mental health project final report: national benchmarking ......national benchmarking project report...

National Benchmarking ProjectReport 2

Mental Health ProjectFinal ReportNovember 2007

9 780755 956005

ISBN 978-0-7559-5600-5

© Crown copyright 2008

This document is also available on the Scottish Government website:www.scotland.gov.uk

RR Donnelley B53891 01/08

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The Scottish Government, Edinburgh 2008



Mental Health Projectii


ISBN: 978-0-7559-5600-5

The Scottish GovernmentSt Andrew’s HouseEdinburghEH1 3DG

Produced for the Scottish Government by RR Donnelley B53891 01/08

Published by the Scottish Government, January 2008


The text pages of this document are printed on recycled paper and are 100% recyclable

Contents

1. Foreword 3

2. Executive Summary 4

3. Principal Recommendations 5

4. Strategic Overview 6

5. Project Principles, Objectives and Approach 7

5.1 Performance Measures for Delivery of Mental Health Services 8

5.2 Mental Health Service Definitions 9

5.3 Existing Data 9

5.4 Costing 16

5.5 Capability Scoping 17

5.6 Information Systems and Information Sharing 18

6. Findings and Recommendations 19

7. Acknowledgements 22

8. Bibliography 23

Contents 1

Mental Health Project2

Foreword 3

1. Foreword

The need to be able to benchmark mental healthservices in Scotland has never been so important,both in supporting the delivery of services and inhelping the NHS to attain its performance targets tomeet the needs of local communities.

Scotland is a leading nation in the provision of mentalhealth services and work around mental healthpromotion and legislation. It is important that we retainour place in this respect, and the key to knowing theextent to which we are making a difference to the livesand wellbeing of our patients/clients and are providingan equitable high quality service, is the ability tobenchmark mental health services on a ‘like for like’basis. This will not only be a first for Scotland butalso for Europe. Indeed, Scotland is working withcolleagues in the WHO Europe who are undertakingwork on the ‘Mental Health Declaration BaselineProject’, supported by the European Commission “toassess the state of mental health activities acrossWHO European Member States on the basis of theendorsement of the Helsinki Declaration and ActionPlan for Europe”.

Over the past eighteen months many people involvedin using and delivering mental health services haveworked together to decide what is needed tomeasure and compare in order to achieve betterpatient/client experience of care, better outcomesfrom the care received and best value for the taxpayer. This work has not only enabled thedevelopment of a shared vision, but more importantlyallowed us to determine how we will start to developa picture of what is working and what is not based oninformation and evidence to achieve improvement. Iwould like to thank all those who have taken the timeand effort to contribute to this work.

This report will be of interest to everyone working inmental health services and to those who use mentalhealth services. The work to date has been frontlineled and going forward will be managed locally andsupported nationally. The report explains whatbenchmarking mental health services hopes toachieve, how it will go about it, and how we will knowif it has succeeded. Our approach is a long-termstrategy requiring the support and involvement ofpatients, clients, carers and health and social careprofessionals. Over the course of the next three tofour years we all will be refining and developing thiswork through the implementation of therecommendations described in the report. I commendthis report to you.

Shona Robison MSPMinister for Public Health

1


2. Executive Summary

The objective of the Mental Health BenchmarkingProject is to support the improvement of mentalhealth services from a basis of a commonunderstanding of the current position. Our approachis to use a range of comparative information to:

• compare key aspects of performance:

• identify gaps in performance

• identify how improvement can be achieved

• implement improvement

• monitor progress and review benefits.

It is estimated that one in four adults in Scotland willexperience some form of mental health problem inany given year. Depression, anxiety and stress aretogether the single largest reason for presenting tohealth services. Twenty-five to thirty percent of allGeneral Practitioner consultations involve depression,stress or anxiety. Mental health services are delivered

through the NHS and local authorities in partnershipwith the voluntary sector and independent sector.NHS Boards are responsible for those with healthproblems either in community or acute settings,whilst local authorities are responsible for securingsocial care and support and other mainstreamservices supporting recovery in the community.

There are just over 6,000 mental health bedsprovided for a range of functions (acute, rehabilitationetc.) and age groups in Scotland, but this is reducingannually. Mental health services are delivered byapproximately 7,000 registered nurses working inboth primary and acute care, just over 1,152psychiatrists (including consultants and doctors intraining) and around 1,098 psychologists. Socialworkers, voluntary sector personnel and other alliedhealthcare professions also make up a significant partof the workforce. Informal carers contribute a widerange of support in addition to the identifiedworkforce.

Expenditure on mental health services was in theregion of £660.9 million for Health and £84.7 millionfor local authorities during 2005/06. We want to lookat where efficiency change could be made, that couldbe re-directed back into other aspects of the mentalhealth service. For example, if we were to agree toachieve a 5% efficiency change across the NHSspend this would be in the region of £35 million. Wecould work towards this over a 3 to 5 year timeframe.

This benchmarking work is aligned to the high levelgeneric outcomes framework for primary andcommunity care being developed by The Joint FutureImplementation Advisory Group. The two workstreams are complementary to each other andsupported by the Mental Health Outcomes CostingPilot work described in this report.

Quality patient experience and healthoutcomes

Efficiency how resources are used andmanaged

Sustainability whether the functions providedby services are appropriate,sufficiently sized andappropriately positioned tomeet the needs of localcommunities in the mediumand longer term

Cost resources are limited and sobest value must be achievedfrom current investment.

Principal Recommendations 5

Improving mental health services successfully isdependant on staff and stakeholders owning,understanding and using mental health information todeliver improvement. From the work we have done,we conclude our challenge is to develop ‘goodenough’ recording and reporting systems in the firstinstance that may only partially meet the needs of allthe stakeholders (Government, Health Boards, staff,service users, general public), whilst developing aclear vision of the final shape of what is needed tosupport benchmarking and continuous improvement.

