Efficient and Effective
Community Mental Health Services
Toolkit – Prototype Version - Oct 12
We are keen for this toolkit to represent all of our experiences across Scotland (and wider) on how to deliver Effective and Efficient Community Mental Health Services, so if you have comments on the contents or additional ideas that you think should be included in the final version then we want to hear from you. We will credit any individual/team whose comments we include in the final version, so please do get in contact and help us to co-produce a document that pools the extensive knowledge that exists across Scotland.
We are also keen to include some brief vignettes about teams who have successfully implemented the approaches outlined in this toolkit. So please do let us know about any work you’ve done locally that you think would make a good example for any sections of this toolkit.
You can feed any comments back by contacting us on . If you put Effective and Efficient CMHTs in the header it will help ensure your email gets through to the right person, first time.
Contents
Page NoSection One - Background and Introduction
· Background
· Introduction to the toolkit / 5
7
8
Section Two - Effective Practice
· Reliable implementation of evidence based care
· Effective team working / 11
13
15
Section Three - Understanding and Managing your Capacity
· Introduction to capacity
· Optimising capacity – reducing DNA and CNA
· Optimising capacity – skill mix
· Optimising capacity – effective meetings
· Optimising capacity – removing non-value adding work
· Optimising capacity – reducing sickness rates / 19
21
32
36
39
41
43
Section Four - Understanding and Managing your Demand
· Introduction to demand
· Managing demand – set clear eligibility criteria
· Managing demand – goal setting, case review and caseload management / 45
47
54
58
Section Five – Undertaking a full DCAQ Analysis
This section is still in development phase and as not yet been issued / 63
Section Six – Tools / 65
Section One
Background and Introduction
Background
In 2012 the Mental Health Pathway Efficiency and Productivity Report was released. The aim of the report was:
· To highlight key opportunities for delivering efficiency savings across mental health services whilst maintaining or improving the quality of care.
· To provide an assessment of the productive opportunities attached to each issue.
· To highlight the key actions needed to release the productive opportunities
· To identify any additional work that is needed nationally.
This report highlighted the potential quality and efficiency opportunities attached to community mental health services and identified a range of issues attached to ensuring that these services are doing the right things and doing those things in the most efficient way.
The work sat within the wider context of the Quality strategy which ‘puts people at the heart of everything the health service does. It establishes our commitment to ensuring that the way in which people receive health care is as important as how quickly they receive it.’
The strategy outlined three quality ambitions. Care should be:
· person centred, meaning that there will be a mutually beneficial partnership between service users, their families and those delivering healthcare services.
· safe, with no avoidable injury or harm to people from healthcare services and the environments will be appropriate clean and safe.
· effective, with the most appropriate treatments, interventions, support and services `provided at the right time to everyone who will benefit and wasteful or harmful variation will be eradicated.
In August 2012 the Scottish Government also launched the Mental Health Strategy 2012-2015. The quality ambitions have been central to the development of this strategy, which aims to ensure that people with mental illness and their carers and families receive high quality, effective, safe, person centred care that is delivered as efficiently as possible.
This toolkit sits within this context and seeks to provide practical guidance to enable community mental health teams to meet the quality and efficiency challenges ahead.
Introduction to the toolkit
Why has the toolkit been developed?
There are a whole range of resources that already exist to support services to meet the challenge of delivering better quality community mental health services with the same or less resource. However, the range of resources can feel overwhelming and leave services wondering where to start and what to use when.
This toolkit has been developed to pull the key resources together in one place and provide guidance on which resource to use when. It aims to provide support and guidance to community mental health services to deliver effective and efficient mental health services and to assist them in identifying and delivering productive opportunities. It also supports the achievement of the three quality ambitions as outlined with the NHS Quality Strategy and will support services to deliver the ambitions outlined with the Mental Health Strategy.
It identifies a wide range of tools already in existence and pulls these resources together into a module format that can then be used by community mental health services to support the release of the high impact opportunities. The programmes and tools which were reviewed for inclusion in the toolkit include:
· Quality Improvement Hub – Service Improvement Tools
· Releasing Time to Care Resources
· Scottish Recovery Indicator (SRI2)
· Integrated Care Pathways (ICP’s)
· QuEST Mental Health DCAQ resources
· Mental Health Collaborative - Improvement toolkit (MHC)
· Mental Health Improvement Game (MHIG) Resources
· Choice and Partnership Approach (CAPA)
· Research Papers
This toolkit is still in development. However, rather than hold it back until every last i was dotted, we’ve decided to put it out to services to allow you to have a go at using it and give us feedback about what works and what needs improving. It is often only by testing something in practice that we find this information out.
Further, you may have additional ideas that we could include in the final version. We are keen for this toolkit to represent all of our experiences across Scotland (and wider) on how to deliver effective and efficient community mental health services. So if you spot something we’ve missed, let us know and we can look at adding it in. We’d like the final version to be co-produced in partnership with community teams across Scotland and hence inclusive of all of your experiences of successfully delivering effective and efficient community mental health services. We’ll reference any individual/team whose comments we include in the final version.
You can feed any comments back by contacting us on . If you put Effective and Efficient CMHTs in the header it will help ensure your email gets through to the right person, first time.
