Urgent and emergency mental health care pathways

Contents Who is this guidance for? 3 Why has it been produced? 3 How should this guidance be used? 4 What data quality issues have been identified? 5 Recording the clinical response priority type 5 Recording referral start times and care contact times 6 Recording of service or team type 9 Recording of activity location 12 What should I do if I have any questions about this or feedback? 14 Copyright 2018 NHS Digital 2

This guidance has been developed to support the improvement of the quality and completeness of data submitted to the Mental Health Services Dataset (MHSDS) used in the analysis of NHS funded urgent and emergency mental health (including both community and liaison) services in England. Who is this guidance for? It is aimed at people and organisations involved in the collection and submission of MHSDS data including: information managers, developers and analysts within organisations providing NHS funded urgent and emergency community mental health services and urgent and emergency liaison mental health services operational managers, service managers and clinical leads of these organisations suppliers of clinical or administrative IT systems to these organisations Why has it been produced? Separate 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) 1. In February 2014, 22 National bodies involved in health, policing, social care, housing, local government and the third sector signed the Crisis Care Concordat 2. 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 NHS Digital and NHS England are working together to develop analysis to support the monitoring of the second area of the Concordat; urgent and emergency access to crisis care. The Five Year Forward View for Mental Health (FYFVMH) set out a priority to improve urgent and emergency mental health services. As part of this work NHS England has issued guidance on urgent and emergency mental health liaison in general hospitals 3, and is expected to publish further guidance on urgent and emergency access to community mental 1 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 2 Available at http://www.crisiscareconcordat.org.uk/ 3 Available at: https://www.england.nhs.uk/mental-health/adults/crisis-and-acute-care/ Copyright 2018 NHS Digital 3

health services. NHS Digital has produced initial exploratory analysis to support the development of this detailed guidance 4. This exploratory analysis has identified some initial areas where work is needed to improve the quality and completeness of MHSDS submissions in order to monitor these services. This document has been produced to highlight these areas in order to give people and organisations involved in the collection and submission of MHSDS data as much time as possible to investigate and address these issues. How should this guidance be used? This guidance highlights key issues to be addressed in future MHSDS submissions. It focuses on those issues which are specific to the monitoring of urgent and emergency mental health (including both community and liaison mental health) services. This is not comprehensive in order for it to minimise repetition of other available guidance or contradict future guidance to be issued by NHS England. It will be superseded as and when further exploratory analysis identifies other areas of focus. Updates to this guidance will be publicised in NHS Digital s Mental Health Information Update. You can subscribe to these by contacting NHS Digital at: Subscribe This should be used alongside the NHS England guidance, NICE guidance and quality standard, as well as the following MHSDS guidance and documentation: MHSDS v3.0 User Guidance 5 MHSDS v3.0 Data Model 6 MHSDS v3.0 Technical Output Specification 7 Mental Health Services Monthly Statistics Metadata 8 Mental health liaison services in the Emergency Care Data Set (ECDS) and MHSDS The new Emergency Care Data Set (ECDS) will record: the reasons (chief complaint) people are attending Accident & Emergency (A&E) departments; diagnoses (suspected or confirmed); injury intent (e.g. intentional self-harm); what time people arrive and what time referrals are made to liaison mental health teams (including integrated crisis & liaison teams, which is the most common model for services for children and young people); and what time people are discharged, admitted or transferred. This should improve overall reporting of activity and waiting times in A&E for people attending with mental health needs. 4 Available at https://files.digital.nhs.uk/publication/m/8/mhsds_monthly_f_apr_p_may_2017- expanalysis_- _crisiscare_feb-apr.pdf 5 Available at https://digital.nhs.uk/binaries/content/assets/legacy/pdf/q/4/mhsds_v3.0_user_guidance.pdf 6 Available at https://digital.nhs.uk/binaries/content/assets/website-assets/datasets/mhsds/mhsds_v3.0_data_model.pdf 7 Available at https://digital.nhs.uk/binaries/content/assets/website-assets/datasets/mhsds/mhsds_v3.0_technical_output_specification_web-2.xlsx 8 Available at https://digital.nhs.uk/binaries/content/assets/legacy/excel/r/3/mhsds_monthly_metadata_v2.20.xlsx Copyright 2018 NHS Digital 4

