Appendix 3. Mental Health. Mental Health Report for the NHS Salford CCG July 2013 Board Meeting

Transcription

1 Appendix 3 Mental Health Mental Health Report for the NHS Salford CC July 2013 Board Meeting 1

2 Mental Health Report for NHS Salford CC July 2013 Board Meeting 1. reater Manchester West Mental Health NHS Foundation Trust (MW) 1.1 Performance and Quality KPIs MW Quality KPIs are reported to all Associate CCs via the monthly Contract Performance Report. KPIs are monitored through the Contracts & Performance Sub-roup, which meets bimonthly. Performance issues were generally managed effectively during 2012/13 via the local commissioning meetings (at Bolton, Salford & Trafford) and there were no significant issues requiring escalation to the MW Executive Steering roup. An overview of the KPI exception is provided below and a detailed KPI update is provided as Appendix 1. The National KPIs (Section 1.2) relate specifically to Salford CC. The reater Manchester KPIs (1.3) and the Local KPIs (1.4) relate to all the Multilateral Contract Associates CCs. 1.2 National KPIs MW performance, based on the April Contract Performance Report is as follows. The year to March 2013 is included for reference. The data below is for Salford CC: Requirement Target Year End 12/13 April 13 CPA 7 day follow up 95% 98% 99% Early Intervention Number in treatment Early intervention New cases % of target 100% 137% 150% Crisis resolution episodes % of target 100% 105% 91% Delayed Discharge 7.5% 1.1% 2.6% Assertive outreach number in Treatment All targets for 2012/13 were achieved. All targets for the first month of 2013/14 were achieved except for Crisis Resolution, for which the percent of treatment episodes against target is 91%. This has been reviewed with the Team Manager to ensure the caseload is increased for month 2. The Team is currently experiencing a shortage of staff and posts are out to advert for recruitment. Commissioners will monitor this to ensure this performance is raised. 1.3 reater Manchester KPIs There are 17 M KPIs, of which 5 are RA-Rated amber and 1 red. Action plans are in place for all amber and red indicators. The red indicator is as follows: Indicator To issue Discharge Summary (Notification of Discharge) to the service user s P within 48 hours of inpatient treatments discharged from Provider premises. The target is 95%, actual achieved in April is 81% Comments A discharge template has been agreed and MW is working with colleagues across M to develop the Hub communication. It is anticipated that electronic communication will be available in Salford by the summer and in Bolton & Trafford by December 2013 NHS Salford CC: Mental Health Report July 2013 Page 2

3 1.4 Local KPIs There are 19 Local KPIs, of which 2 are RA-Rated amber and 4 are red. Action plans are in place for all amber and red indicators. The red indicators are as follows: Indicator Psychiatric re-admissions for functional patients. The target is <= 10.7, actual achieved in April is 11 Discharge Summaries to be sent within 10 working days of discharge. The target is 95%, actual achieved in April is 87% IAPT Access waiting times don t exceed 28 days from referral activation. The target is 100%. For the MW element of IAPT Services (Step 3) the actual performance achieved in April is 18% IAPT percentage of patients moving towards recovery. The target is 50% by This KPI is only reported quarterly, so the first 2013/14 data will be available in July 2013 (Q1 data). Comments This accounts for 19 re-admissions out of a total of 172 during April 2013 Last year achieved was 80%. The target of 95% is a year-end target and an action plan is in place to achieve this. MW Services are continuing actions for reducing waiting times and to ensure that patients are offered first appointments within 4 weeks of the referral being received. Also, Commissioners have employed an expert external Consultant to conduct a scoping study on capacity/demand within the MW Step 3 Service and offer recommendations as to what needs to be done to improve efficiency. This should conclude by July IAPT Services have completed a lot of effective work to progress this target. The recovery rate achieved for 2012/13 was 44% (combined rate, all IAPT Services), and this comfortably exceeded the local trajectory target of 40%. 1.5 Never Events There were no Never Events in April CQUINs 2012/13 CQUINs were signed off at the 24 May 2013 Quality Sub-roup. 2013/14 CQUINs will be reviewed at the Quality Sub-roup as follows: Qtr 1 at 17 Sep 2013 meeting Qtr 2 at 29 Nov 2013 meeting Qtr 3 at 20 March 2014 meeting Qtr 4 [and final sign] off at May 2014 meeting. Quarter 1 milestones aren t yet due; however, latest update on 2013/14 CQUINs is included for information, as Appendix /14 overnance of the MW Multilateral Contract At the MW Joint Executive Steering roup on 20 May 2013 it was agreed that the overnance Structure in place during 2012/13 will be rolled over to 2013/14. MCSU will update for meeting dates and changes to terms of reference, membership etc. NHS Salford CC: Mental Health Report July 2013 Page 3