In order to deliver valid and effective measurableimprovement, a range of preparatory work is requiredto achieve meaningful comparisons. We recommend:

1. Implementation is achieved through the fundedNational Mental Health Improvement Programmeand governed through a Mental HealthBenchmarking Implementation Group (MHBIG)that would work with NHS Boards andstakeholders to deliver the actions detailed in thetable on page 19 of this report.

2. The implementation of the draft service definitionsdetailed in the Technical Appendix to this reportwith all partners working to develop and agreejoint definitions for mental health services andfunctions.

3. Boards and partners work to align costs with theservice definitions and functions.

4. The adoption and development of the draftmandatory measures based on a balancedscorecard approach to performance improvement.To achieve this Boards with partners should:

• undertake a systematic review of informationsystems and their use locally giving an initialpriority to mandatory measures that focus onnational priorities via the national commitmentsand targets for mental health

• draw up an implementation plan to addressthe gaps

• develop local scorecards with partners toaddress local needs and priorities.

Note: the scorecard measures may need refinementfor specific mental health services e.g. children andyoung people.

5. Boards focus on measurable improvement forexample by reducing antidepressant prescribing,changing the pattern of antidepressant prescribingand reinvesting savings in psychological therapies,moving the balance of care from inpatient tocommunity, and reducing the level of hospitalreadmissions as we believe there is scopenationally, to achieve more efficient and focuseduse of mental health resources of up to 5% over 3to 5 years. The potential for improvement in anyparticular area will vary from Board to Board.

Details of findings and the supportingrecommendations can be found in the table on page19.

33. Principal Recommendations


Mental Health is one of the three national priorities forthe NHS in Scotland. The direction of travel and theneed for change for mental health are exactly thesame as for physical health.

Specifically we would like to see:

• better anticipation and delivery of care for thosewho are ‘at risk’ of mental illness

• increased appropriate mental health services forthose living in the most disadvantagedcommunities

• increased support for self care

• better management of admission to, anddischarge from, hospital

• full utilisation of the skills and expertise of thosewho work in our mental health services to deliverbetter care.

4. Strategic Overview

Staffing Mix/Carers

Inte

rnal

Patie

nt/P

ublic

Expe

rien

ce

FIna

ncia

lC

apac

ity

Cultural ChangePartnership

Leadership

Timely Treatment Safety/ChoiceRecoveryHigh Quality Outcomes

Accountability/Responsibilityfor delivering improvement

Recovery orientatedpractice

Multi-Agency integratedpatient focused approach

Investment Strategy – Meet increased/changing demand

Best Value – maximise efficiencyand productivity

Mental Health (Care and Treatment) (Scotland) Act 2003

Better Health Better CareMental Health Delivery Plan

Mental Health Whole System Overview

This strategy map shows an overview of the key components for effective delivery of mental health objectives.

The Mental Health (Care and Treatment) (Scotland)Act 2003 became effective on 5th October 2005. Inaddition to providing three main compulsory powersof detention, the Act legislates on the followingprinciples:

non-discrimination, respect for diversity, equality,reciprocity, child welfare, respect for carers, leastrestrictive alternative, ensuring benefits, and aninformal, participatory approach.

To comply with the Act and legislation arounddiscrimination, robust patient centred data andinformation that cuts across professional andorganisational boundaries, particularly health andsocial services is required. Benchmarking data caninform and support effective efficient compliance withthe law.

Project Principles, Objectives and Approach 7

The principle objective of the Mental HealthBenchmarking project is to improve mental healthservices by using benchmarking to understand andcompare services and their outcomes and to promotebest practice.

The Mental Health Benchmarking and MeasurementGroup through a core team undertook the following inconjunction with partners involved in the delivery ofmental health services:

• assessment of the availability and use of mentalhealth information

• developing a common set of mental health servicedefinitions

• developing a Balanced Scorecard Approach toperformance

• evaluation of current mental health informationsystem implementations

• evaluation of the role of information in joint mentalhealth planning.

These actions were set out to ensure continuousimprovement in mental health services by identifyingand quantifying the steps required to phase theimplementation of a fit for purpose benchmarkingapproach and infrastructure that would:

• enable the identification of the cause and effectbehind significant performance variances

• establish a common understanding of how changecan be achieved

• establish pathways to achieve practicalimprovements.

A Balanced Scorecard Approach was adopted as thisis an inclusive approach that aligns and channels theenergy, ability and specific know-how held by staff inthe organisation towards achieving strategic goals.Balanced scorecards comprise a suite of measuresacross different domains (e.g. Quality, Efficiency,Finance, Future) in order to provide a balanced overallview of performance.

5

Principles of the balanced scorecard

• a strategic management and measurement system that links strategic objectives to comprehensiveindicators

• a unified, integrated set of indicators that measure key activities and processes at the core of anorganisation’s operational environment

• takes into account a combination of “hard” financial measures and “soft” quantifiable operational measures

• these can include: patient, internal, and innovation and learning perspectives

• using the different categories provides a rounded balanced scorecard that reflects organisationperformance more accurately ...

• helps managers focus on their mission ...

• and helps motivate staff to achieve the strategic objectives.

5. Project Principles, Objectives and Approach


5.1 Performance Measures for Delivery of Mental Health Services

Mental Health Overview Whole System Scorecard

Total spend for mental health per 1,000population

% community spend/Total spend

Total mental health drug costs per 1,000population

Persons on incapacity benefit/severe disablementallowance with a mental health diagnosis per1,000 population

Cost

Use of the AVON validated tool to measure patientneeds and promote recovery oriented practice

Mortality rates for severe and enduring mentally illpopulation per 1,000 population

% re-admissions > 7 days/total admissions

% delayed discharges

Suicide rates per 1,000 population

% carer involvement/those who have a carer

% of voluntary inpatient/inpatients subject tocompulsory treatment by Board

% of people on community CTOs/total known tothe Community Mental Health services

Patient safety and risk management

Patient Quality

Total psychiatric beds per 1,000 population

% A&E presentations with a mental health and/orsubstance misuse diagnosis/total A&Epresentations