The specific activity of most liaison mental health services is in scope for submission to the MHSDS. Until the full pathway of people who arrive at A&E and are referred to liaison mental health can be identified through linkage of the ECDS to the MHSDS, NHS England have confirmed that the monitoring of access to liaison mental health services will be undertaken using submissions to the MHSDS. This will include using: information recorded for the date and time of the referral to the liaison mental health team; the clinical response priority type; and the service or team type. As such, while the initial exploratory analysis carried out by NHS Digital focussed on community mental health services, the information included in this guidance applies to both the recording of activity for urgent and emergency access to both community mental health services and liaison mental health services. Where guidance is specific to one pathway this has been detailed in the guidance. What data quality issues have been identified? Recording the clinical response priority type Table MHS101 Referral Data Item Name (Data Dict Element) CLINICAL RESPONSE PRIORITY TYPE IDB Element Name ClinRespPriorityType Data Item Description The clinical response priority of a SERVICE REQUEST. National Code National Code Definition 1 Emergency 2 Urgent/Serious 3 Routine The Clinical Response Priority Type field is used to determine whether a referral is urgent or emergency, a crucial requirement for monitoring these services. Recording of this field was investigated as part of exploratory analysis. Of the 779,823 referrals in MHSDS 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 invalid. What needs to be done? Clinical Response Priority should be recorded for all referrals to teams providing the functions of urgent and emergency support, advice & triage and assessment (including brief follow-up) for people of all ages. The definition for each Clinical Response Priority Type code varies dependant on care pathway and providers should reference national guidance for the pathway in question (for example, the term urgent is currently used to describe a one week waiting time requirement in the context of eating disorder services but means two weeks for urgent cancer referrals 9 ). For the purposes of the urgent and emergency community mental health care pathways, the following definitions have been provided by NHS England: Routine: where an urgent or emergency face to face response is not required, for example where telephone advice is sufficient, or the person is signposted to another service. Urgent: situations that require a face to face response, are serious, where an individual may require timely advice, attention or treatment, but it is not immediately life-threatening. 9 These definitions are presented here for illustrative purposes only. The current definitive definitions for any other care pathway can be found in the relevant national guidance. Copyright 2018 NHS Digital 5

Emergency: An unexpected, time-critical situation that may threaten the life, long-term health, or safety of an individual or others, and requires an immediate response. These definitions are taken from NHS England s guidance on urgent and emergency mental health liaison 3, and apply equally to urgent and emergency community response. The Royal College of Psychiatrists 10 have also set out definitions for urgent and emergency which are consistent with those set out above. In addition, an 'Emergency' response will be indicated if the patient was referred as a result of A&E attendance. Recording referral start times and care contact times Table MHS101 Referral Data Item Name (Data Dict Element) REFERRAL REQUEST RECEIVED TIME IDB Element Name ReferralRequestReceivedTime Data Item Description This records the time the REFERRAL REQUEST was received. This item is only required for 'urgent' priority referrals into services with target waiting times measured in hours e.g. rapid response teams or urgent care. MHS201 Care Contact CARE CONTACT TIME CareContTime The time at which a Care Contact took place. NHS England have confirmed that the response time for urgent and emergency services should be measured in hours. It is expected that definitions for measurement of these pathways will be confirmed in national guidance issued by NHS England in future. The initial exploratory analysis investigated the times used for both the referral and care contacts in order to check the potential accuracy of the response times reporting. In order to determine if a person has received a contact within a certain number of hours, it is essential that 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. The analysis identified a large amount of potential default reporting and rounding for both referral start times and contact times. For example, there are a large number of referral start times recorded as midnight than would be expected (figure 1), and there are a large number of times recorded as being on the hour or half past the hour (figure 2). 10 Available at https://www.rcpsych.ac.uk/pdf/quality%20standards%20for%20liaison%20psychiatry%20services%20- %20Fifth%20Edition%202017.pdf (page 37) Copyright 2018 NHS Digital 6

Figure 1: Percentage of Recorded referral start times for both emergency and urgent referrals on the crisis care pathway, February to April 2017 Source: Mental Health Services Dataset (MHSDS) Figure 2: Percentage of recorded referral start time minutes for both emergency and urgent referrals on the crisis care pathway, February to April 2017 Source: Mental Health Services Dataset (MHSDS) Copyright 2018 NHS Digital 7

What needs to be done? In order to provide the best estimate available for the true response times for these pathways, the recording of Referral Request Received Time and Care Contact Time must be as accurate as possible. Systems must not be configured to record a default time when the true time is not known. Anyone involved in the manual entry of times in administrative systems must not enter default times when the true value is not known. It may be beneficial for the importance of accurate recording of times to be highlighted to front line staff and others involved in data entry. It is accepted that there will be reasons that limit the accuracy of time recording in any administrative system. It is also acknowledged that a certain level of accuracy is required to enable sufficiently robust analysis. As a starting point NHS Digital are looking to understand: To what level do service providers understand their time recording to be reasonably accurate? (e.g. to the nearest hour, half hour, 5 minutes etc.) What issues are service providers experiencing which limit the accuracy of time recording in the MHSDS? What actions are service providers planning or able to put in place to improve the accuracy of time recording in the MHSDS? What support can NHS Digital provide to improve the accuracy of time recording in the MHSDS? We welcome any responses to these questions and will use them to inform the development of this analysis. Please send any response to NHS Digital at enquiries@nhsdigital.nhs.uk quoting Urgent and emergency mental health care pathways guidance in the subject of the email. Copyright 2018 NHS Digital 8

