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Simon Bristow – System Improvement Advisor

The Mental Health System Improvement Team

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Contents

• Introduction to the Five Year Forward View for Mental Health (FYFV-MH)

• Data and service development

• CYPMH – Where are we now?

• CYPMH next steps - The Long Term Plan – (LTP)

• The System Improvement Team (SIT)

• What does good CYPMH good look like?

• Learning from systems

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The Mental Health Services Dataset (MHSDS) is a patient level, output based, secondary uses data set

It delivers robust, comprehensive, nationally consistent and comparable person-based information for children, young people and adults who are in contact with Mental Health Services.

Mental Health Services Dataset

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• Detailed, complicated and new to MH

• Infrastructure resource implications

• Iterative processes to generating accurate and consistent data

Data Challenges

Presentation title

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• Moral imperative to curiosity in how to support our patients to achieve better outcomes

• There are significant unwarranted variations between service offer and outcomes

• We have significant data gaps in mental health, primarily:

• 1. Gaps in evidence base on what works for whom – RCTs for people with SMI often “represent a small atypical minority of the patient population, as up to 80–90% of patients are excluded because of mental or physical comorbidity, suicidal or antisocial behaviour, or substance abuse” (1)

• 2. Gaps in practice based evidence – There are some cohort studies on the real world effectiveness, but as a unified health system our potential to harness data to improve outcomes at individual patient and at population level is huge!

(1) Tiihonen J. Real-world effectiveness of antipsychotics. Acta Psychiatr Scand. 2016;134(5):371–373. doi:10.1111/acps.12641

Why is the data important?

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Data in Improvement Science – Iterative reductions in variation, Informative? Imprecise?

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Big, Beautiful Data

There is significant utility for educators and students in the data reported through:

Model Hospital – detailed inpatient, crisis and community activity data and dashboards accessible to anyone in the NHShttps://improvement.nhs.uk/resources/model-hospital/

FutureNHS collaboration platform – dashboards and message boards on CYPMH, EIP, and crisis activity, interventions and outcomeshttps://future.nhs.uk/

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Big, Beautiful Data

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Detailed profiling tools, drilling down to CCG level are publicly available at https://fingertips.phe.org.uk/profile-group/mental-health

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• This includes detailed, real world health outcomes data at national, regional and CCG level

Big, Beautiful Data

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What good has this done in MH?

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IAPT - 10 years of data

We have a vast, richly detailed data set reporting on the reach, cost, and outcomes of IAPT services across the country, which can be compared by provider, CCG, STP and region.

This enables detailed analysis of variance in commissioning provision and the developmentof evidence informed service development plans and impact measures

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Many of the issues and challenges highlighted below are common, to a greater or a lesser extent, to CYP systems across the country viz.

Variation

There is variation in the needs of children in different circumstances and at different stages of their development. There is variation in the availability and quality of services. And there is variation in the way different parts of the system are commissioned, funded and overseen. (CQC, 2017)

Fragmentation

The system as a whole is complex and fragmented. Mental health care is planned, funded, commissioned, provided and overseen by many different organisations, that do not always work together in a joined-up way. Poor collaboration and communication between agencies can lead to fragmented care, create inefficiencies in the system, and impede efforts to improve the quality of care.

Poor data quality and availability

Significant gaps in the availability of data mean it is difficult to get a clear picture of what services are available to children and young people across the country.

Increased demand with long waits

Evidence suggests that the demand for mental health care for children and young people is increasing. What is less clear is whether the capacity of services is also changing, as there is no reliable data to tell us how many children and young people can be cared for across the mental health system.

CYPMH - The National Context

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https://www.england.nhs.uk/publication/joint-technical-definitions-for-performance-and-activity-20171-8-201819/

Where are we now? – CYP access• The Government set the ambition that by 2020/21 at least 35% of CYP with a diagnosable

MH condition receive treatment from an NHS-funded community service.

• This equates to 70,000 more CYP per year will access services by 2020/21 (compared with

2015/16)

• Estimated prevalence of diagnosable mental health problems in CYP aged 5-16 at 9.6%

(2004 survey)

• The percentage prevalence varies between CCGs according to age, sex and socio-

economic classification (social class)

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• We are a small, national team hosted within NHSE/I, offering improvement

support to commissioners and providers of mental health care.

• We use a collaborative consultancy approach to support organisations with

working together to implement the transformational objectives of the 5YFV-MH

and the Long Term Plan.

• Inevitably, our work is often with systems who are struggling with achieving their

desired position and are in need of support to improve, however we are not a

performance management team.

