Mental Health Rehabilitation

1.1 All mental health trusts, health commissioners and social care commissioners should work together to provide all aspects of rehabilitation services. They should develop and use a local rehabilitation data dashboard. Data should be used for improvement, not performance, using a QI approach. a Mental health trusts to work with their local IT team and Chief Clinical Information Officer to: • establish and maintain robust systems for measuring rehabilitation data; • ensure the local data dashboard includes timely analysis where there is variance, alongside an explanation and contingent actions if necessary; • commit to recording and reporting outcomes consistently for all patients; • measure outcomes using the RCPsych Rehabilitation Faculty Outcomes Framework and locally relevant outcome data. This should cover economic wellbeing and opportunities to work; • ensure all protected characteristics are measured (e.g. ethnicity, gender) to understand and better tackle inequalities; • routinely collect and flow all data to the MHSDS in line with the Information Standard notice as mandated in the NHS standard contract. b Ensure supported housing leaders have access to and contribute to the rehabilitation system data. Data to be integrated between different sectors, with shared outcomes and data for measurement.

1.2 All mental health trusts, health commissioners and social care commissioners, as well as housing partners, should robustly record and monitor all OPPs and report this on a minimum quarterly basis. a Confirm a local definition of OPPs and track numbers in advance of the NHS England and NHS Improvement developed definition being agreed in 2022. b Include reasons for the placement needing to be OPP and, in line with NICE guidance, write to the patient and family including the timeframe as to when they will return to local services. c Data on placements should identify if any groups are particularly over-represented in OPPs, including protected characteristics. d Data should be reported to and discussed at trust boards, with any relevant issues identified then raised with health commissioners, LAs and ICSs if appropriate on a minimum quarterly basis. e Ensure any issues identified are acted on. f Data should be reported both for inpatient and community supported housing OPPs. g Where there is a provider collaborative approach the definition of OPP may be different, recognising there may be a number of providers working together to deliver a seamless pathway of care. Here, it is key to ensure that connections with the LA of origin are maintained as well as the family and local care team connection. h Local systems should continue to monitor Out of Provider Placements (OPPs) for people with rehabilitation needs to highlight gaps in local service provision and to identify health commissioner spend that could be reinvested locally to address people's needs close to home and in the least restrictive environment. NHS England and NHS Improvement should use this information to develop a set of metrics that can be applied consistently between areas which will help drive this reinvestment in local rehabilitation pathways, allow for benchmarking, and demonstrate progress towards delivering high quality local services which support people with rehabilitation needs in the least restrictive setting.

1.3 All trusts, health commissioners and LAs should ensure timely access to rehabilitation services and introduce local 'access and wait times' data to optimise and monitor. This should include rehabilitation services accessing evidence-based interventions and services, in line with relevant NICE guidance. a Identification of all people who meet the criteria for rehabilitation services, including people with complex psychosis as set out in recent 2020 NICE guidance. Be inclusive by default and monitor their wait times into rehabilitation services (inpatient and community). b Time to access of rehabilitation evidence-based interventions to be measured, reported on, monitored and minimised. c Provide in-reach into acute inpatient units to identify those who meet the criteria for rehabilitation. d Include appropriate access to supported accommodation or specialist placements. e Monitor and report on patients coming from early intervention in psychosis services into rehabilitation services, particularly optimising early intervention for rehabilitation. Around 15% of early intervention in psychosis patients should be expected to come into rehabilitation services.

1.4 Coding - rehabilitation care should be coded consistently and accurately. a This should have at least one Whole Time Equivalent (session) of time attached. a GIRFT team to develop MHSDS and SNOMED with NHS Digital. This is pre-existing development work. b Ensure this includes psychiatric and physical health comorbidities. c Include PCSP, SP and PHB coding, with input from the NHS England and NHS Improvement Personalised Care Group.

1.5 A rehabilitation lead clinical information officer to support the rehabilitation data dashboard and the improvement of data quality across the trust and the rehabilitation pathway. a This should have at least one Whole Time Equivalent (session) of time attached.

