Healthcare 13

Information sharing on placements - Swansea Health Community Swansea set out to improve information sharing and access to placements for people with high levels of need not met within existing services. The aim of this improvement was to improve communication between stakeholders and in the long-term reduce the time taken for decision making of applications to the LHB for long term care funding. The outcome was that a clear understanding of local need was communicated to the LHB, a backlog of applications considered, taking account of available funding and a plan developed to repatriate people who have been placed outside of Swansea, to facilitate reinvestment of resources. Information Leaflet on Referral to the CMHT - Gwent Health Community To assist in reducing the numbers of non-attenders for initial appointment, a leaflet for service users/carers was developed outlining what to expect when referred to the Monmouthshire CMHTs. The aim of the leaflet was to: 1. Reduce anxiety for service users/carers 2. Decrease the level of non-attendance at appointments 3. Improve the effectiveness of the assessment 4. Improve the response rate to motivational letters and thus reduce re-attendance at General Practices The leaflet is sent out automatically with every motivational letter to a service user referred to Monmouthshire CMHTs. Initial feedback from service users indicates that they find the explanatory leaflets helpful. Non-attendance rates are being monitored to measure performance. High impact change 3 Manage variation in service user discharge processes Implementing the Care Programme Approach (CPA) - Pontypridd and Rhondda Health Community AIM provided the vehicle to assist in implementation of CPA. The CPA co-ordinator developed the necessary format, guidance documentation and policy which were implemented across the Trust. This was achieved by the CPA officer working with social work team managers & business support data entry staff to ensure that CPA information was correctly recorded on Swift. An audit was undertaken indicating that there is a named care co-ordinator recorded on the case file for 90-95% of cases. The CPA level is recorded on 65-75% of case files. There is a date recorded for the next CPA review in 30-40% of case files. Prior to this initiative CPA had not been implemented. In-patient information - Swansea Health Community In response to feedback from service users, touch screen information consuls have been purchased and will be installed on in-patient wards to provide standardised information. 14 Final Report

The aim of this development is to ensure that in-patients will be better informed of the processes and services available within the hospital setting, which will improve the opportunities for services users to make informed decisions about their care. These screens are used to provide information on medication, health promotion and general well-being. It is anticipated that the provision of information on services, both statutory and voluntary, that are available to service users in the community, will encourage better involvement in discharge planning and impact on the overall length of stay. High impact change 4 Manage variation in access to all mental health services. Criteria for access to secondary care - South West Wales Health Community A process mapping event identified significant variation across the 9 CMHTs within the health community. Criteria was developed to ensure that all opportunities for support in the community are considered at the earliest opportunity. Outcomes of this process have led to reduced variation, an increase in quality and reduced waiting. Care options considered are: Invitation for a specialist Mental Health / Learning Disability Assessment Agreeing an initial crisis plan Advice to the person being referred and / or the referrer Signposting to another service Provision of information Implementation has assisted in reducing inappropriate referrals. Multi Agency Duty Desk - Gwent Health Community Before AIM the duty desk system was manned by administrative staff. Process mapping identified that this led to delays, inappropriate referrals and a lack of confidence in the system by users. Evidence from other CMHTs in Gwent indicated that a duty desk has a number of benefits, including: Improved access with one point of contact Improved information for service users and carers about their care and treatment It was decided that the system required change to ensure a clinician is always available to offer advice and assistance as appropriate and to screen all enquiries to reduce risk and improve timely response. National Leadership and Innovation Agency for Healthcare 15

This system has been mainstreamed and resulted in provision of professional advice on first access to the service. Achieving improvements in: Rapid initial screening Risk assessment of referrals Improved access to service Ongoing evaluation will determine: Reduction in inappropriate referrals Reduction in critical incidents Improved use of service Improved service user and professional satisfaction Threshold Assessment Grid - Cardiff and East Vale Health Community The Threshold Assessment Grid (TAG) assessment tool has been piloted in one CMHT using PDSA methodology. It was identified that many 'urgent' referrals were not urgent. The objective of the initiative was to reduce the number of times CMHT staff had to make an immediate response to a referral, which disrupts their planned work. On average, approximately 4 referrals were received each week by the CMHT, that were classified as clinically urgent by the referrer. The introduction of TAG has resulted in 60% of urgent referrals being assessed as not urgent, enabling these referrals to be processed in the usual way. Development of Therapeutic Interventions - South West Wales Health Community Psychological therapies were delivered from a number of sources: a central psychotherapy department working across the three counties; psychologists attached to the community teams and inpatient units and other staff practising from within clinical teams. The result was extensive waiting lists for both treatment with the psychological therapy department and with a psychologist. A seven step toolkit for the development of psychological therapies in an adult CMHT was developed for application to CMHTs. The toolkit was piloted using PDSA methodology in one CMHT enabling a baseline of skills and supervision to be identified. There is now an ongoing structure for the continuous development of therapeutic interventions which can be integrated into the Professional Development Process. This has also informed the training needs analysis for the health community. High impact change 5 Avoid unnecessary contact and provide necessary contact in the right care setting Reconfiguration of outpatient services - North East Wales Health Community Aston House Deeside outpatient system routinely provided a 3-12 month appointment for all service users. 16 Final Report