• Our core offer to commissioners and providers is providing a detailed diagnostic

review of system challenges, formulating and agreeing system

recommendations, and offering post-diagnostic implementation advice and

support to achieve the desired state.

Who are the System Improvement Team?

Presentation title

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• Our team members are from a variety of clinical and managerial backgrounds,

hold a broad range of skills and experience in the delivery of mental health

services, and hold subject matter expertise in particular areas, including:

• Governance, leadership and culture

• Clinical pathways

• Operational management

• Service improvement methodologies

• Data quality and reporting

• Value for money and productivity

• Waiting list management and patient flow

Skills and Experience

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• We support improvements in patient care by helping systems and providers to deliver and evaluate evidence based treatment pathways

• We take a holistic view, working across whole systems and pathways to support the delivery of national and local standards

• We work with commissioners and providers to agree bespoke support offers based on a menu of possible support interventions

• We use data and risk lists to identify areas of greatest opportunity

• We use qualitative and quantitative approaches (e.g. appreciative enquiry, national benchmarking data and local intelligence) to build a well-informed view of improvement opportunities

• We take care to select the right team for the assignment, matching skills and experience to the specific local context and needs

• We give advice to national teams to help ensure that policy and guidance translates to operational delivery

• We design and deliver workshops to inform and influence at scale

How we work

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NATIONAL

REGIONAL

LOCAL

Guidance on essential

aspects necessary for

operational delivery

Developing capability in

MH delivery oversight

Insight, recommendations,

tools, coaching

Commissioners Providers

Improved patient care

Our Support Offer

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Our Support Offer

Full diagnostic

Post diagnostic support

Targeted diagnostic

Workshops

Tools and resources

Advice, coaching & consultancy

Support for national pilots

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Diagnostic reviews

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Week Phase Purpose / outputs

0 Pre-scoping Describe SIT diagnostic and agreement to proceed.

1 Scoping Agree review scope and objectives with commissioning and provider leads.

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Preparation

Agree visit agenda, venue and attendees with relevant leads. Commissioners

and provider(s) supply documentation and data to inform review.3

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Documentation review

SIT review and assimilate information supplied and undertake analyses.

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6Diagnostic review visit

SIT meet with key staff, people with lived experience and families. Discussion

held at the end of the review to share initial findings.

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Report

SIT produce a detailed system level report, and present this to the system within

approximately 2 weeks of the review.

The system have 2 weeks to review the report for factual accuracy, and agree a

final version of the report and recommendations.

Once agreed, the final version of the report is circulated to the system, and

regional colleagues.

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Action plan Commissioner and provider develop and agree action plans in response to report.12

Full diagnostic reviews of systems follow a seven stage process, requiring approximately 12 weeks for completion

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Learning from diagnostic reviews and 4WW pilots - CYPMH

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These domains and good practice indicators are linked to increasing access to CYP MH services and improving quality, and they inform the SIT diagnostic process.

What Good Looks Like

Domain CYP-MH Good Practice Indicator statement

Strategy &

Sustainability

1. Seamless, system wide collaboration is represented in a joined up vision and clear, sustainable investment

across the locality.

The Model2. A coherent STP wide model for delivery of CYP MH is in place, based on CYP-IAPT values and principles, early

intervention and recovery. The model is co-produced, evidence based, effective and encourages local innovation.

Access & Waits3. Support to CYP who have needs regarding their emotional and mental wellbeing is commissioned and provided

in a way that is easy to access, responsive and requires minimal waits.

Practice based on

best available

evidence

4. The local offer, including the assessments and interventions available to CYP and their parent/carer are evidence

and best-practice based.

Workforce5. The CYP-MH workforce has sufficient expertise and capacity to deliver clinical pathways and plans for

sustainability are in place.

Involvement &

Participation6. There is equitable and meaningful involvement and participation of children, young people and their parent/carer.

Productivity 7. Productivity is reviewed and maximised to ensure efficient delivery and use of resources.

Outcomes

8. Outcomes drive commissioning and service development at a strategic and operational level. Routine Outcome

Measures (ROMs) are used in clinical practice to identify needs, interventions, evaluate the efficacy of treatment and

help determine endings.

Data & Informatics 9. Quality data is being recorded, flowed, and used to ensure clinical quality is maximised.

Culture10. There is a person first, empowering culture, which embraces collective ownership, positive risk taking and

innovation.

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What Good Practice looks like:-

Support to CYP who have needs regarding their emotional and mental wellbeing is commissioned and provided in a way that is easy to access, responsive and requires minimal waits.