Average time to assessment and time tointervention

Average length of stay

Total mental health staff numbers per 1,000population by psychiatrists, AHPs, nurses,psychologists, social workers, MHOs

Efficiency

Training/supervision index

Information quality and capture

Use of mental health information

Number of accredited Integrated Care Pathway(ICP) standards implemented with 100% collectionof prescribed datapoints

Future

Two stakeholder days were held to determine the measures required to manage mental health serviceseffectively. A balanced scorecard of measures was produced and refined through consultation over theperiod of the project:

5.2 Mental Health Service Definitions

A draft glossary of definitions for mental healthservices has been developed in conjunction with allpartners and has undergone wide consultation.These definitions will form the first step in achieving aconsistent picture of what services are currentlydelivered and are framed around what acomprehensive mental health service might look likein terms of primary care mental health, earlyintervention, crisis, assertive outreach, and voluntarysector provision as well as in-patient services. Furtherwork will be undertaken to develop full jointdefinitions with Local Authority and other partners.

This service level information can then be disclosedat various meaningful levels, e.g. Community HealthPartnership (CHP), Board and national level and isvital to support consistent and meaningfulcomparisons.

5.3 Existing Data

Data is available at national level but is of insufficientcoverage, relevance and reliability to provide anaccurate picture of mental health services acrossScotland. High level metrics derived from this datashows variability across Scotland but there are gapsin terms of what we need to know to measure andmanage performance effectively. Examples ofcurrently available data matched to the balancedscorecard are shown in the following table (seeTechnical Appendix for further details).

Project Principles, Objectives and Approach 9 5

Mental Health Project10Cost

NHSBoardArea

Totalexpenditure(£)per

1,000population

(Arbuthnott)forGeneral

Psychiatry

Services

Communityspendasa

percentageoftotalspend

forGeneralPsychiatry

Services

TotalGrossIngredientCost

(£)per1,000population

(Arbuthnott)forMedicines

used

inMentalHealth

(BNF

categories)

IncapacityBenefit/Severe

DisablementAllowance

claimantswith

amentalhealth

diagnosisper1,000population

(Arbuthnott)

NHSArgyll&Clyde

153,923

22.79

21,283

-

NHSAyrshire&Arran

128,629

29.89

17,532

23.56

NHSBorders

140,552

31.83

15,617

17.11

NHSDumfries&Galloway

117,812

33.65

17,936

16.63

NHSFife

108,991

22.44

18,105

23.53

NHSForthValley

134,119

32.61

18,836

24.00

NHSGrampian

157,909

36.52

19,122

23.42

NHSGreaterGlasgow

150,044

45.07

17,793

35.04

NHSHighland

126,685

23.04

15,901

16.62

NHSLanarkshire

97,894

29.14

20,789

30.22

NHSLothian

164,080

24.37

18,252

27.32

NHSOrkney

72,640

60.11

13,517

9.85

NHSShetland

36,015

87.44

11,294

12.93

NHSTayside

159,922

32.30

19,062

22.77

NHSWesternIsles

125,437

6.42

10,026

9.20

Scotland

139,435

31.91

18,516

26.68

PatientQuality

Re-admissions

(%)

Delayed

Discharges

(>=6weeks)

(%)

Crude

suiciderate

per1,000

population

(Arbuthnott)

Community-based

compulsorytreatment

orders(CCTOs)asa

percentageoftotal

compulsorytreatment

orders(CTOs)

-3.05

0.12

-

31.80

4.63

0.14

7.95

33.43

6.95

0.07

9.76

30.38

0.55

0.17

4.26

30.54

1.09

0.16

11.81

27.51

3.87

0.10

10.81

30.02

6.93

0.18

8.84

32.15

2.02

0.15

12.63

33.40

5.80

0.17

5.51

31.08

1.34

0.15

4.20

35.38

2.47

0.17

9.29

29.03

-0.19

-

19.05

-0.10

-

27.79

3.23

0.14

5.33

34.19

12.39

0.17

-

31.81

3.15

0.15

9.00

Efficiency

NHSBoardArea

Totalbedsper1,000

population(Arbuthnott)for

MentalHealth

Specialties

(adjustedforcross-boundary

flow)

Averagelengthof

stay(days)

Nursesper1,000

population

(Arbuthnott)for

MentalIllness

Psychologistsper

1,000

population

(Arbuthnott)within

MentalHealth

MentalHealth

Officersper1,000

population(Arbuthnott)

withinMentalHealth

NHSArgyll&Clyde

1.64

83.38

2.16

0.04

-

NHSAyrshire&Arran

0.92

108.40

1.65

0.03

0.16

NHSBorders

1.17

34.49

2.36

0.06

0.17

NHSDumfries&Galloway

1.06

52.86

1.59

0.04

0.12

NHSFife

1.27

127.87

1.72

0.09

0.13

NHSForthValley

1.22

83.85

2.07

0.03

0.08

NHSGrampian

1.23

114.37

1.95

0.07

0.15

NHSGreaterGlasgow

1.14

78.74

1.73

0.05

0.10

NHSHighland

0.92

61.59

1.80

0.02

0.17

NHSLanarkshire

1.15

71.90

1.43

0.03

0.10

NHSLothian

1.41

66.81

2.48

0.05

0.13

NHSOrkney

--

0.22

-0.19

NHSShetland

--

0.30

0.05

0.11

NHSTayside

1.17

110.72

2.61

0.03

0.10

NHSWesternIsles

1.00

96.10

2.59

-0.15

Scotland

1.21

85.34

2.01

0.05

0.12

Project Principles, Objectives and Approach 11 5Deprivationandurbanisation/ruralityarekeydriversoftheneed,configurationandmixofmentalhealthservices.Thefollowingmapsreflect

thesedriversagainstwhichthemetricsonpage10canbeconsidered.