4 Salford CC is represented at the Executive Steering roup by the Chief Officer and the Chief Financial Officer. 1.8 MW CQC Compliance A recent audit by Mersey Internal Audit of MW CQC compliance reported that MW provided Significant Assurance. A copy of the Mersey Internal Audit Agency Report is available from TPM if required. 1.9 Bed Occupancy Target: Red <=75% & >=95%; Amber 75.1% - 80% & 90.1% - 95%; reen 80.1% - 90% Number of Beds Year End 12/13 April 13 Functional % 97.3% Organic % 67.7% PICU % 102.1% Rehab % 93.6% Total % 92.1% Bed occupancy is high across all beds except Organic. Occupancy figures are not Salford CC specific and include patients from Bolton, Trafford and other areas. If non-salford patients are excluded bed occupancy is significantly lower, particularly on the Rehab Ward MW Staff Sickness Absence Target Year End 12/13 April 13 Sickness Absence % 5.75% 6.8% 8.8% 1.11 Serious Untoward Incidents NHS Salford CC, as the Lead Commissioner for MW receives notifications of SUIs, via STEIS, for all Associate Commissioners. Salford CC will then collate this information and share it with the M Mental Health Lead, Sandy Bering. Sandy will oversee the process and liaise with the relevant Associate CC Commissioner (for the patient concerned). Sign-off will only be after the local CC has confirmed they are content for sign-off to take place. MCSU Total Provider Management Mental Health Team will keep a log of all SUIs, reporting the status of all SUIs outstanding to the relevant MW overnance Meetings. There are 40 legacy MW incidents still showing as open on STEIS at 18 June These incidents date back as far as 2010 and involve patients from across all the Associates CCs. MW met with the SHA some months ago to review each of the incidents and agree sign off for the majority of cases; however, due to organisational changes to the SHA this was not NHS Salford CC: Mental Health Report July 2013 Page 4

