Blog: "Knowledge is Power"
There have been increasing challenges facing the NHS over recent years, including, but not limited to, workforce issues, financial constraints, integrated working with all stakeholders and infrastructure issues. There is hope that Mental Health Services will get more investment in the NHS Long Term Plan. Even with this, there is consensus that “things have got to change,” in order to offer services that are financially sustainable, accessible and offer the best patient experience and clinical outcomes. However, knowing where to start changing or what to address to have the most beneficial impact is a challenge in itself.
Mental Health Providers have always struggled to demonstrate outcomes like their Physical Health Provider colleagues, often claiming that the outcomes are more complex and more qualitative and therefore less quantifiable or measurable. However, even if a system can’t easily demonstrate outcomes, it does have outputs that can be measured and in themselves can highlight variance for further exploration.
For the elimination of acute out of area placements (OAPs) national programme, we have now visited multiple health, social care and integrated care systems across England. Much of the focus of these visits has been on the flow in acute care and the wider system role and impact in that. We have been pleased to observe the increasing use of Quality Improvement, and the blending of qualitative and quantitative data to answer and pose questions. We have also observed many systems increasingly using run charts and SPC to inform developments (https://improvement.nhs.uk/documents/2748/NHS_MAKING_DATA_COUNT_FINAL.pdf), alongside tools like purposive admissions and Red 2 Green to reduce “wasted days” during an admission and people becoming “stranded” on an acute ward.
Whilst each system has its own local intelligence and data on what is working or where there may be gaps and local evaluations of what has been tried to improve pathways historically comparisons across systems were difficult. In recent years one simple way to get a high level impression of a system, is to look at the National Benchmarking Report (@NHSBenchmarking) and use that to inform questions for further analysis.
The National benchmarking reports are published each year and are sent to Provider Trusts. The report will highlight the Trust’s data across a wide range of services and allows for comparison in each of these areas with all other NHS trusts. It also specifically allows for comparison of the provider with other regional trusts by marking these as green, due to bespoke colour coding. There is a registered population and weighted population report provided, however in our experience, focussing on the weighted population report allows for a more accurate comparison.
For the acute OAP national programme in particular, it is very important to note that acute OAPs are not counted in the benchmarking numbers e.g. admissions, bed occupancy etc and so for true benchmarking, the figures in the National Benchmarking Report requires the OAP numbers adding from NHS digital https://digital.nhs.uk/data-and-information/publications/statistical/out-of-area-placements-in-mental-health-services/september-2018
Using the National Benchmarking Report to look at flow
Flow through acute psychiatric care requires specific focus on the three main phases (admission, care received and discharge) and careful consideration of the broader pathway and community services to sustainably manage capacity and demand across the system.
Simple questions for each data set can be helpful to identify variance and areas for further focus and analysis:
Acute care pathway
- Number of admissions- per weighted population does this reflect effectiveness of community services, or the range of alternatives available?
- Number of admissions not known to services- how good is the access to community services?
- Number of admissions of no fixed abode- is this due to a transient population, or issues with housing?
- Use of the MHA – is the acute inpatient gatekeeping assessment effective even when people are detained?
- Lengths of stay- if there are a lot of 0-3 day admissions are the CRHTT/community alternative functioning as they should? If there are a lot of over 60 day admissions- does the rehab pathway need strengthening?
- DTOC- what are the barriers to discharge- do the local authority and CCGs work effectively together? Are there placement/housing issues?
Then looking at the wider issues that impact and influence how well a system flows:
- Investment in inpatient v’s community and activity in inpatient v’s community- is the balance right? Is best use being made of available resource? Community investment should be maximised.
- Number of beds per weighted population- it is good to compare this with others and if this is particularly high- how do the CRHTT and community data sets compare.
- Staffing levels- Are services adequately staffed and have capacity to provide what is needed in the system e.g. safer staffing on wards
- Staff satisfaction, turnover, sickness- do staff feel engaged to work to improve services, can the organisation retain them, do they feel supported which is essential for effective care and good experience of care in addition to the embedding and spreading of QI Bank/agency staff use- is this high- as this not only will affect resource but also affects ability to implement QI work, as staff likely won’t be consistent or invested.
Service User Feedback:
- This is essential, Friends and Family Test feedback is reflected in benchmarking but local level feedback is more valuable and should include involvement in co-production of QI and service redesigns
The National benchmarking report may not provide the answers of where the pressure points or gaps in provision may be, but it can help frame the questions and inform QI projects to identify them. Mental Health Systems committed to improve and develop, need to start somewhere. Having some idea of where best to start, where will offer more overall benefit than harm to all stakeholders, will give the confidence to have a go, and with all quality improvement, what is most important is that regardless of the outcome, it is a bigger failure not to try.