Recording of service or team type Table MHS102 Service or Team Type Referred To Data Item Name SERVICE OR TEAM TYPE REFERRED TO (MENTAL HEALTH) IDB Element Name Serv TeamTypeRefToMH Data Item Description The type of service or team within a Mental Health Service that a patient was referred to A01 A02 A03 A04 A05 A06 A07 A08 A09 A10 A11 A12 A13 A14 A15 A16 A17 A18 A19 A20 B01 B02 C01 C02 C03 C04 C05 C06 C07 C08 C09 D01 D02 D03 D04 D05 E01 E02 E03 E04 Z01 Z02 National Code Definition General Mental Health Services Day Care Service Crisis Resolution Team/Home Treatment Service Crisis Resolution Team Home Treatment Service Primary Care Mental Health Service Community Mental Health Team - Functional Community Mental Health Team Organic Assertive Outreach Team Rehabilitation & Recovery Service General Psychiatric Service Psychiatric Liaison Service Psychotherapy Service Psychological Therapy Service (non IAPT) Early Intervention Team for Psychosis Young Onset Dementia Team Personality Disorder Service Memory Services/Clinic Single Point of Access Service 24/7 Crisis Response Line Health Based Place Of Safety Service Forensic Serv ices Forensic Mental Health Service Forensic Learning Disability Service Specialist Mental Health Services Autistic Spectrum Disorder Service Peri-Natal Mental Illness Service Eating Disorders/Dietetics Service Neurodevelopment Team Paediatric Liaison Service Looked After Children Service Community Young Offenders Service Acquired Brain Injury Service Community Eating-Disorder Service for Children and Young People Other Mental Health Serv ices Substance Misuse Team Criminal Justice Liaison and Diversion Service Prison Psychiatric Inreach Service Asylum Service Individual Placement and Support Service Learning Disability Serv ices Community Team for Learning Disabilities Epilepsy/Neurological Service Specialist Parenting Service Enhanced/Intensive Support Service Other Other Mental Health Service - in scope of National Tariff Payment System Other Mental Health Service - out of scope of National Tariff Payment System Copyright 2018 NHS Digital 9

In order to understand if people in scope for a mental health care pathway are accessing the recommended services, it is important to be able to identify those services with which they are in contact. At the highest level, it is necessary to understand which teams or services the person in scope has been referred to. It is understood that teams or services with similar roles can have different names within provider organisations. In addition, the list of service or team types within MHSDS has been designed to be age agnostic in order to prevent the unnecessary expansion of the code list to accommodate age-specific services. Community mental health services NHS England have confirmed that the current proposal for national guidance for this pathway will require that all NHS funded teams providing functions of urgent and emergency mental health support, advice & triage and assessment should record one of the team types A02 Crisis Resolution Team/Home Treatment Service or A03 Crisis Resolution Team or A19 24/7 Crisis Response Line. This is regardless of what the local team name or model is, or which age groups they serve. These proposals will be confirmed in national guidance for these pathways issues by NHS England in future. This future national guidance will supersede the information presented in this document. Liaison mental health services NHS England have confirmed that the current proposal for national guidance for this pathway will be as follows: For adults and older adults Teams that provide on-site specialist liaison mental health in general hospitals should record team type A11. Adult crisis teams providing in-reach to general hospitals should not record themselves as psychiatric liaison. These teams should record team type A02/A03 (as set out above), and ensure that the activity location type is recorded. For children and young people Teams that provide dedicated specialist CYP mental health liaison in general hospitals to emergency departments and/or wards should use team type C05 Paediatric Liaison Service. Teams that provide crisis response in community settings as well as in Emergency Departments (A&E) / general hospitals, should record team type A03 Crisis Resolution team, and ensure that the activity location type is recorded. Teams that provide a fully integrated crisis & liaison function combined with intensive home treatment should record: Team Type A02 Crisis Resolution / Home Treatment Team and ensure that the activity location type is recorded. Copyright 2018 NHS Digital 10

