north west coast clinical network cyp outcomes and crisis ... … · urgent & emergency mental...

www.england.nhs.uk

Aga Wojciechowska

National CYPMH Programme Team

NHS England

30 November 2018

North West Coast Clinical

Network

CYP Outcomes and Crisis

Workshop

www.england.nhs.uk 2

Session outline

1. Policy background, Long Term Plan and

case for change

2. 2017 audit of CCG commissioned CYP

UEC and IHT services – summary

3. Evaluation of CYP UEC MH care

vanguards – key findings

4. MHSDS data

5. NHS Digital – initial guidance for

improving MHSDS data quality

6. Next steps


Ambition for crisis services set out in Future in Mind (2015)

and The Five Year Forward View for Mental Health (2016)

By 2020/21, NHS England should expand Crisis Resolution and

Home Treatment Teams (CRHTTs) across England to ensure that

a 24/7 community-based mental health crisis response is

available in all areas.

For children & young people, an equivalent model of care

should be developed within this expansion programme

By 2020/21, all areas, including acute hospitals should have

access to CYP MH crisis liaison and crisis response

Background – national policy

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/414024/Childrens_Mental_Health.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf


Improving crisis care for children

and young people

What are we trying to achieve?

The goal is to improve experience and outcomes for children and young people in a crisis, their families and carers by ensuring that they have timely access to evidence

based care as close to home as possible.

In order to do this we need to:

➢ Reduce the number of children and young people attending A&E and their length of

stay

➢ Reduce the numbers of children and young people admitted to paediatric, adult and

general acute wards because of a mental health crisis

➢ Eliminate use of section136 – reduce other inappropriate locations for children and

young people

➢ Improve local bed availability aligned with the development of 24/7 children and

young people community services

➢ Ensure a sufficient national bed stock for surge management in order to eliminate

inappropriate out of area placements

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2017 Voluntary Audit of CCG Pathways

for CYP Urgent & Emergency Mental

Health Care together with CCG Intensive

Community Support Services

Brief Headlines

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Aim:➢ To establish the current stage of development of CYP MH

urgent & emergency mental health care and intensive community services across the country

Method: ➢ A voluntary survey completed by CCG commissioners *

➢ Scope – CYP urgent & emergency care, including intensive community support and admission avoidance facilities

➢ Completed Summer 2017

Key questions:➢ What dedicated CYP U&E MH services exist where, by type

of service?

➢ What hours are these services providing?

➢ What age range are these services for?

* Does not include outreach community services provided from in-patient units commissioned by NHS England Specialised Commissioning - unless co-commissioned by CCG

Audit approach

6

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Crisis Services by Type(to note: analysis of audit to be used for management not for wider publication)

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Key

Non-response or non-interpretable response from CCG

Initial assessment & intervention only (type 1 service)

Initial intervention & brief follow-up only (type 2 service)

Intensive Community Support only (type 3 service)

Combined crisis, liaison & intensive community support (type 4)

CCG services outside these definitions

(G) CCG CYP urgent and emergency mental health care:

highest UEC and intensive community support service type classification


CCG’s providing a

minimum of crisis

assessment & brief follow

up (service type 2):

80% of responding CCG’s

have a minimum of a type 2

service• North region: 81%

• Mids. & East: 64%

• London: 93%

• South: 83%

Audit Findings – Service Types

Key

Non-response or non-intrepretable response from CCG

CCGs covered by Team Type 2 minimum definition

CCG services outside this definition

Percent of CCGs with a minimum service offer of urgent & emergency response - initial assessment and brief follow up 80%

CCGs with a minimum service offer of urgent & emergency response -

initial assessment and brief follow up, (service type 2)


CCG’s providing combined

crisis, liaison and intensive

community support (service

type 4):

52% of responding CCG’s

offer a type 4 combined

service• North region: 45%

• Mids. &East: 47%

• London: 43%

• South: 75%

Audit Findings – Service Types

Key Non-response or non-intrepretable response from CCG

CCGs covered by Team Type 4 definition

CCGs services outside this definition

Percent of responding CCGs reporting a Combined crisis, liaison and intensive community support / intervention service 52%

(E) CCGs reporting a Combined crisis, liaison and intensive community support /

intervention service, (service type 4)

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Summary

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Overall conclusions in 2017• CYP urgent & emergency mental healthcare is being transformed following publication of

FIM, supported by additional investment

• Of responding CCGs (74%)

➢ 93% offer the minimum dedicated, staffed initial crisis assessment response

➢ 52% offer a combination of crisis, liaison and intensive community support – at some level.

➢ 15% of responding CCGs did not offer a dedicated staffed response or offered an initial crisis assessment and intervention only.

