CORPORATE Standard Operating Procedure: Mental Health Services Data Set (MHSDS) Identifier metrics DOCUMENT CONTROL SUMMARY Status: Replacement - R/GRE/sop/04 Version: V2.1 Date: Author/Owner: Rob Abell, Senior Performance Development Manager Sara Reeve, Associate Director of Performance Approved by: Policy and Procedures Committee Date: 23 Ratified: Policy and Procedures Committee Date: 23 Related Trust Strategy or Aims: Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures Provide high quality services, built on best known practice and evaluated through service user and carer feedback and clear process and outcome measures. Deliver all regulatory performance, Quality standards and compliance indicators March 2020 Mental Health Services Data Set, MHSDS, data set, Identifier metrics Compliance with the Performance Metrics in NHS Improvement s Single Oversight Framework Policy
Standard Operating Procedure: Mental Health Services Data Set (MHSDS) Identifiers metrics CONTENTS 1. Introduction... 3 2. Rationale... 3 3. Measurement... 4 4. Scope... 4 5. Summary of responsibilities... 7 6. Non-compliance... 7 7. Trust Expectations... 8 8. Further Guidance... 8 Version History Log Version Date Implemented Details of significant changes 2.0 May 2015 2.1 Reviewed in light of the Single Oversight Framework Reference Documents Referred to Document Document Date NHS Improvement Single Oversight Framework September 2016 Mental Health Services Data Set (MHSDS) v1.1 User Guidance April 2016 IT IS THE RESPONSIBILITY OF ALL USERS OF THIS SOP TO ENSURE THAT THE CORRECT VERSION IS BEING USED All staff should regularly check the intranet site for information relating to the implementation of new or revised versions of this SOP. This SOP will normally be reviewed every 3 years unless changes to the legislation require otherwise. Page 2 of 8
1. Introduction Standard Operating Procedure: Mental Health Services Data Set (MHSDS) Identifier This document details the process by which SSSFT staff must record information for the: Type of Indicator Required by Title Mandatory Indicator x NHS Improvement and CQC Complete and valid submissions of metrics in the Mental Health Services Data Set (MHSDS) to NHS Digital Identifier metrics Commissioner Indicator Trust Indicator x Trust Board The Trusts Information Governance Policy and associated SOPs 2. Rationale The Mental Health Services Data Set (MHSDS) contains record-level data about the care of children, young people and adults who are in contact with mental health, learning disabilities or autism spectrum disorder services. The Mental Health Services Data Set (MHSDS) is a change to the Mental Health and Learning Disabilities Data Set (MHLDDS) standard, which supersedes and replaces this and the following standards: ISB 1072 Child and Adolescent Mental Health Services (CAMHS) data set ISB 1509 Mental Health Care Cluster ISB 1078 Mental Health Clustering Tool MHSDS also incorporates requirements in support of Children and Young People's Improving Access to Psychological Therapies (CYP IAPT), elements of the Learning Disabilities Census (LDC) and elements of the Assuring Transformation (AT) Information Standard. The MHSDS is a patient level, output based, secondary uses data set which delivers robust, comprehensive, nationally consistent and comparable person-based information for children, young people and adults who are in contact with Mental Health Services. As a secondary uses data set it intends to re-use clinical and operational data for purposes other than direct patient care. The MHSDS is unique in its coverage, because it covers not only services provided in hospitals, but also in outpatient clinics and in the community, where the majority of people in contact with these services are treated. It brings together key information from the mental health, learning disabilities or autism spectrum disorder care pathway that has been captured on clinical systems as part of patient care. MHSDS supports a variety of secondary use functions such as: commissioning clinical audit research service planning inspection and regulation monitoring government policies and legislation local and national performance management and benchmarking national reporting and analysis Page 3 of 8
The MHSDS is the data source used for the implementation of Mental Health Currencies and Payment (formerly PbR). As such, the Mental Health Care Clusters, and Mental Health Clustering Tool are implemented through the MHSDS. MHSDS is also planned to be the future source of the Learning Disabilities payment system once requirements are determined. MHLDS statistics are for anyone wanting a comprehensive national picture of the use of specialist mental health, learning disabilities or autism spectrum disorder services in England, including: policy makers commissioners mental health service users members of the public 3. Measurement This overall indicator measures the completeness of the basic service user information and counts the number of valid entries for each of the following data items: Date of birth Service users current gender Service users NHS number Postcode of service users normal residence Organisation code of commissioner Organisation code of service users registered General Medical Practice Target The current target is 95%. Numerator Count of valid entries for each of the selected data items (fields). Denominator Total number of entries. Indicator The indicator is the numerator divided by the denominator, expressed as a percentage. 4. Scope Services in scope of the MHSDS are: Scope Adult Older Persons Dual Diagnosis IAPT (Adult) High Secure Medium Secure Low Secure Learning Disability Autism Spectrum Disorder CAMHS Early Intervention MHSDS (v1.1) No Page 4 of 8