Hig

hlan

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Tays

ide

Gra

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Bor

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Fife

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s&

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2603

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4

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Hig

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Bor

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Dum

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2-O

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3-A

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4-R

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Rem

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Mile

s

Shet

land

139,

435

128,

629

140,

552

117,

812

108,

991

157,

909

150,

044

126,

685

97,8

94

164,

080

159,

922

125,

43715

3,92

3

36,0

15

134,

119

72,6

40

44,4

97

35,0

73

38,4

53

44,7

33

39,6

43

24,4

63 43,7

31 57,6

73

67,6

23

29,1

87

28,5

29 39,9

81

43,6

66

31,4

92

51,6

58

8,05

7

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

Scotland NHSArgyll

& Clyde

NHSAyrshire& Arran

NHSBorders

NHSDumfries

& Galloway

NHS Fife NHSForthValley

NHSGrampian

NHSGreaterGlasgow

NHSHighland

NHSLanarkshire

NHSLothian

NHSOrkney

NHSShetland

NHSTayside

NHSWestern

Isles

NHS Board Area

Total expenditure for General Psychiatry Services

Community spend for General Psychiatry Services

Exp

end

iture

(£)p

er1,

000

po

pul

atio

n

Within Scotland, total expenditure for General Psychiatry Services was £139,435 per 1,000 population. Lothianexperienced the highest rate and Shetland the lowest at £164,080 and £36,015 per 1,000 populationrespectively. Community spend ranged from £8,057 per 1,000 population in the Western Isles to £67,623 per1,000 population in Greater Glasgow.

633.3

700

600

500

400

300

200

100

02003/04 2004/05 2005/06 2003/04 2004/05

EnglandScotland

Financial Years

Pre

scri

ptio

nsp

er1,

000

po

pul

atio

n

2005/06

Anti-depressantsAnti-psychoticsHypnotics and Anxiolitics

388.2

644.0

383.3

651.1

379.9

524.4

308.6

539.6

303.9

550.5

291.6

106.3102.3101.897.397.7101.1

This graph presents the prescription rates for selected drugs used in mental health from 2003/04 to 2005/06.The use of anti-depressants and hypnotics/anxiolitics is significantly higher in Scotland when compared toEngland. However, over the years, the use of anti-psychotics in Scotland has declined by nearly 4%, whilstEngland has increased by 4%.

General Psychiatry Services Expenditure by NHS Board Area

Medicines used in Mental Health: Prescribing rates for Scotland and Englandduring the financial period 2003/04 to 2005/06

12

Source:Scottish Health Service Costs: R240 (as at 31st March 2006), GRO(S) 2005 mid-year population estimates adjusted with 2006/07 Arbuthnott formula. Health Care Expenditure for General Psychiatry Services is by Health Board of Residence and includes resource transfer. The calculation of nationalaverage excludes expenditure where no activity data is available.Community Expenditure includes: Daypatients, Community Psychiatric Team and resource transfer and is calculated as a percentage of total expenditure.Blank/Missing data - data not available and/or small figures.

Sources: Prescribing Information System (ISD Scotland), Health and Social Care Information Centre.

Nurses

Psychologists

Mental Health Officers

NHS Board Area

3.00

2.80

2.60

2.40

2.20

2.00

1.80

1.60

1.40

1.20

1.00

0.80

0.60

0.40

0.20

0.00

Psy

cho

log

ists

and

Men

talH

ealth

Off

icer

sp

er1,

000

po

pul

atio

n

Nur

ses

per

1,00

0p

op

ulat

ion 2.01

2.16

0.160.17

2.36

1.591.72

0.120.13 2.07

0.15

0.17

0.192.61

0.11

0.15

2.59

0.05

0.03

0.10

0.300.22

0.05

0.03

0.02

0.13

2.48

0.10

1.43

1.80

0.10

1.73

0.07

0.05

1.95

0.08

0.09

0.040.03

0.06

0.03

0.040.05

0.121.65

0.20

0.18

0.16

0.14

0.12

0.10

0.08

0.06

0.04

0.02

0.00

Sources:Nurses: Scottish Workforce Information Standard System (SWISS) as at 30th September 2005, GRO(S) 2005 mid-year

population estimates adjusted with 2006/07 Arbuthnott formula. Figures are whole-time equivalents (WTEs) from theNursing and Midwifery section and includes both hospital and community specialties for mental illness(registered and non-registered staff).

Psychologists: Workforce Planning for Psychology Services in NHS Scotland: Characteristics of the Workforce Supply in 2005,GRO(S) 2005 mid-year population estimates adjusted with 2006/07Arbuthnott formula. Figures are whole-timeequivalents (WTEs) for all Applied Psychologists within the Mental Health work area.

Mental Health Officers: 2007 Mental Health Officer (MHO) Staffing Survey, GRO(S) 2006 mid-year population estimates adjusted with 2007/08Arbuthnott formula. Figures are whole-time equivalents (WTEs) as at 31st March 2007. Only MHOs currently practisinghave been included. Figures have been aggregated from local authority level into Health Board area. Argyll & Clydefigures are incorporated into NHS Greater Glasgow (Clyde part) with the remainder incorporated into NHS Highland.

Blank/Missing data: Data not available and/or small figures.

Scotland NHSArgyll

& Clyde

NHSAyrshire& Arran

NHSBorders

NHSDumfries

& Galloway

NHS Fife NHSForthValley

NHSGrampian

NHSGreaterGlasgow

NHSHighland

NHSLanarkshire

NHSLothian

NHSOrkney

NHSShetland

NHSTayside

NHSWestern

Isles

Mental Health Staffing by NHS Board Area

Scotland has 2.01 nurses per 1,000 population. Orkney and Shetland have the lowest levels at 0.22 and 0.30per 1,000 population. Figures for psychologists and mental health officers (MHOs) are at a much lower ratecompared to nurses. Scotland has 0.05 psychologists and 0.12 MHOs per 1,000 population.

Note: MHO figures are the responsibility and control of the local authorities and are shown against Boards forinformation purposes only.