• Of services currently in place,

➢ 62% offer an extended hrs or 24/7 pathway which may operate across teams

➢ 94% of CCGs do not specify a lower age range - or this is under 5 years

• Arrangements for 16&17 years olds may differ in some areas and may be more vulnerable

2nd national voluntary survey of CYP MH UEC and IHT ➢ Closed on 31 August 2018

➢ Administered by CCQI (College Centre for Quality Improvement of Royal College of Psychiatrists).

Its aims are to:

➢ Provide an update on service provision nationally

➢ Develop understanding of pathway and patient journey

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Accelerating improvements for

children and young people’s

urgent and emergency mental

health care

Evaluation of children & young

people’s urgent and emergency

mental healthcare vanguards

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Sites1. Barking & Dagenham,

Havering & Redbridge (BHR)

2. Durham & Darlington

3. Leicester, Leicestershire and

Rutland (LLR)

4. North Yorkshire, York & Selby

(N. Yorks)

5. Solihull

6. South Tees, Hartlepool and

Stockton on Tees (Teesside)

7. Bradford

8. Cambridgeshire and

Peterborough (C&P)

CYPMH UEC Vanguard Sites

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Eight urgent and emergency care (UEC)vanguard

sites - established in summer 2016 to accelerate improvements for

CYP Mental Health Urgent & Emergency (crisis) Care

Aims• Accelerate existing plans to

test CYP urgent & emergency

care models

• Refine or expand existing

models

• Develop effective approaches

to improve: outcomes, clinical,

performance, information on a

routine basis ( including local

baseline)

• Evaluate new models tested

and share learning


CYPMH UEC Delivery Models

➢ CYP combined crisis, liaison & intensive home treatment (6

sites)

➢ All ages UEC response - initial assessment & intervention only or

combined with intensive home treatment (2 sites )

➢ Sites covered a range of population and geographical areas

• CYP population: 48k to 239k CYP under 18

• Geographical area: 205 km2 to 3754 km2

➢ Operation and delivery across sites varied in relation to

• Stage of development • opening times

• intervention options • 24/7 pathway integration &

continuity

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Evaluation Aims

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➢ Develop the evidence base to understand different models to support development of CYP MH UEC services nationally

➢ Identify common themes

➢ Examine impact and potential cost-effectiveness

➢ Focus on core UEC pathway and metrics

➢ Note : Developments outside of core scope evaluated locally (e.g. crisis café, drop-in facilities, parent training.)

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1. Response Times

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Across all sites, an average of 83% of CYP

referrals to crisis & liaison services were seen

within four hours of a referral being made.

Site BHRBrad-

fordC&P LLR

Soli-

hull

Tees-

sideDurham

4 hr response

performance 93% 93% 99% 72% 56% 81% 88%

Sites with lower performance (<80%) were not fully staffed

or had problems with data collection.

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2. Service User Experience

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Sites with high service user satisfaction demonstrated

care that included

• Prompt access • Individual flexible plans

• Choice of locations • Continuity

Continuity of care – from a single practitioner where possible

was highly valued particularly in brief intervention and IHT.

Important components also included

• Involving families

• Co-produced agreed treatment options and,

• Goal orientated approaches (NB goal based outcomes)

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Rate of presentations remained stable in most sites.

• Initial surge observed in some new services (eg LLR)

• 5.2 to 7.9 presentations per 1000 CYP pa for 24/7 CYP-dedicated teams

• Lower presentation rates for 2 all ages services (C&P, Bradford) and

‘flexible office hours’ team (BHR)

• Presentation pattern although brief view reflects established teams

3. Crisis Presentation Rates

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0

20

40

60

80

100

120

February March April May June July

Presentations per 100,000 CYP by month

BHR Bradford Cambridge Durham

Leicester Teesside Solihull

Initial assessment rates per

staff wte for CYP-dedicated

services varied between 3.6 to

7.1 per wte per month.

Assessment rates impacted on

by levels of presentation,

geography but also team remit

– eg IHT episodes may include

much more follow-on activity.

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Creating person-centred comprehensive, seamless 24/7 pathway was a

common challenge

Critical success factors for improved service user experience and

outcomes included:

• continuity of care

• close joint working.

• clear operational processes between different teams

• active awareness raising of the team’s role and its operating model

4. Seamless Pathways

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Factors found to strengthen joint working included:

Efficient case

management and

handover processes

including risk

management

Active promotion of

service’s aims and

ways of working to

stakeholders

Robust operational

processes for accessing

specialist skills

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5. Partnerships & Engagement

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➢ Participation by CYP service users and carers played a powerful role in

shaping service vision and in supporting implementation

➢ Strong leadership partnerships with stakeholders, cross

boundary working and a flexible approach to crisis management were

success factors for a CYP crisis service

➢ CYP receiving IHT follow-on support used crisis services less often

subsequently. Re-access rates:Solihull = 12%; Teesside = 19%

Less integrated service = 41%

➢ Services developing close working with ‘blue light’ agenciesreported a reduction in CYP ambulance transportation.

