Improvement Team Simon Bristow System Improvement Advisor 1 | - - PowerPoint PPT Presentation

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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

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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

• utcomes 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 NHS https://improvement.nhs.uk/resources/model-hospital/ FutureNHS collaboration platform – dashboards and message boards on CYPMH, EIP, and crisis activity, interventions and outcomes https://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 development

• f 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?

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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

• f 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

• perational 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 Pre-scoping Describe SIT diagnostic and agreement to proceed. 1 Scoping Agree review scope and objectives with commissioning and provider leads. 2 Preparation Agree visit agenda, venue and attendees with relevant leads. Commissioners and provider(s) supply documentation and data to inform review. 3 4 Documentation review SIT review and assimilate information supplied and undertake analyses. 5 6 Diagnostic 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. 7 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. 8 9 10 11 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 Model

• 2. 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 & Waits

• 3. 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. Workforce

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

sustainability are in place. Involvement & Participation

• 6. 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. Culture

• 10. 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
• perational 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
• f 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 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

• f 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

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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?