5 facilitated prior to 31 March The MW SUI Lead is currently working with Salford CC (Ingrid O Neill) with a view to facilitate sign off by Salford CC. Between 1 April and 18 June 2013 there have been 7 incidents, 6 of which relate to Salford and 1 to Bolton. The Salford SUIs are as follows: 22 April. Admission of under-18 to Adult MH Ward. Bed request from A&E liaison for patient who was currently in A&E. No bed was available on appropriate wards 22 April. Unexpected Death of a Community Patient (not in receipt). Suspected drug related death. 23 April. Abscond - patient failed to return from overnight leave. 6 May. Abscond - patient cited they went on day leave to the shops and then to an associate s house. The Patient indicated that they did not have the money to return to the ward. 6 May. Abscond at the 00:00 check the client was found not to be in their room. Staff had contact with the patient on the ward at the 23:00 check. There was no evidence of breakage to fittings in the room or on the ward to indicate the patient had left by these means. 9 May. Abscond - following an escorted cigarette break, staff member turned to lock garden door and realised the client had climbed up onto the ledge of the windows adjacent to the stairs back to the ward and climbed out of the window before jumping onto the ground of the car park area around the back of the hospital. 2 Mental Health PbR Having achieved its set objectives, the NW Mental Health PbR roup, at its meeting on 28 January 2013, agreed it was time to reconfigure MH PbR arrangements across the NW. As a result the reater Manchester MH PbR roup was established, with membership drawn from commissioner, provider & contract leads across the M footprint. The reconfiguration to a M roup was supported by recent restructuring to PCTs/CCs; for example, establishment of Cluster-wide CSUs where provider management follows existing contract arrangements by wrapping contract teams around the MH contracts, thereby enabling local PbR roups to work on MH PbR as it impacts on the individual Multilaterals and to also share across M where appropriate. In addition, reconfiguration would enable the individual Trusts to continue at their own pace and allow them to focus on specific areas they, and their commissioners, deemed were local priorities, thereby avoiding the one size fits all scenario. Accountability of the M roup is to the M Contract Steering roup, chaired by the Salford CC CFO. At its April 2013 meeting the MCS requested 2 pieces of work: A MH PbR Work-plan identifying key work-streams, risks and issues for 2013/14. A Financial Impact Statement identifying the impact on M CCs of moving from the historic block arrangements to MH PbR. Both these pieces of work are in progress and will be reported to the next meeting of the M MH PbR roup on 20 June. To ensure delivery of local priorities the reater Manchester West MH PbR roup, established in 2012, will continue: it is attended by contract leads from the 3 principal CC Commissioners. Salford interests are represented by CSU TPM. It is expected a first draft of financial values will be available shortly; however, in view of the attention this information is likely to receive it is important that providers have sufficient opportunity for thorough review and validation checks. NHS Salford CC: Mental Health Report July 2013 Page 5

6 3 MH Liaison (RAID) The published evidence from the RAID Service in Birmingham shows impressive results relating to Acute Hospital efficiencies (e.g. reduced lengths of stay, deflections & bed closures) and general efficiency of the service i.e. responding to referrals very quickly, so avoiding breaches and delayed discharges. A local task and finish group for this development work has been established, chaired by Salford CC Mental Health P Lead, Dr Tom Tasker. 4 IAPT The full year data for 2012/13 showed pleasing results in relation to progress towards the primary national targets, which is focused around increased population prevalence entering treatment (target being 15%) and also in the move towards a 50% recovery rate. The end of year figures showed prevalence at 12.9% (exceeding the trajectory target of 12.6%) and recovery rate at 44% (exceeding trajectory target of 40%).These are the most important KPIs as they feature in the CC performance framework. There are some concerns about waiting times for access to Step 3 service (MW) who are dealing with more demand than was anticipated and contracted for, referred to in the table above. This performance area is being closely monitored. A number of P Practice visits were conducted between March and June, targeting high referring Practices, which have a corresponding high numbers of patients not accepted for treatment: this was with a view to reducing inappropriate referral demand. 5 Other Mental Health Providers Contract monitoring meetings are in place for the other Mental Health providers, the two largest of which are Six Degrees and START: both are performing to the standards required by Salford Commissioners. A review is being undertaken of the services commissioned at Start in Salford to inform the future shape and delivery of the service and clarify and establish the expected outcomes of the service. There are no adverse issues that need to be raised in this report for any other third sector Mental Health contracts. NHS Salford CC: Mental Health Report July 2013 Page 6