Pwll Glas and Wrexham South CMHTs piloted a change in culture of routine follow up appointments to no follow up unless clinically indicated. The pilot involved one consultant clinic with appointments requested by the care co-ordinator or service user. The aim of the improvement was to: Reduce duplication of contact Encourage use of the recovery model utilising a holistic multidisciplinary perspective Increase capacity of the consultant Provide all service users greater choice Quicker access to a consultant appointment Since implementation, the number of appointments has dramatically reduced, resulting in increasing consultant capacity, no waiting list for routine appointments and reduction in non-attendance for appointments rates. Increased consultant capacity has expanded the potential for home visits, case discussion, advice and consultation between the consultant and the multi-disciplinary team. Extra capacity within administrative staff has been achieved owing to a reduction in greeting service users, arranging appointments and typing of appointment letters. Graph 1 demonstrates the decrease in activity levels. Graph 1 Data for Out Patient Appointments 30 25 Clinic capacity set at 24 follow up appointments Number of booked appts. 20 15 10 5 0 1 2 3 4 5 Consecutive Clinics Jun-05 Jun-06 GP practice website development - Neath, Port Talbot, Bridgend and West Vale Health Community This initiative set out to improve the interface between primary and secondary care by improving the design of the local website in a GP practise to provide easier access to other agencies. Using PDSA methodology, amendments to the existing website were identified and the GP's understanding of voluntary organisations improved. This improvement has been developed to reduce referrals to secondary care services and to ensure that patients receive care at the right time in the right place by the right person. Evidence will be collated to spread and encourage use by all GP practices. National Leadership and Innovation Agency for Healthcare 17

Review of observation policy- North West Wales Health Community This initiative tested the effect of nurse-led decision making. Nurses are now able to review a patient's observation status and discontinue observation as appropriate. This change has resulted in a significant reduction in staff costs relating to status 3 obs (constant 1:1) from 23,359 April Sept 2005 before the change in policy to 6,602 April July 2006. Whilst other variables such as variation in patients needs during the two periods may have contributed, a three fold improvement has been achieved. This was one of a number of improvements in North West Wales that is likely to have achieved a reduction in average length of stay depicted in graph 2. Graph 2 North West Wales KPI 1 data 25 UCL = 25.48 Length of Stay 20 15 10 X = 14.68 5 LCL = 3.87 Jan-05 Mar-05 May-05 July-05 Sep-05 Nov-05 Jan-06 Mar-06 May-06 Month Starting Reminder system for appointments at CMHT - Cardiff and East Vale Health Community 'Did not attend' (DNA) rates at a CMHT were high. In order to try to improve this, a pilot was agreed for an appointment reminder system. Reminder letters were sent out to service users one week before their appointment, commencing on 26th January 2006. Results for February and March indicate a significant improvement, and whilst there have been considerable monthly variations in DNA rates in the past, these early results are encouraging as depicted in graph 3. Graph 3 Reducing DNA rates 60% 50% 40% 30% 20% 10% 0% Before Initiative Doctor s initial assessment clinic Following Initiative Assessment clinic 18 Final Report