30% reduction in ambulance transportation of CYP in crisis in Durham

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6. Staffing – UEC teams

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➢ UEC teams led by highly experienced nurse leaders

➢ Teams staffed by mental health practitioners – incl. social workers and

occupational therapists as well as RSCN, RLDN nurses

➢ Diverse team competencies actively developed through recruiting and/or

training a broad skill-set including:

➢ learning disability, ASD, substance misuse, youth justice etc.

➢ Close / integrated working with community CYPMH teams and C&A

psychiatrists was a crucial and critical success factor underpinning

➢ access to psychiatric support

➢ specialist skills (e.g. psychology, ASD assessment)

➢ an integrated care pathway

IHT teams (see next slide) evidenced a more diverse skill mix within the team

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7. Staffing – IHT/ICS

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Intensive Home Treatment / Intensive Community Support

➢ All dedicated CYP teams included intensive home treatment (IHT) as

an integrated part of their offer. (This differs from AMHS model )

➢ NB ‘home treatment’ has been adopted an overarching, recognised term

but ‘community intervention’ more accurate – some IHT pathways

deliberately avoid home appointments and home may not be safe place for

some CYP.

➢ IHT teams evidenced a more diverse skill mix within the team, including

• support workers • clinical psychology • specialist psychiatry

➢ Dedicated CYP teams implemented core practitioner staffing within a

broad range:

• 8 to 20 wte per 120,000 U18 CYP

➢ Reflects minimum viable team, team remit (IHT, scope, hours), funding etc

➢ Some posts not substantively funded or non-recurrent

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8. Cost reductions

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Cost reductions in CCG local services by avoiding

➢ community CYPMHS multi disciplinary team activity

➢ A&E attendances

➢ paediatric / medical ward admissions

Cost reductions were assessed in relation to service design: not all designs

achieve full impact, e.g.

➢ ‘crisis assessment only’ teams will not avoid mdt follow-ups;

➢ A&E based assessments may increase CYP MH A&E attendances

More mature, fully implemented, integrated models evidenced greater cost

reductions.

➢ Technical issues precluded analysis of impact on mental health beds across all

Vanguard sites

➢ Not all cost reductions were applicable to all designs - or data was not available.

➢ Further un-quantified reductions accrued from reduced disruption and demand

for in-hours and out-of-hours medic on-call

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Overall Conclusions

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➢ Strong performance against a locally agreed four hour 24/7 response standard where

services were fully staffed by dedicated CYP crisis and liaison service

➢ Children & young people, their families and partner agencies all valued the new

services very highly and made influential contributions to service development and

delivery.

➢ Most Vanguard sites offered a combined crisis and intensive home treatment pathway:

Early indications suggest that fully resourced services were able to balance the

demands of crisis response with those of scheduled follow-on and intensive care and

that this contributes to reductions in re-attendance.

➢ Mature, dedicated CYP services also reported relatively stable rates of crisis

presentation

➢ Services increased the proportion of CYP responded to in community settings and

reduced trends of increased CYP MH crisis presentations to emergency departments

and admission to paediatric wards.

➢ Strong partnerships and integrated working with the wider community CAMH team was

a critical success factor to ensure both access to specialist skills and a smooth flowing

patient pathway.

➢ Delivering a full, integrated – joined up – 24/7 cost-effective pathway for local CYP and

their families is a common challenge for commissioners.

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Improving MHSDS data quality

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This guidance has been developed to

support the improvement of the quality

and completeness of data submitted to

the Mental Health Services Dataset

(MHSDS) used in the analysis of NHS

funded urgent and emergency mental

health (including both community and

liaison) services in England.

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National level MHSDS data –

response times

25

Source: MHSDS data (April-July 2018)

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National level MHSDS data –

median time to contact (hrs)

26


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Local level MHSDS data –

crisis teams referrals

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urgent referrals response times

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Local MHSDS data – urgent

referrals median response time

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Local MHSDS data – emergency

referrals response times

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response times

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liaison referrals

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Local MHSDS data – liaison

response times (from A&E)

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liaison response times (from A&E)

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Referral and Care Contact Data

Quality Measures

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Improving MHSDS – what data quality

issues have been identified? (1)

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Recording the clinical response priority typeThe Clinical Response Priority Type field is used to determine whether a referral is urgent or emergency, a

crucial requirement for monitoring these services. Recording of this field was investigated as part of

exploratory analysis.