2. Trusts, health commissioners and social care commissioners should develop whole system rehabilitation pathways, using a local needs assessment and based on NICE guidance and NHS England and NHS Improvement policy and guidance relating to community mental health transformation as part of the NHS Long Term Plan. a Health and social care commissioners, along with trusts, to undertake a needs assessment and formulate plans around a whole system rehabilitation service offer, including inpatient, community, and specific clinical support into supported housing and early identification of rehabilitation needs. b Ensure that the numbers of patients coming through to services tallies with the identified need, including those coming from early intervention for psychosis services, where timely access to rehabilitation services can positively impact on their trajectory. c Ensure patients and carers are included in the development of rehabilitation services. d Trusts to undertake a gap analysis based on the 2020 NICE guidance best practice. e Trusts to work with system partners – including health commissioners and social care commissioners, VCSE, housing partners and care providers, to develop a plan or a whole system rehabilitation pathway. Sufficient operational support and proper funding of the support element in housing is necessary for success. f Good practice around agreeing responsible commissioner and care of homeless people should be developed. g Commissioning to ensure local care, and length of stay (LoS) to be monitored to facilitate least restrictive options.

3. All trusts, health commissioners and LAs should develop robust systems to bring patients treated out of area back to their local area. a A senior named placements co-ordinator, as part of the CRT, to review and plan the person's move back to local care, and in the community wherever possible. Need to have or be directly linked with commissioning powers under the Care Act (e.g. social worker involved in reviews), or Mental Health Act Section 117, Continuing Care, or the Children and Family Act 2014 (up to 25 years old). Education, health and social care to support planning or work directly with commissioners to bring the person back into local care. b All systems are expected to develop a PHB offer for those eligible and use PCSP to ensure care is aligned to people's own identified health and wellbeing outcomes. c Develop an adequate complement of supported housing of different levels of support and expertise (using the NHS Digital accepted terminology). d Should OPPs be deemed necessary, the national procurement framework should be used, with clear oversight and monitoring systems in place and arrangements to ensure care is appropriate to the person's needs, with contracts to work towards discharge back to the person's local team. e Consider whether mental health rehabilitation could be explicitly included for support from the Better Care Fund 2021/22, in order to develop local community mental health rehabilitation pathways and repatriate people back to their funding LA.

4.1 Trusts and health commissioners should develop standardised care pathways and service frameworks in line with NHS Digital definitions from the service framework of community rehabilitation teams and typology of different inpatient rehabilitation services from RCPsych Rehab Faculty. Provider collaboratives will come into play. a Trusts to use these definitions to develop a whole system rehabilitation pathway. b Co-develop service frameworks covering inpatient rehabilitation units and CRTs. Coverage of inpatient rehabilitation units would be similar to that of the Secure Care Programme. The frameworks would be developed with multidisciplinary input, and in co-ordination with developing guidance products from NHS England and NHS Improvement related to provider collaboratives and the Long Term Plan. c Include advice on staffing complement. d Ensure that PCSP and PHB are included to reflect legislation (Section 117).

4.2 NHS-led provider collaborative programmes to consider provider collaborative model for whole care pathway for people with complex emotional needs. a The provider collaborative programme to develop clear outcomes to be delivered by a Complex Emotional Needs/EUPD, provider collaborative model.

5. Trusts, health commissioners and LAs should ensure that a dedicated community mental health rehabilitation service/team is developed across all health commissioners/LAs. a Trusts to develop a robust system to ensure oversight of community provision for those in placements or with complex care packages. b All trusts or health commissioners should have a dedicated community mental health rehabilitation service/team which should be NICE guidance concordant for the cohort of people with complex psychosis. c Trusts to follow the standards outlined in the CCQI AIMS-Rehab Community Teams (currently being piloted). Include MDT – as per NICE guidance. Caseload numbers to be outlined. Interface with Community Mental Health Framework to be considered. d Ensure LA secondment of staff into this team, who can operate the Care Act collaboratively. An integrated team, and jointly set up, to run the responsibility for rehabilitation.

6. All trusts should work with their local partners to proactively improve provision of different levels of supported housing in their area, aligned to the local level of need, using a flexible model. a Urgently improve the availability and provision of specialist supported housing in each area, proportionate to the local need. b LAs, health commissioners and provider trusts to use the needs assessment to develop a housing strategy over each ICS/STP. This should be an integrated commissioning strategy. c LA supported housing framework (including outcomes) to be developed for different types of rehabilitation supported housing with health partners, in which the needs of mental health are understood and met. d Ensure strategic optimisation of funding for supported housing e.g. such as Greater London Authority grants which can be accessed by housing providers for capital funds; housing associations have access to specific capital grants for specialist supported housing and can also adapt existing housing too to meet needs. The Care and Support Specialist Housing Fund (CASSH funding) should also be looked into. e Follow MHCLG supported housing national expectations. This reiterates the need for local needs mapping and also provision to an agreed standard.