High impact change 6 Increase the reliability of interventions by designing care around what is known to work and that service users and carers inform and influence Focus groups - South West Wales Health Community Focus groups of service users with long-term mental health problems were held in Pembrokeshire County to elicit views on primary care services. Sessions were jointly led by a service user and project manager, which assisted in building a relaxed atmosphere and encouraged users to participate in discussions. The sessions were used to elicit views on physical care as a physical health policy for mental health is under development. Feedback from participants indicate that user facilitation is a useful way of eliciting a valuable contribution from service users. Involvement with AIM has been especially high and one service user presented both locally and nationally to share the added benefit of engagement for the health community and the building of skills and confidence. Meaningful Day Project - Powys Health Community Service users have been engaged in the provision of activities that are 'useful and meaningful to recovery' on the in-patient unit to address boredom that some patients experience, which can develop into frustration and the perpetuation of a non-therapeutic environment. A diverse range of activities, including art and craft sessions, a guitar group, yoga, exercise and relaxation groups, a woodwork group, pottery and a gardening group are available. Service users facilitate some of the groups as well as individuals, who previously had no contact with mental health services. An evaluation, has demonstrated positive feedback with individuals reporting enhancement of self-esteem and self worth. The project has also increased links with the voluntary agencies. High impact change 7 Apply a systematic approach to enable the recovery of people with long term conditions Tidal Model- Gwent Health Community A number of health communities have used AIM as a vehicle to achieve SaFF targets. Gwent health community implemented tidal model in January 2006 in one acute, adult ward. The expected high impacts are: Increased therapeutic contact with patients Reduction in untoward incidents Reduced admissions Reduced length of stay Reduced observations Reduced levels of deliberate self harm This required involvement of all staff in the development of the process and engagement with service users. Expert training was secured from Phil Barker 9 over a two day period and was undertaken on a multi agency basis. 9 The Philosophy and Practice of Psychiatric Nursing, Churchill Livingstone, Edinburgh: 1999 e-mail phil.barker@ukf.net National Leadership and Innovation Agency for Healthcare 19

Activity focused on development of an environment where service users could take ownership of their care and treatment by protecting time to ensure involvement between clinicians and service users. The results have been positive in the initial stages. Patient advocacy is now in place and feedback from service users demonstrate a perceived improvement in patient care and therapeutic relationships. Information leaflets have been updated to incorporate the methodology of the Tidal Model as a direct request from carers. Employment of a part time ward clerk has provided additional support to manage protected time. Average length of stay (LOS) has not been affected but the ward is now collecting discharge and LOS measures to monitor impact. Service users driving environmental improvements - Pontypridd and Rhondda Health Community PDSA methodology has supported the implementation of improvements to the inpatient environment. Service users played an active role in identifying opportunities, including improved provision of secure lockers and improvements to the patio area. Service users also identified a deficit in available activities during evenings. Fund raising events raised 134 to enable 4 viewing boxes to be purchased to increase television choice. Refocusing Model - North West Wales Health Community A model for the in-patient unit has been developed drawing on aspects of both refocus and tidal models. One element of the model is the introduction of 'protected time' on Gwalchmai Ward. Protected time is contact over and above the contact provided as part of routine hospital admission and therefore may not be appropriate for all patients. An audit of records from Gwalchmai 22/3/06 to 26/7/06: Protected time cancelled due to safety concerns. Interruptions due to: Twice Mental Health Act enquiries. Consultant visits. TTO arrangements for discharge. CMHT inquiry. Patients engaged with protected time: 11% Patients engaged in other activities during protected time: 40% Patients refusing to engage with protected time: 49% These results need to be interpreted with care. 51% of patients were engaged in some activity, either protected time or some other activity. 49% refused, possibly for a number of reasons: (a) too unwell; (b) general issues of non-engagement/compliance; (c) activities not seen to be relevant; (d) having enough contact/therapy already The next stage of the improvement programme is to refine the audit tool to highlight how time is used i.e. what therapies take place, interruptions & reasons for refusing to participate. Consideration is being given to targeting of protected time at specific patients using specific evidence-based interventions, at the right time in the patient s recovery. All wards in the Hergest Unit are now implementing protected time. 20 Final Report

High impact change 8 Improve service user flow by removing queues Improving allocation of a care co-ordinator - Conwy and Denbighshire Health Community Process mapping identified a number of weaknesses in existing systems. One team identified that they needed a more robust allocation process to reduce the time from assessment to allocation in the secondary care team. Using PDSA methodology the team agreed to allocate for a 6-week assessment period to complete CPA and agree a care plan, or provide short-term intervention, or signpost to other agencies or discharge. Each case would be discussed in the weekly meeting, to identify service user needs and the case assigned to the most appropriate professional for longer term intervention if required. It also facilitated shorter-term interventions where appropriate to address needs in a more timely fashion, reducing potential risks and empowering service users. A reduction in the waiting list for allocation from 14 individuals to none has been achieved as depicted in graph 4. Other opportunities identified and the next step is to address the capacity deficit of care co-ordinators, using a workload management tool and supervision. Graph 4 Reducing waiting for allocation 14 12 10 8 6 4 2 0 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 First access service daily triage of referrals - North East Wales Health Community Referrals into the First Access Service were allocated at a weekly meeting: up to 50 referrals were discussed each Friday, tying up all staff for about 3 hours each week. At a process mapping event, it was identified that weekly appointment allocation created a delay in the patient journey. A PDSA cycle was undertaken to test daily triage of referrals to enable service users to receive an earlier appointment and spread the teams workload more evenly. Referrals are now allocated on a daily basis by a senior member of staff, processed quicker and returns are now staggered throughout the week as they are no longer sent out on the same day. Time previously used for the weekly allocation meeting is used for peer supervision and case review. Along with other improvements, this has resulted in waiting times being reduced from 12 weeks to 8 working days within 3 months. National Leadership and Innovation Agency for Healthcare 21