Filled SubstantiveFilled locumVacantEstablishment 06

14.0

8.59

9.60

4.24

5.97

7.55

9.37

7.14

8.44

7.32 7.327.57

8.68

10.81

12.20

10.3011.14

3.89

5.12

6.28

8.30

10.90 10.90

9.249.73

3.57

0.250.25

1.380.631.230.68

0.16

0.790.61

1.110.50

0.810.91 0.91

1.73

0.590.36

12.0

10.0

8.0

6.0

4.0

2.0

0.0

Co

nsul

tant

Psy

chia

tris

tsp

er10

0,00

0p

op

ulat

ion

Scotland NHSAyrshire& Arran

NHS Borders NHS Dumfries& Galloway

NHS Fife NHS ForthValley

NHSGrampian

NHS GreaterGlasgow &

Clyde

NHSHighland

NHSLanarkshire

NHSLothian

NHSTayside

Island Boards

NHS Board Area

Sources: Scottish Division and the Specialty Training Board for Mental Health, 2006 Census (30th September 2006). GRO(S) 2006 mid-year populationestimates adjusted with 2007/08 Arbuthnott formula.

Notes:1. Figures are whole-time equivalents (WTEs).2. Greater Glasgow and Clyde currently shows all the former Argyll and Clyde consultants within that area. Lomond and Argyll is now part of NHS

Highland, but these figures do not reflect that change yet.3. No 2006 data has yet been collected from the Island Boards. The establishment figure was 3 in 2005.4. Blank/Missing data - data not available and/or small figures.

Consultant Psychiatrists split by post and NHS Board Area as at April 2007

This graph illustrates consultant psychiatrists per 100,000 population by post and Board area. Overall, 2005/06has witnessed a small increase in consultant establishment. Grampian has the highest establishment figures,equating to 12.20 consultants per 100,000 population.

13

Speciality

Co

nsul

tant

Psy

chia

tris

ts(W

TE

)

Academic CAMHS Forensic GeneralAdult

Liaison Learningdisablilty

Management Old agepsychiatry

Psychotherapy Substancemisuse

Unavailable

220.0

200.0

180.0

160.0

140.0

120.0

100.0

80.0

60.0

40.0

20.0

0.0

14.3 13.8

49.4 52.435.1 36.4

203.0 211.8

13.9 13.8

34.5 34.0

6.3 6.2

73.4 76.6

17.0 16.6 21.3 23.4

5.8 7.3

2005

2006

Consultant Psychiatrists split by Speciality as at April 2007

Looking at consultant psychiatrists by speciality shows us that overall, there were more consultants workingwithin the specialties when comparing 2005 and 2006. The General Adult specialty is the highest at 211.8WTE, a 4.3% increase on last year.

Filled SubstantiveFilled locumVacantEstablishment 06NHS Board Area

Sta

ffG

rad

e/A

sso

ciat

eS

pec

ialis

tsp

er10

0,00

0p

op

ulat

ion

Scotland NHS Ayrshire& Arran

NHS Borders NHS Dumfries& Galloway

NHS Fife NHS ForthValley

NHS Grampian NHS GreaterGlasgow& Clyde

NHS Highland NHS Lanarkshire NHS Lothian NHS Tayside Island Boards

5.0

2.68

0.21 0.250.18

0.99 0.99

0.45

3.07

2.23

4.00

4.46

2.65 2.65 2.60 2.60

3.11

3.453.20

3.69 3.77

4.604.87

1.431.58

0.250.27

0.61

0.310.340.340.15 0.15

2.87 3.122.85

4.0

3.0

2.0

1.0

0.0

This graph displays staff grade and associate specialists per 100,000 population by post and Board area.Lanarkshire and Borders show the highest establishment rates at 4.87 and 4.46 per 100,000 populationrespectively.

Staff Grade and Associate Specialists split by post and NHS Board Area as at April 2007

14

Sources: Scottish Division and the Speciality Training Board for Mental Health, 2006 Census (30th September 2006).Notes:1. Figures are whole-time equivalents (WTEs).

Sources: Scottish Division and the Specialty Training Board for Mental Health, 2006 Census (30th September 2006). GRO(S) 2006 mid-year population estimates adjusted with 2007/08 Arbuthnott formula.

Notes:1. Figures are whole-time equivalents (WTEs).2. Greater Glasgow and Clyde currently shows all the former Argyll and Clyde consultants within that area. Lomond and Argyll

is now part of NHS Highland, but these figures do not reflect that change yet.3. Blank/Missing data - data not available and/or small figures.

Sources:Average Length of Stay: SMR04, ICD10 (Analysis based on principal diagnosis of mental illness). Data for year ending 31st March 2006.Delayed Discharges: ISD(S)1 (Patients ready for discharge). Data for year ending 31st March 2006.Blank/Missing data not available and/or small figures.

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

31.81 31.8033.43

30.38

27.51

30.54

30.02

32.1533.40

31.08

35.38

29.03

19.05

27.79

34.19

NHS Board Area

Rea

dm

issi

ons

(%)

Scotland NHS Argyll

& Clyde

NHSAyrshire & Arran

NHS Borders

NHS Dumfries

& Galloway

NHS Fife NHS Forth Valley

NHS Grampian

NHS Greater Glasgow

NHSHighland

NHSLanarkshire

NHSLothian

NHSOrkney

NHSShetland

NHSTayside

NHSWestern

Isles

This graph illustrates the percentage of readmissions by Board area. Across Scotland, readmissions were31.8%, with the highest percentage in Lothian (35.4%) and the lowest in Shetland (19.1%).