7 QUALITY KPIs Detailed Report Appendix 1 National KPIs Indicator Threshold 2013/14 RA Comments Number of new cases of psychosis served by early intervention teams year to date % of inpatient admissions that have been gate-kept by CRHT Team % of people under adult mental illness specialties on CPA followed up within 7 days of discharge from psychiatric in-patient care Access to psychological therapies should be improved: increase in number of people who have completed treatment within the reporting quarter having attended at least two treatments People with LD disabilities and/or autistic spectrum conditions should be able to access mainstream services when necessary 95% of target 145% Is also a Monitor Indicator 95% 99% Is also a Monitor Indicator Operating standard of 95% 97% Is also a Monitor Indicator Rate of recovery higher than previous quarter until 50% recovery rate achieved, when achieved maintained Compliance with reen light Toolkit Requirements. Requirements as evidenced in the Annual Report 47% A task & Finish group is established. 50% is 2015 target Achieved Sleeping Accommodation Breach >0 Nil Breaches Failure to publish Formulary Yes/No The Trust Formulary has been agreed Duty of Candour Each failure to notify the Relevant Person of a suspected or actual Reportable Patient Safety Incident (per uidance) In progress A Duty of Candour Statement is currently being prepared reater Manchester KPIs Ref. Indicator Threshold 2013/14 RA Comments M1 VTE; RCA of all confirmed cases of PE/DVT acquired by service users whilst in hospital 100% N/A to MW Services M2 M3 M4 Issue discharge letters to service users P in accordance with timescales specified in locally agreed Transfer of Care Protocols. Format of discharge letters to be agreed locally Issue Discharge Summary (Notification of Discharge) to the service users P within 48 hours of inpatient treatments discharged from Provider premises Discharge summary agreed locally but must meet the Royal College of Ps standards as a minimum 95% 95% TBA locally 81% Discharge template is agreed. MW is working with colleagues across M to develop hub communication. Expected electronic communication in Salford by summer and Trafford & Bolton by Dec 13 Naming conventions discussed in Apr 13. Directorates renaming & standardising letters Template agreed as 12/13 CQUIN: MW leading piece of work across M to develop consistent MH Discharge NHS Salford CC: Mental Health Report July 2013 Page 7

8 Summary Ref. Indicator Threshold 2013/14 RA Comments Increasing early access for women 90% of patients N/A M5 to maternity services M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 Provider cancellation of new outpatient appointments Nutritional & weight assessment (HIA) undertaken within 5 days of admission and reviewed as clinically indicated for patients over 60 % of malnourished inpatients >60years who have a treatment plan agree with dietetics. Treatment plan must include the goals and review dates. All patients on wards with daily pharmacy visit should have medicines reconciled by a pharmacist/ pharmacy technician within an agreed timeline (3 working days) of admission All staff who have direct patient contact to receive basic level awareness training for dementia % of dementia patients whose discharge/transfer from hospital was completed within 48 hours of being deemed fit for discharge / transfer % of dementia patient case notes that have carer views recorded in them within Memory Service Teams only. % of complaints responded to within timescale negotiated with the complainant the response period SI 309, 2009 paragraph 13 (7) where appropriate. All Serious Incident (SI) investigations completed and issued to Commissioners < 45 working days from date of incident (60 days for homicides). Extensions to be agreed in writing with Salford CC All SI notified to Commissioners within 2 working days of provider being notified (but < 72 hours) All pressure ulcer grade 3 or 4 to be reported as SUI To comply with the SHA Safeguarding Standards Audit Toolkit (covers Adults & Children) Timeframes agreed locally for cancelling/ rebooking appointments 90% 90% 95% Minimum of 50% 95% minimum 100% 100% A A A A A Need to agree timeframes with commissioners for cancelling/ rebooking appointments Is part of admission process, STAR risk assessment used and the Trust is shortly to recruit 2 dieticians into post. 100% of service users are screened at admission. Not all services have support of dietician, hence Trust establishing its own dietetic service (in post end June 13) Work ongoing to improve data quality and frequency of reporting to enable more timely identification of new admissions and ensure outliers are identified and visited within 72 hour target Action plan in place. >80% staff has undertaken dementia awareness training. E-learning model developed. Data extraction for reporting figures is currently being developed A MATs task & finish group commences Q2. Audit will take place in Q4 On target to achieve Notification of incident in line with Salford CC. Detailed report to be presented to Quality roup in Sep 13 Achieved 100% No grade 3 / 4 pressure ulcers recorded 90%. Baseline & agree stretch targets with commissioners for indicators 2&3 Section 11 audits are completed in line with required timescale NHS Salford CC: Mental Health Report July 2013 Page 8