Common actions required:-

• Awareness raising of Access Target within both provider and CCG

• Leadership around monitoring and driving increased access

• Apportioning of activity for providers, so expectations are clear

• Agree a validation process for review what is flowing to MHSDS

• Establish clear performance structure to monitor progress of each providers achievement of their proportion of the Access Target

• Developing PTLs and associated management and governance processes – comparable to PH

• Developing definitions, standards, monitoring and reporting processes for internal waits

1. Access & Waits

18/19 19/20 20/21

32% 34% 35%

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What Good Practice looks like:-

• Seamless, system wide collaboration is represented in a joined up vision and clear, sustainable investment across the locality.

Common actions required:-

• Must be considered as a system transformation wider

than traditional CAMHS

• Establish a coherent, joined up governance structure

between STP, CCG, LA and providers

• Develop the community offer (wider system offer for

prevention/emotional wellbeing)

2. Strategy & Collaboration

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What Good Practice looks like:-

The CYP-MH workforce has sufficient expertise and capacity to deliver clinical pathways and plans for sustainability are in place.

Common actions required:-

• Clear training strategy aligned to demand

• Establish peer support worker roles

• Develop a plan for building and maintaining

sustainable future workforce

• Consider skills required at different steps

• Prioritise the wellbeing of staff teams;

cascade and role model the behaviour

wanted in the service.

3. Workforce

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What Good Practice looks like:-

The local offer, including the assessments and interventions available to CYP and their parent/carer are evidence and best-practice based.

Common actions required:-

• Define clear treatment pathways and indicated dose

• Use data to understand demand and

requirement for specific pathways

• Joint plan to manage waits for neuro-

developmental diagnostic services

• Make step up and step down seamless and

robust in community offer

• Prioritise NICE recommended treatment

• Ensure offer includes plans for those who fall outside of clinical pathway definitions

• Ensure outcomes are primary driver

to clinical practice

4. Practice Based on Best Available Evidence

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What Good Practice looks like:-

A coherent STP wide model for delivery of CYP MH is in place, based on CYP-IAPT values and principles, early intervention and recovery. The model is co-produced, evidence based, effective and encourages local innovation.

Common actions required:-

• System thinking wider than traditional CAMHS

• Establish coherent, joined up governance re: transfers

joint working, and complex cases

• Develop the community offer (wider system) and VCS

provision

5. The Model

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What Good Practice looks like:-

There is equitable and meaningful involvement and participation of children, young people and their parent/carer

Common actions required:-

• Participation developed within

the system

• Engage CYP to develop model

design

• Peer support workers are in place

and valued

6. Involvement & Participation

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What Good Practice looks like:-

• Productivity is reviewed and maximised to ensure efficient delivery and use of resources.

Common actions required:-

• Use data to understand demand and requirement for specific pathways

• Use Access apportionment as part of demand and capacity projections

• Review flow from access to timely discharge – cover the whole CYP journey

• Link improved clinical offer to productivity

through use of outcomes to measure treatment progress

7. Productivity

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What Good Practice looks like:-

• Outcomes drive commissioning and service improvement at a strategic and operational level including the use of Routine Outcome Measures (ROMs) to evaluate effectiveness, lead service improvement, inform interventions and help determine endings.

Common actions required:-

• Systems in place to report outcomes

effectively

• Ensure outcome use is clinical useful to CYP

• Ensure outcomes are the primary driver

of clinical practice

• Validation process for review of

what is flowing to MHSDS.

8. Outcomes

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What Good Practice looks like:-

• Quality data is being recorded, flowed, and used to ensure clinical quality is maximised.

Common actions required:-

• Awareness raising of Access Target within both provider and CCG

• Agree a validation process to review data flowing to MHSDS.

• Establish clear performance structure to monitor progress of each providers achievement of their proportion of the Access Target

• Have a clear Data Quality strategy to improve confidence in data

9. Data Quality

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What Good Practice looks like:-

• There is a person first, empowering culture which embraces collective ownership, positive risk taking and innovation.

Common actions required:-

• Ensure treatment offer is recovery focused

• Collective leadership shown across the system

- evidencing system thinking wider than

traditional CAMHS

• Prioritise the wellbeing of staff teams;

cascade and role model the behaviour

wanted in the service.

10. Culture

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• We are working to scale up the learning from system reviews into a tool for use in the rest of the country

• Process of funnelling to the detail from Domain -> GPI -> Elements -> Key Lines Of Enquiry (KLOE) to give a score to support areas to decide what to focus on to improve.

