The four-hour waiting time target for A&E is a totemic indicator of health care performance. It generates more media headlines than any other NHS performance measure, and on this website the A&E waiting time indicator is the most visited page. Above all other performance measures, it is seen to best describe the trajectory of a health service under strain. On world mental health day, Geraldine Strathdee, National Clinical Lead for the Mental Health Intelligence Network and a former NHS England Clinical Director for Mental Health, considers whether there could be an equivalent indicator of quality for mental health care.
QualityWatch publishes a range of indicators relating to mental health care across quality domains. These include what could be described as the ‘litmus’ warning signs of deterioration in the factors of care that underpin community mental health services: provision of information, support with housing, employment, support for carers, quick access to skilled help in a crisis, and the coordination of care.
The data revealed by these indicators are very interesting and I believe argue for a new community quality composite indicator, which could act as an equivalent to the 4-hour A&E waiting time target in warning of a system under pressure.
A perfect storm for quality
There is a ‘perfect quality storm’ for mental healthcare at the moment, responsible, in my view, for a deterioration in quality. This perfect storm results from a combination of factors.
First, for several reasons, there has been a decline in patients feeling supported to get information and housing. Carers also report that they are not getting the support they need.
Mental health leads healthcare in the transformation to out-of-hospital care. Over the past two decades there has been a planned major reduction of hospital and bed-based care as mental health has moved into the community. In 2015, NHS benchmarking of all mental health providers found that 98% of mental health care takes place in the community.
This shift has been accompanied by neither the necessary increase in community funding, nor in proportionate spend between hospital and community care (see HMT Treasury costing unit and the Mental Health taskforce implementation reports )
There has been a lack of the necessary review of staff skillmix and capacity. Mental health is not a specialty that requires expensive buildings or high tech equipment, but the right skillmix and training of our teams is absolutely critical to achieving the outcomes and standards needed.
In mental health care, most clinicians believe strongly that stable accommodation and support is fundamental to creating the environmental conditions that enable a person to feel safe and secure. It’s also key to helping vulnerable people access the rehabilitation and recovery focused interventions and support they need, and is a major factor in preventing relapse and improving recovery.
Staff and skills
The question is, how can people best be supported to access accommodation and support? Herein lies the conundrum. In non-mental health NHS care, there appears to be a clear understanding that in order to help people get the housing they need, and any reasonable adjustments required, they need the input of expert local authority social workers and care workers. But these have been reducing as access to local authority mental health funding reduces, or separates away from integrated community teams of health and social care professionals.
In mental health, the skills expected of staff are arguably greater than that in physical health care. Because of our holistic, biopsychosocial approach to people's needs, there has always been an expectation that all staff in community mental health teams will prioritise securing social stability (housing, training, employment), in addition to providing more traditional expertise. The NICE/SCIE-approved mental healthcare packages include information provision to help the person feel more in control, enable self management and make informed decisions about their care, physical healthcare and healthy lifestyle coaching, safe optimised medicines, individual and family psychological therapy, and rehabilitation interventions such as Individual Placement support and crisis and relapse prevention planning.
To provide this evidence-based comprehensive package of care, the right workforce, with the right level of training and skills is essential. The trends in mental health workforce have been changing without any quality risk alerts. This is due to both changes in commissioning, integrated community provider patterns and the flexing ‘down’ of skillmix to meet providers’ block contract financial pressures.
These packages also need coordination of the different elements. This is delivered by care/case managers, where a ‘one stop shop’, responsible, accountable professional helps the person secure the various inputs they need, and ensures there is regular review of the care plans in line with changing improvement and needs. Within mental health, this has been done under the Care Programme Approach policy where the person is allocated a care worker who ensures that the biopsychosocial assessments are undertaken, that care plans are developed to address all needs, and that they are reviewed at regular intervals. The Mental health Intelligence network psychosis briefing has found a staggering 200-fold variation in provision of Care coordination (CPA) within mental health trusts. And the 2015 NHS benchmarking data found a really significant reduction in care coordinators and senior experienced staff skillmix.
Other significant early quality deterioration warning signs are that there has been growing evidence of an increase in delays in the transfer of care; an increase in out-of-area placements; and a reduction in the provision of supported accommodation and residential care in level areas and of access to personalized budgets.
A composite indicator
In light of this ‘perfect storm’ for quality deterioration, we need to use the data available to develop an indicator that can act as a warning signal about their combined effects. This warning signal indicator could be a composite of factors that include:
-Patient reported provision of information to self manage and relapse prevention
-Level of support and access to accommodation in local areas
-Level and trend in delayed transfers of care and out-of-area placements
-Patient-reported experience in relation to housing
-Carer-reported experience in the Friends and family test as well as in the CQC annual survey
-Level of care coordination provision in mental health teams
While a new composite indicator will help us to recognise the combination of factors straining the mental health care system, we also require sustainable solutions to some of the factors creating this ‘perfect storm’ scenario.
For instance, we need to be more focused on empowering patients and carers. This would include a new relationship between ‘activated’ patients and carers, and intensive self-management and peer support. We could learn from other countries’ empowered citizens initiatives and the democratisation of knowledge. In Detroit, for example, a ‘zero suicide’ quality initiative was very successful, with patients and social networks properly engaged from the outset.
Mental Health logistics are needed to improve our poorly devised, clunky pathways of care. There are some encouraging signs that transformation, using Lean and pathway process mapping, is leading to outstanding quality improvements, including reductions in repeat crises, admissions and the mental health human rights nirvana of safe reductions in repeat detentions under the Mental Health Act.
Led by the 111 crisis management programme, and using digital innovation, three areas (Cambridge, Herts. and South London) are piloting bed capacity management systems, with already impressive reductions in the use of police cells and out-of-area placements. Perhaps most importantly going forward, there should be an urgent review of mental health care planning and the provision of the essential case management one-stop-shop multidisciplinary and multi-agency teams that have been so successful for those with the most complex needs in other countries.
I want to end this world mental health day blog on a note of hope. It is truly wonderful to see the major improvement in outcomes in the areas that have commissioned and are providing Early Intervention Psychosis teams. Cornwall is an example where EIP patients are receiving coordinated care and accessing full NICE care packages. Instead of the heart-sinking standard of just 6% of people recovering sufficiently to access employment, well over 50% are being helped back to education, training and employment!