Readmissions (7 days or more) by NHS Board Area

140.00

130.00

120.00

110.00

100.00

90.00

80.00

70.00

60.00

50.00

40.00

30.00

20.00

10.00

0.00

NHS Board Area

(%)D

elay

edD

isch

arg

es(>

=6

wee

ks)

Ave

rag

ele

ngth

of

stay

(day

s)

108.40

83.3885.34

127.87

52.86

34.49

83.85

114.37

78.74

61.59

71.9066.81

110.72

96.10

2.47

1.342.02

3.87

5.80

3.23

12.39

14.00

12.00

10.00

8.00

6.00

4.00

2.00

0.00

6.93

1.090.55

6.95

4.63

3.05

3.15

Scotland NHS Argyll

& Clyde

NHSAyrshire & Arran

NHS Borders

NHS Dumfries

& Galloway

NHS Fife NHS Forth Valley

NHS Grampian

NHS Greater Glasgow

NHSHighland

NHSLanarkshire

NHSLothian

NHSOrkney

NHSShetland

NHSTayside

NHSWestern

Isles

Average length of stay (days)Delayed Discharges (>=6 weeks) (%)

Average Length of Stay and Delayed Discharges by NHS Board Area

The average length of stay in Scotland was 85.3 days. Fife had the highest average length of stay at 127.9days, which is 50% greater than the Scotland figure. Delayed discharges were 3.2% for Scotland. Dumfries &Galloway had the lowest percentage at 0.55%, whilst the Western Isles figure was 12.4%.

15

Source:SMR04 Linked Database (based on discharges and Health Board of Residence). Data for the year ending 31st March 2005 is provisional: data from Fife and Greater Glasgow andClyde Health Boards (and therefore the Scotland total) are incomplete. Interpret with caution. Argyll & Clyde figures are incorporated into NHS Greater Glasgow (Clyde part) with the remainder incorporated into NHS Highland. Mental Health Specialties G1: General Psychiatry (Mental Illness), G21: Child Psychiatry, G22: Adolescent Psychiatry, G3: Forensic Psychiatry and G4: Psychiatry of Old Age. Numbers of readmissions for spells of inpatient treatment (lasting 7 days or more) within 365 days of patient's discharge from a previous spell of treatment (any length of stay) as a percentage of total admissions.


5.4 Costing

Costs and activities are not meaningfully matched formental health services, which results in difficulty inmaking accurate judgements about best value ofservices. Non-financial information will need to bedeveloped and aligned with financial data. This islikely to require commitment and investment by localand national partners and the development of a clearframework around which this information can bedeveloped.

Costing information is required to: inform leaders,managers, employees, patients and the public aboutthe financial implications of re-designed services, newinvestment and their relationship with measurableuser outcomes. It will become increasingly importantin the field of public performance reporting.

The diagram below shows how service definitions,service functions and outcome measures will bealigned with costing information.

ConventionalTerminology

Mental HealthDelivery Plan Mental Health Outcomes Costing

CostingActivities

Costs related tounits of ouput

CostingStages

Stage 4Outcome-based

costs

Stage 3OutputMetrics

Cost Pools

Stage 2ActivitiesDrivers

Stage 1Costs

Mapping of Mental Health Delivery Plan toconventional terminology and the stagedcosting approach.

Matching toActivities/Processes

Input Costs perUnit of Resource

Allocation ofoutput costs to

purpose ordirected

commitments

Outcomes/MH Delivery Plan Commitments(Outcome-based Costing)

Functions

Services

Crisis Response/Resolution

Out of Hours Crises CommunityMH Teams

Management ofMH Problems

Benchmarking & Measurement

Clinical governance, Corporate Governance,Performance Management, Public Performance

ReportingEvidience-based Improvement

(Financial & non-Financial Indicators)

Activities, Programmes, Processes/ICPs(Activity-Based Costing)

Strategy Strategy

Outputs Functions

ProcessesActivities

ServicesICP

Inputs Inputs/Resources

Objectives(outcomes)

Commitments(Outcomes)

(Joint Resourcing Group/National Benchmarking Project)

NHS Greater Glasgow and Clyde and NHS Forth Valley with partners are undertaking an exercise to matchfinancial information to the work done on service definitions and the non-financial measures.

Project Principles, Objectives and Approach 17

5.5 Capability Scoping

During April to July 2007 visits were made to allmainland Boards and associated local authoritypartners and a video conference held with one IslandBoard. The purpose of the exercise was to:

• communicate the purpose and objectives of theMental Health Benchmarking and MeasurementProject

• seek Board input to current activities

• assess locally available mental health information

• evaluate mental health system implementations

• evaluate the role of information in joint mentalhealth planning.

Key issues which emerged were as follows:

Approach to Performance Improvement

There was strong support for a Balanced ScorecardApproach to comparative performance in mentalhealth services. Boards and partners have expressedan interest in developing multi-partner balancedscorecard approaches to performance in mentalhealth services.

Consistent Definitions

There was broad consensus on the draft servicedefinitions with the main areas requiring furtherclarification around the specific functions carried outin these areas.

Responsibility and Accountability forImprovement

Boards and local authorities do not collect and reportdata in a consistent manner, e.g. health and localauthorities categorise differently. In addition,information/data gaps also exist, e.g. communityactivity.

There was consistent understanding around thebeneficial role of reporting to achieve improvementbut in general the approach was ad hoc and the

credibility of the exercise undermined by weaknessesin the data integrity.

Generally, there were few high level managementreports available at frontline/client facing functions,with a broad range of approaches to managementreporting at local level for mental health services bothfor NHS Boards and NHS Boards and partners.There are incomplete and inconsistent approaches tothe provision of feedback on improvement activities.

Many Boards and local authorities however, are ableto produce a wide range of local reports, includingboth some standard reporting and a wide variety ofad hoc reports. Reports generated includeinformation about:

• Waited and Waiting Times

• Bed management/utilisation

• Admissions/Discharges

• Contacts

• Referrals

• Occupancy

• Risk Assessments

• Critical Incidents

• Team/Community Activity

• Joint reporting – Single Shared Assessment, JointPerformance Framework

• Clinical/Staff Governance reports

• In one Board, six localities/joint teams provideinformation on activity every six weeks to theMental Health Partnership Board, which is used tolook at training and local issues.

Mental health services across Scotland are deliveredthrough a range of management and accountabilitystructures with some undergoing change over theperiod of the visits. These structures are majorinfluencing factors on the range and level of reports inuse.