9 Local KPIs Ref. Indicator Threshold 2013/14 RA Comments L1 Improvement to services for people with mental health issues and Learning Disabilities L2 L3 L4 L5 L6 L7 L8 L9 L10 L11 Reduction in Psychiatric Readmissions for Organic patients Psychiatric Re-admissions for Functional patients Improving the physical health and wellbeing of inpatients Improving the physical health and wellbeing of patients. Inpatient Services Only Develop and agree a Performance Management Framework for the MATS (Memory Assessment Teams) Service Persons identified as belonging to a Vulnerable roup to have Care Plans tailored to their specific needs. To develop an effective strategy to elicit service user feedback in real time Review ALOS for Functional inpatients, all discharges Review ALOS for Organic inpatients, all discharges Outpatient DNAs to be kept at a minimum level MW defined action plan as part of the Health Economy response to the reen Light Toolkit (LT) All Directorates have Health Economy Action Plans to address requirements of the LT and ensure compliance with Monitor target Target <=2.2 Nil Target achieved Target <= This accounts for 19 readmissions out of a total of 172 admissions during April 13 All admitted inpatients to have a physical health check on admission. Includes LD. Recording smoking status of all patients accessing secondary care services, recording referrals to smoking cessation service/drug & alcohol treatment programme, reported as a proportion of secondary care service users who are smokers. Number of patients referred to smoking cessation service Audit tool to be agreed with commissioners. Baseline Agree % improvement on baseline Baseline Agree % improvement on baseline Baseline Agree target % 96% 86% All patients on admission to inpatient facilities have physical health check within first 24 hours of admission. Smoking status is recorded in the Trust s PHIT (Physical Health Improvement Tool) in first month of admission. Smoking status is recorded in the Trust s PHIT (Physical Health Improvement Tool) in first month of admission. An internal Audit found 78% of cases reviewed in-patients with a recorded disability do have their needs addressed in CPA Plans. An action plan is in place to monitor this. A Survey users every quarter. And uses video diaries. Trust is planning to expand further by introducing real time feedback via ipads Is subject to ongoing Director 33 review. April demonstrates improvement on 12/13 average LOS, of 38 days 86 Improvement on 12/13, average was 89 days, with a peak of 170 days mid-year. Work ongoing by Dementia ALOS roup 14.7 To date no targets have been identified by commissioners NHS Salford CC: Mental Health Report July 2013 Page 9

10 Ref. Indicator Threshold 2013/14 RA Comments L12 To develop good practice guidance re recording of information about children and caring responsibilities Revision of indicator has been discussed with commissioners and feedback is awaited TBC Awaiting commissioner feedback L13 L14 L15 L16 L17 L18 L19 Develop and agree a Performance Management Framework for MDO Service Commissioner requires discharge summaries to be sent within 10 working days of discharge In relation to risk management and risk assessment, the PCT will require assurances that all individuals have clear risk assessments and risk management plans in relation to Assertive Outreach and these are up-to-date and have appropriate reference to crisis management. The PCT will build this into performance management processes. IAPT Access Waiting times for service do not exceed 28 days from referral activation IAPT Data percentage of patients for whom the national IAPT minimum dataset is captured IAPT Quality percentage of patients for whom completion of a validated assessment tool is used to evaluate service impact up to 2 additional validated assessment tools for intervention IAPT Additional percentage of patients moving towards recovery 100% of all Assertive Outreach service users will have risk assessment and risk management plans in place [within agreed timeframe of accessing the service] which will be up to date and will reference appropriate crisis management. Current framework for the A MO:DEL Service being reviewed for suitability for rollout 87% Last year was 80%. 95% is a year-end target and a plan is in place to achieve this. All service users are in receipt of risk assessment and management plans and these are reviewed as part of CPA process and as required. All management plans include crisis management 100% Services are continuing 18% actions for reducing waiting times to ensure patients are offered first appointments within 4 weeks of referrals being received 90% 100 Achieved 80% 108 Achieved 50% 47% A task & finish group is established. 50% is the 2015 target. Current figure is up from 41% last year NHS Salford CC: Mental Health Report July 2013 Page 10

