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Sarah Khan – Deputy Head of Mental Health
NHS England
Measuring and monitoring quality in
mental health: preparing to
implement the new access & waiting
time standards
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1. Context for the introduction of access and waiting time standards for mental health services
2. The standards to be introduced from 15/16
3. The data challenge:
• What data do we want?
• What data do we have?
• What are we doing about it?
4. Measurement challenges, opportunities and hopes for the future
This presentation
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1. Context for the introduction of
access and waiting time standards for
mental health services
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MH 5YP: rebalancing the system
Right care
Right time
Right setting
Prevention
Early intervention
Effective care
Recovery
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The system is currently not in balance
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There is a 15-20 year gap in the life expectancy of
individuals with serious mental illness compared
with the rest of the population
Health promotion
activity, physical health
assessments and
interventions need to
be integrated at every
level if the 15-20 year
mortality gap is to be
closed.
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We are also missing opportunities to deliver better and
higher value care to individuals receiving treatment for
a physical health condition If we are to improve outcomes and quality of
life for individuals with physical health needs,
then:
a. Promotion of positive mental health as
part of condition management
b. Recognition of mental health needs
c. Timely access to expert assessment and
evidence based mental health care
Will need to be integrated at every level of
the physical healthcare system.
a + b + c
= reduced demand from repeat
attendances in primary care, UEC
and outpatient clinics
= reduced acute length of stay
= better outcomes at lower cost
for individuals with long term
conditions
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2. The standards to be introduced from
2015/16
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From 1 April 2016:
• More than 50% of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral.
• 75% of people referred to the Improving Access to Psychological Therapies programme will be treated within 6 weeks of referral, and 95% will be treated within 18 weeks of referral.
• £30m investment is to be targeted on effective models of liaison psychiatry in a greater number of acute hospitals.
The October announcement
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The Autumn Statement
The Autumn Statement 2014 outlined the provision of additional
funding of £30million recurrently for 5 years to be invested in a central
NHS England programme to improve access for children and young
people to specialist evidence-based community CAMHS eating disorder
services. Part of this programme funding will be used to develop an
access and waiting time standard.
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The Spring Budget
The Spring Budget 2015 included an announcement of £1.25bn new
mental health funding over the next 5 years (£250m per year) to
improve access to mental health services for children and young people
and for mothers experiencing perinatal mental illness.
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Rt. Hon. Norman Lamb
Minister of State for Care and Support
“We need standards for access to mental health treatment for people
of all ages that balance the equivalent standards for physical health.
We need the same quality of data and transparency about
performance for mental health services for people of all ages so that
long waits for effective treatment are visible and have to be tackled.”
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3. The data challenge
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• The new access and waiting time standard requires that, by 1 April 2016, more than 50% of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral.
• The standard is ‘two-pronged’ and both conditions must be met for the standard to be deemed to have been achieved, i.e.
A maximum wait of two weeks from referral to treatment; and
Treatment delivered in accordance with NICE guidelines for psychosis and schizophrenia - either in children and young people CG155 (2013) or in adults CG178 (2014).
• Most initial episodes of psychosis occur between early adolescence and age 25 but the standard applies to people of all ages in line with NICE guidance.
The EIP standard
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What are we aiming to do?
In 2011, No Health Without Mental Health, highlighted the effectiveness of EIP services. When delivered in accordance with NICE standards they help people to recover from a first episode of psychosis and gain a good quality of life.
We want to ensure that:
• Duration of untreated psychosis is reduced and anyone with an emerging psychosis and their families and key supporters can have timely access to specialist early intervention services which provide interventions suited to age and phase of illness.
• Individuals experiencing first episode psychosis have consistent access to a range of evidence-based biological, psychological and social interventions as recommended by NICE.
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We want to be able to understand:
• Referral to treatment times in a way that makes sense for the FEP pathway;
• Whether people experiencing FEP are accessing the full range of interventions recommended by NICE;
• The outcomes people with FEP are achieving as a result of treatment;
• The nature, size and skills of the EIP workforce – wte, profession, competency to deliver interventions recommended by NICE.
What data do we want from national datasets to support implementation?
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1. We commissioned the National Collaborating Centre for Mental Health to support the programme and establish a reference group of EIP experts to:
• Design the RTT pathway;
• Specify the interventions that would need to be captured;
• Specify the outcomes dataset.
2. We worked with the HSCIC and provider information experts to agree the associated changes required to the MHLDDS and the timeframe for delivery.
3. We established 4 Regional EIP Preparedness Programmes and tasked them with undertaking workforce surveys that would provide granular data regarding skill-mix and competencies.
4. We are working with HQIP to commission a national clinical audit of EIP services to understand the current level of NICE concordance.
5. We are working with the RCPsych (CCQI) to establish an accreditation scheme for EIP services.
What are we doing about it?
