Mental Health – Adult Crisis and Acute Care

Each ICS/STP area should ensure that it understands the needs of the local community and the demand for mental health services, employing Joint Strategic Needs Assessment (JSNA) where appropriate. a Trusts to review local population needs assessments such as JSNA and to take into account factors known to increase mental health needs and demand, including but not limited to the vulnerable groups highlighted in the report to help drive their strategic plans between 2022-2025. b Services commissioned to accurately reflect local needs (not just existing demand) to ensure these groups are not being doubly disadvantaged. c Trusts to ensure data is segmented to take account of variation in local area needs. d Trusts need to work with commissioners to ensure clear information is provided about what is available for local communities, and this is shared and taken into account when estimating demand for trust-provided SMI services. e Trusts to co-produce all service developments, and redesigns with those who will access such services, will help deliver those services and those affected by those services.

Trusts need to work with system partners to ensure that it is clear which needs IAPT services have been commissioned to meet locally. a Ensure that all planning of SMI services takes into account IAPT-commissioned deliverables, outcomes and prevalence. b Ensure that IAPT services are delivered in line with the IAPT manual, and with NICE guidance on psychological therapies.

Trusts need to work with system partners to understand and mitigate increased demand on SMI services related to COVID-19. a Ensure the sustainability of new and/or modified practices such as rollout of 24/7 access lines, and wider use of remote working models and technology established during COVID-19 to improve or assist use of available capacity. b 24/7 crisis lines to link in to 111 telephone services. c Trusts to work with their ICS/PCN and with the relevant national bodies as partners to understand and mitigate the impact of COVID-19 on SMI services.

Trusts must ensure that the aims of the NHS LTP Mental Health Implementation Plan and LTP transformation funding are met locally. a All trusts to work with system partners to ensure that the Mental Health Investment Standard is met locally, and that they have nominated finance/transformation leads at senior level with a thorough understanding of the Standard, and can specifically identify the growth in investment expected in each service area between 2018/19-2023/24, and works with ICS/CCGs to ensure the trust receives its share of investment in line with that growth. And to regularly report at board and ICS and STP level on the success of implementing the requirements set out in the NHS LTP Mental Health Implementation Plan. b Trusts to contribute to new NHS England and NHS Improvement national financial planning process to allow triangulation between CCG stated growth in mental health investment and mental health trust income (and, where necessary, reconciliation between the two).

Trusts need to work with partners locally and through national bodies to establish and train sufficient numbers of professionally qualified staff – including nursing and medical staff, allied health professionals (AHPs), and clinical psychology, pharmacy and social work staff – to meet the patient need for SMI services in England. Trusts also need to reduce vacancy rates and the reliance on agency and locum staff. a Key national bodies to ensure that there are adequate numbers of undergraduate and postgraduate training opportunities to meet trust-level workforce demand. b Trusts to identify gaps in being able to recruit and retain staff with the necessary qualifications to fill key roles currently and in relation to future development of services to work with partners, including but not limited to Health Education England, to map demand and capacity for future workforce so that supply meets future need.

Trusts need to carry out regular ongoing consideration of opportunities to improve skill mix and evaluation of the impact of any changes or innovations. Such opportunities might include increasing the numbers of peer support workers and professionally qualified staff, including nursing, medical, AHP, clinical psychology, pharmacy and social work staff, and increasing the range of posts such as physician or nurse associates, to further develop new roles (both professionally qualified and non-professionally qualified) and models of care delivery. a Trusts to routinely consider skill mix in any workforce reviews or developments, such as the national projects referenced in the NHS LTP Mental Health Implementation Plan, to be based on local needs assessments, including JSNA and the best available evidence.

Trusts need to ensure that existing staff capacity is efficiently utilised and clinician time used to best effect; trusts also need to look at staff wellbeing and support. a Trusts to consider implementation of voice dictation software for data entry. b Trusts to improve the IT infrastructure and functionality of systems for timely input and retrieval of information. c Trusts to review use of staff time (particularly professionally qualified staff), and clearly outline expectations and deliverables in terms of time management in clinical practice to make best use of professional skills. d Trusts to ensure that opportunities are seized from developing the framework for core digital capabilities in mental health services, building on work underway e.g. as described in the Topol Review.

Trusts need to ensure that their systems are not routinely running at or very near maximum capacity in order to reduce staff burnout and risk of errors, give sufficient flexibility to deal with surges in demand, and allow system thinking and review time. a Trusts to ensure that average inpatient bed occupancy rates are no more than 85% in line with Royal College guidelines. b Trusts to work on optimising patient flow using tools such as the Red2Green approach. c Trusts to work with system partners, including commissioners, to be clear how much capacity has been commissioned for each locality, and how much of the expected demand for SMI services can feasibly be met. d Trusts to ensure that there is clarity from commissioners for people whose needs do not reach the threshold for the commissioned capacity in the SMI service and for local community and primary care staff, as to what is locally available for them. e Ensure that non-human capacity (such as inpatient accommodation, information systems, team bases and clinical facilities) is fit for purpose and adequate capital investment is available to modernise outdated facilities. f Trusts with commissioners to report on all NHS funded acute/PICU bed usage for that area, whether it is being provided by trust-based beds, or other providers (in and out of local area), so that total capacity and usage is routinely visible in board reports.