11 Appendix /14 CQUINs National and Regional CQUINs Indicator Comments National 1 NHS Safety Thermometer All data collected as required by the Nursing Quality & Leadership Team and submitted in accordance with the agreed schedule Regional 1 Advancing Quality - Dementia Due to AQ timescales 13/14 progress cannot be reported until Aug 13. The Trust is on track to achieve all targets for 12/13 Regional 2 Advancing Quality Psychosis Due to AQ timescales 13/14 progress cannot be reported until Aug 13. The Trust is on track to achieve all targets for 12/13 reater Manchester CQUINs Indicator Comments M 1 Avoidable admissions Dataset queries set up and ready to run at end of quarter. Dataset for 12/13 sent to Directorates to identify themes. Themes due to be finalised June 13 M 2 Transfers of Care: clinical peer reviews Areas of review to be agreed with Commissioners. Need to pick 2 areas. Suggestions are RAID (interface with Acute) & Lithium prescribing to build on 12/13 M 3 Transfers of Care: end of life Processes are being developed M 4 Transfers of Care: homelessness Protocols are being drafted M 5 M 6 M 7 Alcohol: identification of problematic alcohol use in agreed settings Academic Health Science Network: develop protocols to support Clozapine prescribing & patient care in Primary Care Academic Health Science Network: engagement Training implications are being scoped Protocols are being drafted The Executive link has been established M 8 Improving Dementia Care Plans are being finalised Local CQUINs Local 1 Local 2 Indicator Improving Dementia Care: AQuA dementia antipsychotic prescribing Improving Dementia Care: MATS Team, improving patient care & experience Comments The internal audit has been completed for April Processes are being developed Local 3 Recovery Baseline data is being collected Local 4 Local 5 Local 6 Improved communication on admission to hospital Physical Health Checks: community, hard to reach groups P Communication: Community Services Decision on how to record on ICIS reached in April 13. Meeting to discuss initial information due in May 13. Wording on Carer Leaflet agreed. Quarter 1 Action Plans include improving contact with carers within 72 hours Issue obtaining MHS Number from Ps to identify relevant clients. Solution currently being sought Naming conventions have been discussed during April 13. Directorates renaming and standardising letters NHS Salford CC: Mental Health Report July 2013 Page 11

12 Pre-Qualification Criteria Indicator 3 million lives: set a trajectory for 13/14 for increasing planned use of telehealth /telecare technologies International & commercial activity: demonstrate that clear plans are in place to exploit the value of commercial IP, either stand alone or in collaboration with AHSN Digital First: establish a 12/13 baseline and trajectory for improvement to reduce inappropriate face to face contact Carers for People with Dementia: demonstrate that plans are in place to ensure that for every person who is admitted to hospital where there is a diagnosis of dementia their carer is sign-posted to relevant advice and receives relevant information to help and support them Comments A baseline position was submitted to Commissioners at end of Q4 12/134 A position statement was submitted to Commissioners at end quarter 4 12/13. Subsequently the Trust has signed off its policy on Intellectual Policy. The Trust CEO is the nominated AHSN representative A position statement on the first 10 Digital First priorities was submitted at end of Q4 12/13. Details of priorities going forward are still under discussion with Commissioners Plans are in place to achieve quarter 1 milestones NHS Salford CC: Mental Health Report July 2013 Page 12