• Of the 779,823 referrals in MHSDS which started between 1 February and 30 April 2017, 170,845

(22%) of these had no Clinical Response Priority recorded.

• Of the 779,823 referrals, 96,189 were to the community based crisis response teams.

• Of these referrals relating to the crisis care pathway, (16%) had no Clinical Response Priority type.

• A further 4,110 could not be categorised as the codes submitted were invalid.

What needs to be done?

Clinical Response Priority should be recorded for all referrals to teams providing the functions of urgent

and emergency support, advice & triage and assessment (including brief follow-up) for people of all ages.

For the purposes of the urgent and emergency community mental health care pathways, the following

definitions have been provided:

Routine: where an urgent or emergency face to face response is not required, for example where

telephone advice is sufficient, or the person is signposted to another service.

Urgent: situations that require a face to face response, are serious, where an individual may require

timely advice, attention or treatment, but it is not immediately life-threatening.

Emergency: An unexpected, time-critical situation that may threaten the life, long-term health, or

safety of an individual or others, and requires an immediate response.

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37

Recording referral start times and care contact timesThe response time for urgent and emergency services should be measured in hours.

The initial exploratory analysis investigated the times used for both the referral and care contacts in order

to check the potential accuracy of the response times reporting. In order to determine if a person has

received a contact within a certain number of hours, it is essential that the recording of both the referral

time and the contact time must be precise to the unit of time below that, i.e. to a number of minutes. If it is

not precise to that level then some cases may be reported as receiving a contact within a certain number

of hours when this was not the actual experience of the person referred.


• In order to provide the best estimate available for the true response times for these pathways, the

recording of Referral Request Received Time and Care Contact Time must be as accurate as possible.

• Systems must not be configured to record a default time when the true time is not known.

• Anyone involved in the manual entry of times in administrative systems must not enter default times

when the true value is not known.

• It may be beneficial for the importance of accurate recording of times to be highlighted to front line staff

and others involved in data entry.

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38

Recording of service or team typeIn order to understand if people in scope for a mental health care pathway are accessing the

recommended services, it is important to be able to identify those services with which they are in contact.

Community mental health services

All NHS funded teams providing functions of urgent and emergency mental health support, advice & triage

and assessment should record one of the team types A02 Crisis Resolution Team/Home Treatment

Service or A03 Crisis Resolution Team or A19 24/7 Crisis Response Line. This is regardless of what the

local team name or model is, or which age groups they serve.

Liaison mental health services – for children and young people

• Teams that provide dedicated specialist CYP mental health liaison in general hospitals to emergency

departments and/or wards should use team type C05 Paediatric Liaison Service.

• Teams that provide crisis response in community settings as well as in Emergency Departments (A&E) /

general hospitals, should record team type A03 Crisis Resolution team, and ensure that the activity

location type is recorded.

• Teams that provide a fully integrated crisis & liaison function combined with intensive home treatment

should record: Team Type A02 Crisis Resolution / Home Treatment Team and ensure that the activity

location type is recorded.


• Where a service or team’s remit is to provide urgent and emergency support, advice triage and

assessment, and/or intensive home treatment, and they do not provide other functions then these

should be included in MHSDS submissions with the relevant service or team type recorded as per this

proposed guidance.

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39

Recording of activity locationIn order to understand what services are being delivered it is important to know where the location of any

assessment is taking place, in addition to knowing the service or team a person is referred to. For

example, full and accurate recording of activity location will allow analysis of the data to show where

community crisis teams are routinely providing crisis response to A&E departments.


Service providers should ensure accurate and full recording of the activity location type for any

assessments undertaken as part of these pathways.

NHS Digital would welcome any feedback on issues services providers are experiencing with recording

this information. Please send any response to NHS Digital at [email protected] quoting ‘Urgent

and emergency mental health care pathways guidance’ in the subject of the email.

mailto:[email protected]

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Improving data – next steps

40

➢ Share NHS Digital’s guidance for improving UEC MHSDS data quality with:

• information managers, developers and analysts within organisations providing NHS funded

urgent and emergency community mental health services and urgent and emergency liaison

mental health services

• operational managers, service managers and clinical leads of these organisations

• suppliers of clinical or administrative IT systems to these organisations

➢ Review the guidance and encourage relevant colleagues and teams to feed back

to NHS Digital directly. NHS Digital welcome responses to the questions outlined in the

guidance and will use them to inform the development of the analysis. Please send any

response to NHS Digital at [email protected] quoting ‘Urgent and emergency

mental health care pathways guidance’ in the subject of the email

➢ Review the urgent and emergency mental health care MHSDS data for your

area / organisation and continue to monitor it monthly to support data quality improvements

➢ Public reporting of MH UEC MHSDS data on response times begins – TBC

mailto:[email protected]

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