Trusts need to use routinely collected data to explore unexplained variation in reception and acceptance of referrals. a Trusts to establish and maintain robust systems for measuring demand (referrals received) and supply (referrals accepted into treatment). b Trusts to include timely analysis (as part of the board quality dashboard) of where variance occurs – i.e. more referrals received than accepted or first point of contact is not through Route 1 – alongside an explanation and any necessary contingent actions. c Trusts to segment data on referrals (received and accepted) to identify if any groups in the local community are under or over-represented at any entry point, and to report on this to trust board and system partners. d Trust to flag any identified issues in ICS/STP and PCN discussions.

Trusts need to engage with patients and carers to identify and reduce avoidable barriers to patient access to SMI services, as well as ensuring that they have fast-track access to CMHTs and other recognised best practices for referral and patient pathway routes. a Trusts to provide access options such as email, text and video consultations, and other digital solutions for service users for whom telephone access is a barrier. b Trusts to provide clear information on referral and access routes on the trust public website for each service. c Trusts to work with local communities to ensure that potential barriers to access for any part of the community are identified and addressed to reduce inequity of service. d Ensure that the national standards on accessible information are met.

Trusts need to monitor, analyse and report on step-up in intensity of services to ensure that step-up is essential, timely and equitable. a Trusts to use established techniques such as (but not limited to) the following: • Capture the purpose of step-up • Step-up when essential, not as a last resort • Use of Red2Green or similar flow improvement methodology • Patient-initiated follow-up. b Trusts to establish clear systems for timely step down when purpose of step-up has been achieved. c Trusts to capture and use information on system step-up issues such as high rates of section 136, high rates of section 2, high rates of first contact with SMI services or inpatient admission via A&E in discussions with ICS/PCNs to reduce high rates. d Trusts to use robust sustainable models for 24/7 access. e Trusts to regularly review factors that could potentially impact flow to ensure that people do not become stranded in community teams or inpatient services. f Trusts to ensure that trusts services are routinely using evidence-based ways of reducing DNA and no-contact rates.

Trusts need to ensure that person-centred care and co-production of care plans is standard (including to the maximum extent feasible within the law for those detained under the MHA). For people who lack capacity, care planning should follow the principles and rules set out in the Mental Capacity Act. a Trusts to ensure the electronic health record clearly highlights any documents provided by the person to support reviews and/or contacts (e.g. advance directives, hospital passports). b Trusts to ensure all assessments and formulations are routinely shared with the person in a timely manner to allow for clarification or correction of any factual errors. c Trusts to select the contact method – face-to-face, video link, telephone, text or email – most suitable for delivering the most appropriate intervention, taking into account each person's needs and wishes. d Trusts to reduce duplicate assessments by recording once and using often by having timely access when needed to information entered by any team. e Trusts to ensure that all of the above are part of the board quality review. f Trusts to develop crisis plans as part of care plans in line with NICE guidance.

Trusts need to record robust, publicly available outcome and intervention data, and share this with partners and people accessing services as appropriate – in the process meeting (but not being limited to) regulatory requirements. a Trusts to commit to recording and reporting outcomes consistently for all patients including – as a minimum at least one clinician rated outcome measure such as paired HoNOS scores. b Trusts to routinely record and share patient outcome measures such as DIALOG with a view to linking this into work already underway in relation to the LTP Mental Health Implementation Plan. c Trusts to link outcomes with interventions delivered – this requires robust recording and reporting systems that do not reduce clinical capacity by taking significant clinical time to input – using the move to SNOMED CT to help drive this. d MHSDS and Model Hospital to be the repository for key data to reduce numbers of ad hoc information requests, and ensure ability for robust benchmarking to help drive quality improvement at all levels.

Trusts need to capture and analyse the impact of all interventions to assess risks and benefits as part of evidence-based practice. a Trusts to work with system partners and use technological advances to develop robust systems for capturing and reporting the use and impact of interventions – both unwanted outcomes (whether harmful or not) and achievement of desired beneficial outcomes – on an intent to treat basis.

Trusts need to increase awareness of whether variation is warranted or unwarranted. a Trusts to promote positive variation in terms of better/best practice as it relates to the specific trust. b Where variation in intervention or outcome relates to not using best, evidence-based practice such as Clozapine or CBTp or Family Intervention in line with NICE guidance, trusts to review reasons for this (including with system partners, if necessary). c Trusts to reduce unwarranted variation using guidance such as in LTP EIP services recommendation on increasing NICE concordance. d Trusts to flag unwarranted variation to the ICS/STP and PCN where it is due to factors outside of trust control.

Trusts need to develop and report robust ways for capturing interventions and outcomes for services that are heavily linked into partnership working (for example, psychiatric liaison offers a range of ways of working with acute hospitals over and above work in urgent and crisis care, older-adult services link into wider initiatives such as Ageing Well/frailty programmes, and crisis response services are typically multi-agency linked). a Trusts to work with system partners to develop robust ways for capturing and reporting the contribution by trust-based services interventions and outcomes to the overall system responses to improving health and wellbeing of people with SMI.

Reduce litigation costs by application of the GIRFT programme's five-point plan. a Clinicians and trust management to assess their litigation claims covered under Clinical Negligence Scheme for Trust (CNST) notified to the trust over the last five years. b Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk c Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support d Claims should be triangulated with learning themes from complaints, inquests and serious untoward incidents (SUI)/serious incidents (SI)/Patient Safety Incidents (PSI) and where a claim has not already been reviewed as SUI/SI/PSI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all staff in a structured format at departmental/directorate meetings (including multidisciplinary team meetings, Morbidity and Mortality meetings where appropriate). e GIRFT clinical leads and regional hubs to share with trusts examples of good practice where it would be of benefit.