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4. Measurement challenges,
opportunities and hopes for the future
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19
A relatively complex pathway Referrer suspects
first episode psychosis
(FEP)
Referrer suspects
first episode psychosis
(FEP)
Urgent / emergency
referral made
flagged as suspected
FEP
Urgent / emergency
referral made
flagged as suspected
FEP
Central triage point?
Central triage point?
Clock starts when
central triage point
receives referral
Clock starts when
central triage point
receives referral
Clock starts when EIP
service receives referral
Clock starts when EIP
service receives referral
Onward referral to EIP service
Onward referral to EIP service
Patient invited for
EIP assessment
Patient invited for
EIP assessment
DNA?DNA?
Active monitoring / watch and
wait
Active monitoring / watch and
wait
EIP assessment commences
EIP assessment commences
DNADNA
Active monitoring / watch and
wait
Active monitoring / watch and
wait
EIP assessment completed
EIP assessment completed
FEP?FEP?
Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. NICE concordant package of care commenced.
Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. NICE concordant package of care commenced.
Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. Specialist ARMS assessment commenced.
Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. Specialist ARMS assessment commenced.
ARMS?ARMS?
Commence NICE
concordant package of
care
Commence NICE
concordant package of
care
Onward referral to
appropriate service or discharge
Onward referral to
appropriate service or discharge
Y
N
Y
N Y
N
Y
N
Y
N
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20
Referral to clock start
1. Referrer suspects
first episode psychosis
(FEP)
1. Referrer suspects
first episode psychosis
(FEP)
2. Urgent / emergency
referral made
flagged as suspected
FEP
2. Urgent / emergency
referral made
flagged as suspected
FEP
Central triage point?
Central triage point?
3a. Clock starts when
central triage point
receives referral
3a. Clock starts when
central triage point
receives referral
3b. Clock starts when EIP service
receives referral
3b. Clock starts when EIP service
receives referral
Onward referral to EIP service
Onward referral to EIP service
Patient invited for
EIP assessment
Patient invited for
EIP assessment
Y
N
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Assessment
1. Patient invited for EIP
assessment
1. Patient invited for EIP
assessment
2a.DNA or cancella
tion?
2a.DNA or cancella
tion?
3a. Active monitoring / watch and
wait
3a. Active monitoring / watch and
wait
EIP assessment commences
EIP assessment commences
2b. DNA or cancellation?
2b. DNA or cancellation?
3b. Active monitoring / watch and
wait
3b. Active monitoring / watch and
wait
EIP assessment completed
EIP assessment completed
Y
N
Y
N
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22
Assessment to clock stop
1. EIP assessment completed
1. EIP assessment completed
FEP?FEP?
2a. Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. NICE concordant package of care commenced.
2a. Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. NICE concordant package of care commenced.
2b. Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. Specialist ARMS assessment commenced.
2b. Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. Specialist ARMS assessment commenced.
3. ARMS?
3. ARMS?
Commence NICE
concordant package of
care
Commence NICE
concordant package of
care
Onward referral to
appropriate service or discharge
Onward referral to
appropriate service or discharge
Y
N
Y
N
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• Risk of increased administrative burden for clinicians
• High variation in incidence of psychosis – need to be careful not to penalise unjustly areas with low incidence when we start to measure the standard
• Will we be able to go higher than 50% in future given the DNAs rule?
• How can we ensure that the ‘second prong’ of the standard (NICE concordance) is afforded just as much priority as the 2-week wait?
• How can we guard against perverse incentives (e.g. what about the people already receiving care for psychosis?)
• Routine clinical outcome measurement is not yet well embedded in many places
Other measurement challenges
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• The changes to the dataset will support the introduction of A&W standards across the piece (not just EIP). There is an opportunity to improve radically our intelligence on mental health care and make this transparent:
How long do people wait?
For effective care?
How good are their outcomes?
• Opportunity to improve the information available to people accessing services to enable them to make choices.
• Opportunity to learn from the acute sector (who have been measuring waiting times since the 1950s!)
• Opportunity with new ECRs and improved technology to get smarter about how we collect data.
• Opportunities for regulators to have far improved data on quality and outcomes – CQC, TDA, Monitor
• Opportunity to use the new dataset to support the design of more effective payment, lever and incentive systems (e.g. a best practice tariff for EIP?)
Measurement opportunities
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• We want to get the EIP standard right. This standard has the potential to improve the lives of thousands of people and their life opportunities.
• The way that we measure the standard is critical – it can’t ‘just’ be a waiting time standard. It must also be about the quality of care that people access after the clock stops.
• We hope (subject to future spending review decisions) to take a very similar approach to the introduction of other access and waiting time standards:
A clinically informed maximum waiting time (RTT)
For access to NICE-concordant care.
• This approach has the potential to support transform care, improve outcomes and have a significant impact on ‘rebalancing’ the system.
• There is an awful lot to do and collaboration is essential!
Reflections and hopes for the future