How to work with the toolkit
The toolkit has been presented in a modular format to help break the work down into manageable steps. It provides guidance and ideas on how to take work forward. Some of these resources (such as relevant modules from the productive series) have copyright restrictions which mean we can’t reproduce them here. Other resources are simply too large to reproduce in full within this toolkit. In these cases we provide hyperlinks over to relevant websites. Please note that a license is in place which allows all NHS Scotland staff to access the productive resources online.
We hope the guidance is relatively easy to follow, however implementing the ideas requires skilled facilitation and management of change. The toolkit assumes that those using it will have a basic background knowledge on how to use and present data to inform improvement work, how to map processes and how to test change ideas at a small scale prior to full scale implementation. Therefore, if you do not have those skills in your team you may want to seek some input from your local improvement team.
Ideally, you want to start with the effective practice section as this underpins all the other work. However, the reality of the current workload and financial pressures is such that you may need to do other things first to create some capacity to then start looking at your care processes and outcomes. What probably matters more is that you start somewhere that makes sense to you, given the issues you are facing locally.
Within each section, the toolkit encourages you to start by assessing your current state and then use this information to inform where you direct your improvement work. This means that data, both qualitative and quantitative, underpins the approaches recommended in this toolkit. You will almost certainly need some analytical support to help you with the data presentation. In particular, we recommend that you don’t start any new data collection work unless you are clear who will analyse the data. It is really demoralising for staff to put effort into collecting data and then find that nothing is done with it.
Once you’ve assessed your current state you should then have some useful information to guide your improvement work. Each section then goes on to provide you with ideas/guidance on addressing some of the more common issues that occur. However, we know there are more ideas out there so please do let us know if you think we’ve missed anything significant.
When using this toolkit please note we recognise that there is no agreed terminology for referring to individuals with mental health problems who are using mental health services. For ease of reading this document we use the terms service user and client. We hope this does not cause offence to those who prefer different terminologies.
Section Two
Effective Practice
Reliable implementation of evidence based care
Why is this important?
Highly efficient services that are doing the wrong things are not productive. Therefore a vital part of delivering productive community mental health services is ensuring that services are designed to meet the needs presenting using the best possible evidence.
Understanding your current state
Use clinical outcome data
Ideally services should be routinely collecting, analysing and using clinical outcome data to identify opportunities for improvement. Clinical outcomes should be used and discussed routinely in individual practitioners supervision sessions and NHS Boards should be looking at the variance between different team’s clinical outcomes and then understanding whether that variance is warranted (i.e. based on different case-mix) or is indicating opportunities for improvement (i.e. may highlight skills/training issues)
In reality, very few services are in a position to do this at the moment. However, it’s important for the longer term to put a plan in place as to how you will get to the point where you are routinely collecting, reporting and using clinical outcome data.
Assess your current pathways against agreed standards/pathways
Every service should have agreed local integrated care pathways against which you can assess current practice. If you haven’t already completed work locally to develop pathways then you could assess practice against the national ICP standards which can be found in the Mental Health Integrated Care Pathway Toolkit. .
There are two main options here:
· Routine reporting analysis
The ideal we are trying to reach is that any variance from agreed pathways is routinely reported and coded so that services can understand why the variance is happening. In some cases the variance will be for clinical reasons and may in fact be driven by the specific and unique needs of the service user (warranted variation). In other cases the variance will be because of service factors that need to be addressed such as the evidence based therapy not being offered because it is not available locally (unwarranted variation).
· Random audits
However, very few services are routinely recording data that enables this type of analysis. Therefore the other option is to select a random sample of individuals discharged over a given time period and then map their journey against an agreed pathway, identifying any variance. You then need to understand whether the variance is warranted or unwarranted. For unwarranted variance, an action plan should be agreed and implemented to address it. You will need to repeat the audit on a regular cycle so that you can start tracking whether improvements are happening.
Please note – we do not recommend that you assess your current state purely by mapping what staff members think happens to individuals. Whilst this can be a valuable part of assessing your current state, you need to test this against what actually happens to individuals
Assess the recovery focus your services by using SRI2
When assessing your current state, it is important to get a sense of how recovery focused your services are. The SRI2 tool provides a way of assessing your current state in relation to the recovery focus of your teams/services. It provides the opportunity for people who provide the service, and people who use the service along with their carers, to rate aspects of the service against ten recovery indicators. This results in stimulating and reflective conversations, leading to an action plan which is then fed into the web based tool. The resulting service improvements can be recorded and celebrated, and the next SRI 2 scheduled, thus ensuring continuous improvement and service development.
Delivering reliable implementation of evidence based care
If your current state analysis has identified opportunities for improving your delivery of evidence based care, you then need to put a plan in place to address these. Approaches that you may find useful are:
· Using the Model for Improvement to test ideas at a small scale prior to then rolling out those that are successful.
· Routinely auditing a random selection of case notes to identify whether you are managing to reduce unwarranted variation.
· Using run/control charts to identify statistically significant changes.
· Using project management techniques to ensure actions are followed through.
· Ensuring discussions on outcome data are routinely included as part of clinical supervision.
You will find more information on the first four of these approaches in Section Six.