• Collaborative approach to develop the Elements which make up the full picture for managing a domain

• Building robust Key Lines Of Enquiry to help areas think about the detail

• Scoring system…

Developing The CYPMH Maturity Tool

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Example from CYPMH Maturity Tool

Domain Access & Waits

CYP MH Good

Practice

Indicator (GPI)

Statement

Support to CYP who have concerns regarding emotional and

mental wellbeing is commissioned and provided in a way that is

easy to access, responsive and requires minimal waits.

Element 3 A CYP-friendly summary of the access policy is available.

Key Lines Of

Enquiry

(KLOEs)

Is the access policy published on the provider's website? Has

this been generated in collaboration with CYP and their

families?

Scoring

0 Nothing in place (no evidence)

1 Fair (limited evidence of implementation or impact, document

available)

2 Good (significant evidence of implementation, limited impact)

3 Very good (full implementation, clear evidence of demonstratable

impact)

4 Best Practice (evaluated, approach refined, maximum impact)

This is one of the 10 general themes

This statement describes what good

practice would look like (and is one of 10 GPI

statements)

The scoring system.

This is a description

of the elements

required to achieve the GPI. There

are multiple for each GPI These are prompt questions to think about achievement of the element.

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• Access and waiting time policies and governance structures

• Patient Tracking Lists

• Pathway analysis (to treatment, and to discharge)

• Caseload management tools and minimum standards

• Interim pathways and using patient flow methodologies

• Productivity, and measuring capacity

Co-Producing Implementation Tools to Support Standards

Presentation title

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Valued Care in Mental Health – leading change

https://improvement.nhs.uk/improvement-offers/valued-care-mental-health-national-improvement-model/

Quality, Service Improvement and Redesign tools – suite of change management resources

https://improvement.nhs.uk/resources/quality-service-improvement-and-redesign-qsir-tools-type-task/

QSIR college

https://improvement.nhs.uk/resources/qsir-programme/

SAFER bundle for improving inpatient flow

https://improvement.nhs.uk/resources/safer-patient-flow-bundle-implement/

Managing Referral to Treatment

https://improvement.nhs.uk/resources/elective-care-guide/

Practical NHSI Resources for Leading Change in the NHS

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MH-SIT representatives for your region

REGION NAME MOB E-mail address

South West Els Drewek 07810 030 100 els.drewek@nhs.net

East of England Michael Watson 07879 113 249 m.watson@nhs.net

South East Nick Gitsham 07730 376 404 nick.gitsham@nhs.net

North West Sarah Butt 07714 777 070 sarah.butt1@nhs.net

NE & Yorkshire Simon Bristow 07894 237 994 simon.bristow@nhs.net

Midlands Sarah Wright 07597 393 067 sarah.wright72@nhs.net

London Michael Watson 07879 113 249 m.watson@nhs.net

Additional NAME MOB MOB

MH-SIT Frances Igbonwoke, Tues-Thurs 07900 715 163 f.igbonwoke@nhs.net

contacts Sharon Harvey, Tues-Thurs 07519 293 324 sharon.harvey11@nhs.net

North East and Yorkshire

1. Cumbria and the North East

2. West Yorkshire and

Harrogate

3. Humber, Coast and Vale

4. South Yorkshire and

Bassetlaw

North West

5. Lancashire and South

Cumbria

6. Greater Manchester

7. Cheshire and Merseyside

Midlands

8. Staffordshire and Stoke on

Trent

9. Shropshire and Telford and

Wrekin

10. Derbyshire

11. Lincolnshire

12. Nottinghamshire

13. Leicester, Leicestershire

and Rutland

14. The Black Country

15. Birmingham and Solihull

16. Coventry and

Warwickshire

17. Herefordshire and

Worcestershire

18. Northamptonshire

East of England

19. Cambridgeshire and

Peterborough

20. Norfolk and Waveney

21. Suffolk and North East

Essex

22. Bedfordshire, Luton and

Milton Keynes

23. Hertfordshire and West

Essex

24. Mid and South Essex

London

25. North West London

26. Central London

27. East London

28. South East London

29. South West London

South East

30. Kent and Medway

31. Sussex and East Surrey

32. Frimley Health and Care

33. Surrey Heartlands

35. Buckinghamshire,

Oxfordshire and

Berkshire West

42. Hampshire and Isle of

Wight

South West

34. Gloucestershire

36. Cornwall and the Isles of

Scilly

37. Devon

38. Somerset

39. Bristol, North Somerset

and

South Gloucestershire

40. Bath, Swindon and

Wiltshire

41. Dorset

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Simon.Bristow@nhs.net

Any Questions?