5


There was wide variability in the amount, purposeand focus of information used in the planning anddelivery of mental health services.

Further information regarding good practice can befound in the Technical Appendix.

National Information

There were concerns from those delivering mentalhealth services that the Scottish Health Services CostBook does not encompass all the relevant, direct,indirect, resource transfer and community costs andthat the data is not comparable.

There was a lack of national information on qualityand patient satisfaction.

Data Quality

We found that data quality is varied across theservice and that this is related in part to individualpractice and recording. Some of the issues withrespect to data quality are as follows:

• Provisional Status of National Returns

Problems of validating and returning records locallyon a timely basis leads to incompleteness of thenational returns. This impacts on the time period,which can be selected for analytical purposes.

Further information regarding the status of nationalreturns can be found in the Technical Appendix.

• Data Validation

The level of data validation varies between Boardsand partners. Most Boards use a mixture of systemssuch as PCSMR and PiMS to validate data, however,other additional checking/validation is inconsistent.Quality issues arise from the conflict between theactual inputting of data into the mandatory fields byclinicians and the need to perform other duties i.e.clinical/workload priorities.

• CHI Compliance

Most Boards have good CHI compliance but noneachieve 100%.

Further information regarding CHI compliance can befound in the Technical Appendix.

• Timeliness

The timeliness of updating information varies betweenBoards and local authorities. Common themes thathave emerged relate to:

� Capacity issues

� Clinical commitments

� Lack of mobile technology

� Dual records, i.e. electronic and paper based

� Individual practice and recording

� System limitations/difficulties.

Competing clinical pressures on frontline staff werecited as the major barrier to timely updating ofinformation for mental health services.

5.6 Information Systems andInformation Sharing

A multitude of systems (information and IT) existwithin and between Health Boards and localauthorities. These systems have different levels offunctionality and are used by various members ofstaff. The systems range from paper based manualsystems, computerised real time/other systems and avariety of ad hoc databases.

There are system limitations that constrain thesharing of health and social care information betweenBoards and local authorities. This issue is furthercompounded by incompatibility of IT systems, i.e.they do not link with each other.

No Board or partnership has a fully integratedcomprehensive system.

Project Principles, Objectives and Approach 19 66. Findings and Recommendations

The following table details these findings, the required actions and timescales for completion.

Detailed Recommendations

Findings Recommendations Responsibility Timescale

National Data

F1 Classification and descriptionof current mental health servicesis patchy and suffers from a lackof common definitions of similartypes of services making itdifficult to make meaningfulcomparisons. There is strongsupport from Boards andpartners for the adoption ofcommon definitions for mentalhealth services.

R1 NHS Boards classify and quantifytheir services using the service definitionsdetailed in the Technical Appendix to thisreport.

R2 Local Authority, social work, andvoluntary organisations are equal partnerswith the NHS in contributing to thewellbeing, health and services provided toindividuals with mental health problems.We recommend the work on servicedefinitions and functions be extended intoa comprehensive joint social work, healthand partners listing.

NHS Boards

Boards andpartners

April 2008

September2008

F2 Nationally available data doesnot currently reflect the way inwhich the service is delivered.The majority of mental healthservices are delivered in thecommunity but the national datadoes not fairly reflect this.

F3 The Scottish Health ServicesCost Book does not encompassall the relevant direct, indirect,resource transfer and communitycosts and the data is notcomparable, as services aredescribed and manageddifferently in each Board with theirrespective partners from localauthorities and otherorganisations.

R3 Core definitions of mental healthservice functions are developed andmapped to the range of services andassociated resources being delivered andplanned across Scotland.

The new national clinical/social datastandards developed and piloted to covercommunity encounters/interventions(ICIC) would provide the basis for thework.

R4 Boards and partners align costs withmental health activities using a consistentmethodology across all NHS Boards andpartners through the recommendations ofthe Mental Health Costing Pilots inGreater Glasgow and Clyde and ForthValley, which are being undertaken inconjunction with partners.

R5 MHBIG update the presentation anddisclosure of mental health activities andcosts in the Scottish Health ServicesCost Book to fully reflect mental healthservice delivery and outcomes from thework undertaken in the costing pilots.

MHBIG

Boards andpartners

MHBIG

April 2009

April 2009

April 2009


Findings Recommendations Responsibility Timescale

F4 There are gaps in the areas ofquality and patient satisfaction,which are critical areas for serviceimprovement.

R6 The quality and patient satisfactionmeasures in the mandatory scorecard aredeveloped and adopted.

MHBIG April 2009

Reporting and Improvement

F5 There is wide variability as tothe completeness and timelinessof the submission of national databy Boards, which results inrelatively out of date comparisons.

R7 We recommend NHS data is senttimeously to ISD, analysed and reportedon and social work data sets fromsupporting people, and local areas (e.g.Care First) are analysed and reported onin conjunction with NHS data by MHBIG.

NHS Boards andMHBIG

April 2008

F6 There is also variation as tothe completeness and timelinessof local data at partnership level,which results in inconsistencybetween parts of the system andlong lead times before ameaningful review of informationcan be undertaken locally. Acombination of competing clinicalcommitments, lack ofstreamlining and integration ofinformation systems were foundto be constraining factors at locallevel.

R8 Adoption of the draft definitions forhealth and development of jointdefinitions for health and partners willsupport integrated planning, reportingand performance management as willrecommendation R7.

Boards andpartners

September2008

F7 Boards demonstrateddifferences in the capability oflocal information systems in termsof capture and reporting ofinformation across partners,which meets users needs. Thereis currently no informationsystem, which is considered fullyfit for purpose.

R9 Coding of the datasets, which willflow from work on definitions andfunctions into systems currently in useand those undergoing development, willallow extraction and presentation of dataon an integrated basis. Our work on thecapability visits has confirmed that somesystems do have the capability ofsupporting the necessary dataset.

Some Boards are already creating jointdata warehouses and/or joint systems toallow information sharing and enhancethe integrated approach.