High impact change 9 Optimise service users and carers flow through the service using an integrated care pathway approach Care Pathway for Community Mental Health Teams - Conwy & Denbighshire Health Community A care pathway for CMHTs was introduced to reduce variation in practise across the 5 CMHTs. The aim was to improve access and equity to the service. Process mapping was used to identify variation and the CPA process used to agree minimum standards and to track the variances in the pathway. The care pathway will in time, enable the organisation and teams to monitor performance. Since the pathway is based on promoting recovery, the next phase of development will be to incorporate N.I.C.E. guidance. Electronic Pathways - South West Wales Health Community The system of care provided to service users was varied, with no equity of provision or agreed quality standards. A consistency of approach to care was required, to improve screening, assessment and care planning through: Establishing minimum quality standards Agreeing processes that are both responsive and understandable to service users / carers / staff Developing care pathways An electronic pathway for the CMHT episode and adult acute in-patient episode of care has been developed. The final pathway has been split into three separate pathways: Pre Referral / Referral / Screening Assessment / Care Planning / Review Discharge The piloting and implementation of the pathway has been undertaken in small stages and with the help of PDSA cycles. Key areas of learning: For new processes to be effective there must be ownership by those involved in the activity New processes should not be developed in isolation but as part of a whole system approach The work developing a care pathway is as useful as the pathway itself in establishing good practices and improving the patient journey. 22 Final Report

01/01/2005 01/02/2005 01/03/2005 01/04/2005 01/05/2005 01/06/2005 01/07/2005 01/08/2005 01/09/2005 01/10/2005 01/11/2005 01/12/2005 01/01/2006 01/02/2006 01/03/2006 01/04/2006 Length of stay Graph 5 length of stay - South West Wales 400 300 200 100 0 Graph 5 demonstrates that a reduction in both variation and average length of stay has been achieved since January 2006. High impact change 10 Redesign and extend roles in line with efficient service user and carer pathways to attract and retain an effective workforce Support, Time and Recovery Worker - Powys Health Community The objective was to improve the therapeutic mental health facilities across the county by implementing a service-wide training programme and through the introduction of Support, Time and Recovery (STR) Workers. A training package developed in Australia was identified and adapted for use in Wales. A three-day pilot of the delivery of the training package was completed and evaluated. Adaptations have been made resulting in an appropriate programme for use in Powys. Multi-agency agreement on creating STR worker posts was achieved and funding secured. There is an in-house competency based structure with an allocated trainer, supervisor and assessor and completion of a training log. The Trust aims to train all of these care workers to national vocational qualification, level 3. National Leadership and Innovation Agency for Healthcare 23

Measurement of Improvement Key Performance Indicators An essential element of collaborative methodology is to collate evidence to demonstrate sustainable service development, monitor progress and allow comparisons across different areas. 2 key performance indicators (KPIs), were identified, to measure activity at identified bottlenecks in the pathway of care and help identify variation in service provision: Key Performance indicator (KPI) 1, collects data on length of stay, hospital admissions and discharges KPI 2 collects referrals from primary care to CMHT and waiting time to first appointment plus outcomes of assessment. These measures focus achievement of the AIM goal and objectives - improved flow and quality of care with timely and appropriate access to secondary services. Development The expert reference group advised the national programme team of key areas that should be considered for measurement. These were used by the steering group to develop the 2 KPIs, which were agreed by the locality project managers and finalised in May 2005. It was agreed that the national measures should be collected locally by the project managers on a monthly basis, collated centrally and then disseminated locally. Data entry and analysis training Data analysis of KPI information has been provided throughout AIM by the data analysis team at NLIAH. AIM has begun the process of improving the skills in understanding information to support the improvement agendas and manage performance at a local level. Anomalies in KPI 1 data collection The AIM data collection process identified some anomalies in data collection that are of importance to national mental health services in Wales: Inconsistent use of terminology, such as discharge and transfer Variation in admission criteria, particularly for older people with mental illness Variation in reporting of length of stay A lack of robust procedures relating to the quality of data entry 24 Final Report