7. Develop and optimise partnership working to improve patient and system outcomes and value. 7.1 All trusts and health commissioners should develop Local Provider Collaboratives (LPC) when commissioning services. These may extend to include supported housing and other VCSE care provision. a Giving due regard to the approach of and opportunities provided via the national NHS England and NHS Improvement Provider Collaboratives in Mental Health Programme, systems should be clear for all relevant stakeholders, including patients and carers, to work collaboratively and, where possible, in an integrated manner, to provide local rehabilitation and recovery services. b Use the needs assessment to understand whether a provider collaborative between mental health trusts would benefit a local system. This can help support rehabilitation services to be commissioned and provided, within their local areas. c Health commissioners to consider delegated budgets, with clear risk sharing should demand increase. Financial efficiencies to be kept by the collaboratives to develop local rehabilitation pathways, strengthening community provision especially. d Consider provider collaborations across the whole pathway, including housing and VCSE providers.

7.2 All trusts and health commissioners should create systems to provide an integrated model of physical and mental health care, ensuring the physical healthcare of those in rehabilitation services is prioritised and effective arrangements for access to physical health referrals are in place. This includes reasonable adjustments to facilitate access and care. a Record mortality data per mental health trust routinely and centrally. Rehabilitation patients should be included as a key cohort within overall local plans (at primary care or ICS level) to improve the physical health care of people with SMI, both in the community as well as in inpatient settings. b All patients should have: • a GP (including inpatients - an SLA may be needed by the trust for inpatients); • a shared care arrangement in place; • physical health checks and screening; • tailored plans for smoking cessation for those with SMI and to reduce obesity, are likely to be the most effective way of reducing long term conditions. The 2020 NICE Mental Health Rehabilitation guidance, including the four-week comprehensive assessment, should be used to ensure all is covered. It is important to track: • physical health commissioning for quality and innovation (CQUIN) data in rehabilitation teams; • that shared care is signed up to and what this looks like in the new Community Mental Health Frameworks; • rehabilitation patients using acute physical healthcare beds.

8. All trusts, health commissioners and social care commissioners should invest in developing a skilled and competent MDT workforce within their mental health rehabilitation systems, particularly as part of local ICS community mental health transformation plans. a Routinely consider skill mix in any workforce reviews or developments. b HEE, alongside a whole system approach and with all relevant other stakeholders, to continue to consider the training needs of the MDT workforce to provide best practice, skills and competencies needed and applied in context into mental health rehabilitation. c Consideration given to resourcing HEE to develop the articulation of these competencies more formally, harnessing this in an overarching framework, across the whole system. d Assess existing guidance so as not to replicate some of the core training that some specialties, particularly occupational therapy and psychiatry, already incorporate. e Ensure staff wellbeing is a core part of the regular reviews with a clear implementation plan. f Ensure inequalities monitoring of patient experience, outcomes and staff progression is undertaken and reviewed. Ensure the incorporation of training and actions to address inequalities are embedded in rehabilitation services. g Education providers to develop rehabilitation training to be delivered to staff. h Support and train patients and carers to access and use digital support, care and treatment. i All staff to have training on access and funding for housing and housing-related issues.

9. All trusts, health commissioners and LAs housing providers should use data informed continuous QI approaches across the whole system of mental health rehabilitation. a All rehabilitation pathways should demonstrate use of routine clinical data to drive QI programmes. The expertise should be at the trust and provider collaborative level. b Trusts to work with RCPsych AIMS-Rehab to inform and support local rehabilitation QI programmes. This could include using tools such as Quality Indicator for Rehabilitative Care [QuIRC]/(QuIRC-SA) c Regional quality networks should be established. Include LA and supported housing and care staff and partners. This may be through the RCPsych regional College Engagement Networks.

10. Trusts and other service providers should utilise digital technology in developing and delivering rehabilitation services. a All rehabilitation units/services to invest in and improve digital technology to ensure good communication and to facilitate frequent clinical reviews. b Staff skills and competencies to reflect supporting and training patients and carers to access and use digital support, care and treatment. To include social prescribing and enable digital access. c Consider the issue of digital exclusion and how to overcome this.

11. Standardise and systemise processes and protocols around procurement. a Use trusted providers, fewer and as close to home as possible, while still optimising care and outcomes. The national OPPs framework to be used and this to be updated to reflect current best practice annually. b Standards around specialist rehabilitation staff training need to be incorporated into standardised OPP contracts.

12. 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 SI/ PSI and where a claim has not already been reviewed as 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 MDT meetings, morbidity and mortality meetings where appropriate). e GIRFT clinical leads and regional teams to share with trusts examples of good practice where it would be of benefit.