R10 In the medium to long term, existingsystems should be improved or newsystems developed in line with theNational IM&T strategy, that will adopt awhole system approach and to allowsystems to link into each other.

Boards andpartners

MHBIG

To beconfirmed

To beconfirmed

Findings and Recommendations 21 6Findings Recommendations Responsibility Timescale

Reporting and Improvement

F8 We found that data quality isvaried across the service and thatthis related in part to individualpractice and recording.

Boards highlighted thatinformation in support of theMental Health Act should beimproved and streamlined.

R11 While it is recognised that regulardissemination and review of informationwill lead to improvement in the quality ofthe data, all Boards should achieve afocus on improving data quality byundertaking an audit to identify gaps indata quality and implementing an actionplan to address the gaps. Therequirements from all areas of relevantlegislation should be specificallyaddressed.

It is expected that a systematictransparent approach to data qualitychecks and use of exception reportinghighlighting missing codes, outliers, andshifts in activity etc. would form part ofthe plan.

NHS Boards September2008

F9 Generally there were fewmanagement reports available atfrontline/client facing functions,with a broad range of approachesto management reporting at locallevel for mental health servicesboth for NHS Boards and jointreporting for NHS Boards andpartners. There are incompleteand inconsistent approaches tothe provision of feedback onimprovement activities.

R12 Boards should adopt a localreporting framework using the BalancedScorecard Approach in support ofaccountability frameworks whereperformance is reported at Board, CHP,joint team and individual practitioner level.MHBIG will support Boards in developingthe mandatory national indicators shown(see page 8).

This approach will also support theperformance management structure thathas been put in place by the MentalHealth Delivery Plan ImplementationBoard and will feed into the reviews thatare undertaken with Boards, localauthorities and others twice a year andthe annual accountability reviews thatMinisters undertake each summer.

Boards should develop local reportingframeworks using the same approach tofocus on local priorities. Suggestedmeasures, which can be used, are shownin the Technical Appendix, Appendix C.

NHS Boards andMHBIG

April 2009

F10 Boards and partners haveexpressed an interest indeveloping multi-partner balancedscorecard approaches toperformance in mental healthservices.

R13 It is recognised that the scope ofmental health services is very wide andso, specific scorecards developed in thecontext of the high level mental healthscorecard may be required for specificaspects of the service e.g. perinatalservices.

MHBIG As required

22

7. AcknowledgementsThe Mental Health Benchmarking Core Steering Group would like to thank the many individuals withinNHSScotland, the local authorities and the voluntary and independent sectors who have supported andcontributed to this piece of work.

Core Group

Dr Denise Coia Project Director, Principal Medical Officer Mental Health

Mrs Kirsty Anderson Lead Analyst, Mental Health Benchmarking Project

Dr Shelah Dutta National Service Lead, Benchmarking

Mr Patrick McGrail Joint Future Manager

Mr Alex McMahon Head of Mental Health Delivery and Services Unit / Mental Health Nursing & LearningDisability Advisor

Mrs Linda Reid Senior Liaison Officer and Social Work Advisor

Mr Mark Sanderson National Information Lead, Benchmarking

Steering Group Advisory Members

Mr Derek Barron Nursing Director, Mental Health Partnership

Mr James Boyd Formerly Assistant Head, Healthcare Information Group

Mr Mike Brown Performance and Information Manager

Dr Graham Bryce Consultant Child and Adolescent Psychiatrist

Dr Roch Cantwell Consultant Perinatal Psychiatrist

Mr Dick Fitzpatrick Projects Manager, Mental Health Strategic Programme

Mrs Ruth Glassborow General Manager, Mental Health

Dr Kathy Leighton Consultant in Child and Adolescent Psychiatry

Mrs Pat McGorry Information Services & Programme Manager

Mr Danny McLaren Head of Service, Primary Care Division

Dr Alastair Philp Formerly Programme Principal, Improving Mental Health Information Programme

Ms Hazel Soutar Finance and Performance Management Director

Mrs Frances Wiseman Strategic Planning and Workforce Development Manager (Mental Health)

Maps

Dr Mette Tranter Senior GIS Analyst, National Services Scotland

Mental Health Project

23 8Bibliography

8. BibliographyBalanced Scorecard: Translating Strategy into Action, Robert S. Kaplan and David P. Norton, HBS Press (1996)

Better Health Better Care – A discussion document, Scottish Executive (2007)

Building a Health Service Fit for the Future, Scottish Executive (2005)

Building and Nurturing an Improvement Culture, Improvement Leaders’ Guide, NHS Modernisation Agency(2005)

Delivering for Health, Scottish Executive (2005)

Delivering for Mental Health, Scottish Executive (2006)

Fair to All, Personal to Each – The next steps for NHSScotland (2004)

Getting Better All the Time – making benchmarking work, Audit Commission (2000)

Implementing Benchmarking, Faculty of Finance and Management, ICAEW Good Practice Guideline (2003)

Leading Improvement – Personal and Organisational Development, Improvement Leaders’ Guide, NHSModernisation Agency (2005)

Measuring at a Local Level – An IPH Reference Guide, NHS Modernisation Agency (2004)

Mental Health Action Plan for Europe – Facing the Challenges, Building Solutions, WHO Europe (2005)

Mental Health (Care and Treatment) (Scotland) Act 2003

Mental Health Declaration for Europe – Facing the Challenges, Building Solutions, WHO Europe (2005)

National Child and Adolescent Mental Health Service Mapping Exercise, Department of Health and DurhamUniversity (2004)

On Target – The Practice of Performance Indicators, Audit Commission (2000)

Strategy Maps: Converting Intangible Assets into Tangible Outcomes, Robert S. Kaplan and David P. Norton,HBS Press (2004)

The Measures of Success – Developing a balanced scorecard to measure performance, Accounts Commission(June 1998)

10 High Impact Changes for Mental Health Services, National Institute for Mental Health in England (2006)

10 High Impact Changes for Service Improvement and Delivery – A guide for NHS leaders, NHS ModernisationAgency (2004)



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