What needs to be done? Where a service or team s remit is to provide urgent and emergency support, advice triage and assessment, and/or intensive home treatment, and they do not provide other functions then these should be included in MHSDS submissions with the relevant service or team type recorded as per this proposed guidance. Recent survey data submitted to NHS England suggests that for adults, a minority (around 3-4%) of areas have the same team providing urgent and emergency response in addition to other functions (e.g. the same team that provides routine mental health care may also provide the urgent and emergency functions). It is expected that the proportion of such teams is likely to be higher for children and young people s services, as well as older adults. In these cases, it may be less appropriate to record these team types in the MHSDS line with the proposed guidance above. Doing so may inappropriately show some people as accessing these pathways than is true or exclude people inappropriately from other mental health pathways. NHS England and NHS Digital need your feedback to understand the possible size and implications on the monitoring of mental health pathways of any services or teams which combine the functions or crisis resolution and/or home treatment with other functions. If this is the case for any services or teams in your provider organisation we would be grateful of any information you can provide. The questions below may guide the feedback you provide, but please include any other points you consider relevant: Which teams or services in your organisation does this impact? What other functions do these teams carry out? How many people access these teams for crisis resolution and/or home treatment? How many people access them for the other functions? How many access them for both? Do you have a preferred suggestion for how urgent / emergency activity in these teams should be recorded in MHSDS? Please send any feedback to NHS England at england.adultmh@nhs.net quoting Urgent and emergency mental health care pathways MHSDS guidance in the subject of the email. Any feedback will be used to inform the development of the final national guidance for these pathways. Copyright 2018 NHS Digital 11

Recording of activity location Table Data Item Name IDB Element Name MHS201 Care Contact ACTIVITY LOCATION TYPE CODE ActLocTypeCode Data Item Description The type of LOCATION for an ACTIVITY: where PATIENTS are seen where SERVICES are provided or from which requests for SERVICES are sent. National Code National Code Definition Patient main residence or related location A01 A02 A03 A04 Patient's home Carer's home Patient's workplace Health Centre premises B01 B02 Other patient related location Primary Care Health Centre Polyclinic General Practitioner and Ophthalmic Medical Practitioner Premises C01 General Medical Practitioner Practice C02 Dental Practice C03 Ophthalmic Medical Practitioner premises Walk In Centres, Out of Hours Premises and Emergency Community Dental Serv ices D01 Walk In Centre D02 D03 Out of Hours Centre Emergency Community Dental Service Locations on Hospital Premises E01 E02 E03 E04 E99 Out-Patient Clinic Ward Day Hospital Accident and Emergency or Minor Injuries Department Other departments Hospice premises F01 Hospice Nursing and Residential Homes G01 G02 Care Home Without Nursing Care Home With Nursing G03 G04 Children s Home Day Centre premises Integrated Care Home Without Nursing and Care Home With Nursing H01 Day Centre Resource Centre premises J01 Resource Centre Dedicated Facilities for Children and Families K01 K02 Sure Start Children s Centre Child Development Centre Educational, Childcare and Training Establishments L01 L02 L03 School Further Education College University Copyright 2018 NHS Digital 12

Table Data Item Name IDB Element Name Data Item Description National Code National Code Definition L04 Nursery Premises L05 Other Childcare Premises L06 Training Establishments L99 Other Educational Premises Justice and Home Office premises M01 M02 M03 M04 M05 Prison Probation Service Premises Police Station / Police Custody Suite Young Offenders Institute Immigration Removal Centre Public locations N01 N02 N03 N04 N05 Street or other public open space Other publicly accessible area or building Voluntary or charitable agency premises Dispensing Optician premises Dispensing Pharmacy premises Other Locations X01 Other locations not elsewhere classified What needs to be done? In order to understand what services are being delivered it is important to know where the location of any assessment is taking place, in addition to knowing the service or team a person is referred to. For example, full and accurate recording of activity location will allow analysis of the data to show where community crisis teams are routinely providing crisis response to A&E departments. Service providers should ensure accurate and full recording of the activity location type for any assessments undertaken as part of these pathways. NHS Digital would welcome any feedback on issues services providers are experiencing with recording this information. Please send any response to NHS Digital at enquiries@nhsdigital.nhs.uk quoting Urgent and emergency mental health care pathways guidance in the subject of the email. Copyright 2018 NHS Digital 13

What should I do if I have any questions about this or feedback? NHS England s crisis and acute care workstreams have been set up to support the commissioning and provision of high-quality, responsive, 24/7 accessible mental health services for people who may be seriously ill and need of urgent support. If you have any questions or feedback about this work please contact NHS England at: england.adultmh@nhs.net NHS Digital are the national information and technology partner to the health and social care system. This work involves the development, collection and analysis of national administrative datasets including the Mental Health Services Dataset (MHSDS). If you have any questions or feedback about this work please contact NHS Digital at: enquiries@nhsdigital.nhs.uk Please quote Urgent and emergency mental health care pathways MHSDS guidance in the subject of any correspondence. Copyright 2018 NHS Digital 14