Liaison Psychiatry Independent Sector Non-NHS Funded (Optional) MHSDS is referral driven. Each monthly submission should include all open/active referrals within that reporting period, which includes: referrals that were opened in the reporting period referrals that closed in the reporting period referrals that were open throughout the reporting period, even if no activity took place. The MHSDS is intended to capture data relating to patients of any age. Required Field Date of birth Guidance Every effort should be made to identify the patient s correct date of birth, or date that the patient has estimated to be their date of birth. However, where the patient s DOB cannot be determined precisely, an estimation should be provided. If it is not possible/appropriate to estimate then the data item should be left blank (Null). Estimates should not change once they have been made. Once the actual DOB is identified, it should be recorded and submitted correctly. Service users current gender Service users NHS number Postcode of service users normal residence When estimating a patient s DOB a consistent approach should be used, for example: use 1st July if only the year is known, 15th of the month if only the month is known, 1st January for beginning of the year, 31st December for end of the year, 25th December for Christmas etc. National Code 0 'Not Known' means that the sex of a PERSON has not been recorded National Code 9 'Not Specified' means indeterminate, i.e. unable to be classified as either male or female. Where the NHS Number is not known, this should be left blank. All postcodes are validated against the Gridall file available from the ODS. Where the person has no fixed abode this should be recorded as ZZ99 3VZ. If the postcode is unknown ZZ99 3WZ should be used. Organisation code of commissioner For overseas residents, please use the pseudo country postcode found in the Country names and pseudo country postcodes in pseudo country postcode order file on the HSCIC web page: Data supplied by the Office of National Statistics. The postcode will be recorded in the format ZZ99 xxz, where xx denotes the country pseudo postcode. This is the organisation code of the organisation that initiated the provision of care or Team Referral record. The Organisation Code (Code of Commissioner) may be a specialist commissioner. The Department of Health document Who pays? Establishing the Page 5 of 8
Responsible Commissioner sets out a framework for establishing responsibility for commissioning an individual's care within the NHS (i.e. determining who pays for a PATIENT s care). Organisation code of service users registered General Medical Practice It is the responsibility of providers to derive and allocate the correct commissioner code for the healthcare activities they provide. The commissioner code describes which commissioning organisation has payment responsibility, differentiating activity paid for by NHS England (including subdivisions thereof), Clinical Commissioning Group (CCG) commissioners and other commissioners as appropriate. Guidance on this can be found in the NHS England publication: Data Services for Commissioners. The following default ODS codes apply: GP Practice Code not applicable - V81998 - should be used where a PATIENT should not have a registered GP Practice, due for instance to them having only recently entered the country GP Practice Code not known - V81999 - should be used where it is not possible to determine a PATIENT's registered GP Practice code, but it is known that they should have one, or where it is impossible to determine whether they should or shouldn't have a registered practice (for instance the PATIENT cannot communicate and is unidentified). No Registered GP Practice - V81997- should be used when a PATIENT presents, who is not currently registered at a GP Practice, but is eligible to be registered should they wish to. Child and Adolescent Mental Health Services (CAMHS) The MHSDS is a patient focused data set and includes children and adolescents receiving specialist CAMH services operating in tiers 2, 3 and 4 of the four-tier strategic framework. Further details of the CAMHS four-tier strategic framework can be found on the website Every Child Matters. It also includes children and adolescents who are thought to have a mental illness, learning disability or autism spectrum disorder in receipt of any other secondary mental health care service such as the new community based eating disorder services for children and young people. Scope does not include Non-specialist CAMH services, and the provision of CAMH tier 1 services which are likely to include services provided by: GPs Health visitors Schools Social services departments Youth justice Voluntary agencies Children and Young Persons Improving Access to Psychological Therapies (CYP IAPT) Programme The Children and Young People's Improving Access to Psychological Therapies Programme (CYP IAPT) works with existing Child and Adolescent Mental Health Services (CAMHS) including the voluntary sector and local authorities to transform delivery at Tiers 2 and 3 across the country. A primary requirement for the MHSDS was to include all CYP IAPT data (where possible) to allow submission through the MHSDS, retiring the separate CYP IAPT collection and submitting through the MHSDS. Page 6 of 8
5. Summary of responsibilities Designation Responsibilities Clinical Staff Capture required patient demographic Information upon assessment Ensure any missing demographic details for patients who are treated are obtained from them Record information in the clinical IT system. Clinical Teams have primary responsibility for recording accurate data at point of assessment. Information must be entered into the clinical system within 24 hours of the assessment taking place. Ward & Team Managers Ensure any missing demographic details for patients who are treated are obtained from them Record information in the clinical IT system Validate reports and any figures showing as breaches/non compliant, correct the record if necessary, including updating patient records on the clinical system and provide feedback All staff Every person who has contact with either: a) a service user (either face to face or telephone contact) or b) any individual (either face to face or telephone contact) The service users care must be recorded within the progress notes within the clinical system. Information Team Provide reports as required from the Data Warehouse Specification and publication of reports as specified in line with the definition in this document. Where performance falls below the KPI threshold the Information Team will provide the Executive Lead with the details of the shortfall. Compliance or otherwise will be included in the Finance and Performance Sub Committee and Trust Board papers submitted on a monthly basis. Any ad hoc requests for information and data pertaining to this indicator will all be assessed and dealt with by the Information Team Executive Lead Request, where necessary, a narrative reason behind the shortfall from the responsible teams Identify actions for the Directorate management teams to address the shortfall Service Leads Oversee the completion of actions to (which may involve developing action plans) to address under-performance Provide narrative to the Executive Lead as required Provide evidence of service improvements established to address performance Performance On an ongoing basis, will review and monitor the performance Development Team trends of this indicator, informing the formal performance review process and providing remedial action with teams where Directorate Management Teams 6. Non-compliance appropriate. This KPI should be reviewed on a monthly basis by the relevant Directorate management team meetings. This indicator features in NHS Improvement s Single Oversight Framework, and as such is a national Page 7 of 8
priority target which NHS Trusts are expected to achieve. Failure to meet this target is a breach of our Foundation Trust s terms of authorisation. This indicator is reported to NHS Improvement on a quarterly basis and as such affects the overall segmentation score for the Trust. The indicator is also reported to our commissioners and noncompliance can result in monetary penalties and so affect the funding available for patient care. 7. Trust Expectations To meet the statutory and commissioner requirements. To use the Trust s clinical system to record this activity in accordance with the data quality requirements. Distribution of information and data regarding this indicator will only be shared with external agencies through nominated contacts. The Trust Information Team will validate all requests for information and data regarding this indicator prior to their distribution. The following directorates are in scope of the statutory and contractual targets: o Mental Health, Specialist Family Services, Forensic & Criminal Justice Service, Learning Disabilities 8. Further Guidance Appendix Guidance documents on the clinical processes for RiO The SQL code used to produce the information from the SSSFT data warehouse and reports NHS Digital See latest guidance on the RiO Quick Reference Guides and Manuals website http://intranet.sssft.nhs.uk/rio/sitepages/rio7%20qr G.aspx or contact the RiO Support Team on 01785 783270 for further support and assistance Contact the Trust Information Team who will provide you with the latest version of the SQL code used to produce reports http://digital.nhs.uk/mhsds Page 8 of 8