Quality and Efficiency Support Team (QuEST)
Directorate for Health Workforce and Performance
Efficiency and Productivity
Mental Health Pathway
Meeting the challenge - delivering
better quality care with less
resource
WELCOME
Quality and Efficiency Support Team (QuEST)
Directorate for Health Workforce and Performance
Efficiency and Productivity
Mental Health Pathway
The challenge ahead…
Ruth Glassborow, Mental Health Lead, QuEST
Mental Health – The Challenge
• One of the top public health challenges. Mental illness:
– affect more than a third of population each year
– second largest contributor to the burden of disease (19% of DALYs)
– account for just under 40% of years lived with disability
• Challenge of doing more with less:
– significantly undertreated but growing levels accessing treatment
– increasing prevalence of dementia
• Growing evidence of extra physical health costs associated
with mental illness
Reframing the Challenge
TACTICAL
STRATEGIC
PRODUCTIVITY &
EFFICIENCY
SERVICE
OPTIMISATION
CRES
DEALING WITH
THE 5%
TRANSFORMATION
SPENDING THE 95%
BETTER
Mental Health Efficiency and Productivity
What we set out to do…
• Key opportunities for productivity and
efficiency savings
• Assessment of productive opportunity
• Key actions to release productive
opportunity
• Additional work nationally to support
NHS Boards in realising productive
opportunity
Improving quality whilst reducing costs
Key Themes
• Evidence Based Care
• Removing unwarranted variation and waste
• Maximising the potential of the workforce
• Prevention of illness and relapse
• Self Management
• Co-production
• Involvement of families and communities
We recognise that not all variation is bad
and indeed some is good and necessary
What is going on in your system?
•Identify variation
•Understand the variation
•Act to reduce quality issues
Literature Review
Key
Productive
Opportunities
Expert Opinion
Stakeholder Opinion
Benchmarking Data
In addition the group highlighted Long Term Conditions and Mental Health, Better response to people with Borderline Personality Disorder,
Out of Area Admissions/Independent Contracting and Proactive Management of Medically Unexplained Symptoms as areas where further
work is needed to assess the productive opportunity and/or the key actions for releasing them.
Optimising the number of
psychiatric beds through effective
community services and
infrastructures
Inpatient/Community Balance
• Effective alternatives to inpatient admission and
facilitating early discharge
• Crisis prevention approaches including
targeting high risk groups for admission
Hypothesis - significant quality gains and efficiency
savings attached to preventing the crisis occurring in the
first place.
Inpatient/Community Balance
Figure 1a: Two-fold variation in bed days for all adult psychiatric admissions
Bed days per 100,000 population
Bed days per 100,000 NRAC adjusted population for all Adult Mental Health admissions by NHS
Board and Specialty 2009/10
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
NHS
Grampian
NHS Borders
NHS
Ay rshire &
Arran
NHS
Dumf ries &
Galloway
NHS Greater NHS Lothian NHS Tay side
Glasgow &
Cly de
NHS Forth
Valley
NHS
Highland
NHS Fif e
NHS Board
G1 - General Psychiatry
G4 - Psychiatry of Old Age
Scotland Total
NHS
Lanarkshire
NHS
Western
Isles
Inpatient/Community Balance
Five-fold variation in bed days for admissions with a primary diagnosis of
psychoactive substance misuse (including WI fifteen fold)
Bed days per 100,000 NRAC adjusted population for admissions with a primary
diagnosis of Psychoactive Substance Misuse by NHS Board 2009/10
Bed days per 100,000 Population
3000
2500
2000
1500
1000
500
0
NHS
Western
Isles
NHS
Grampian
NHS Fife
NHS
Borders
NHS
Lothian
NHS
Tayside
NHS
Dumfries &
Galloway
NHS
Highland
Health Board
Board
Scotland
NHS
Greater
Glasgow &
Clyde
NHS Forth
Valley
NHS
Ayrshire &
Arran
NHS
Lanarkshire
Inpatient/Community Balance
Five-fold variation in bed days for admissions with a primary diagnosis of
adult personality and behavioural disorder (including WI forty fold)
Bed days per 100,000 NRAC adjusted population for admissions with a primary
diagnosis of adult personality and behavioural disorders by NHS Board 2009/10
Bed days per 100,000 Population
1200
1000
800
600
400
200
0
NHS
Western
Isles
NHS
Grampian
NHS
Tayside
NHS
Lothian
NHS Fife
NHS
Highland
NHS
Borders
NHS
Lanarkshire
Health Board
Board
Scotland
NHS
Greater
Glasgow &
Clyde
NHS
Dumfries &
Galloway
NHS
Ayrshire &
Arran
NHS Forth
Valley
Inpatient/Community Balance
Ten-fold variation in length of stay for older people with psychosis
Average Length of Stay (days)
Average Length of Stay (days) for admissions with a primary diagnosis of psychosis in G4 Psychiatry of Old Age by NHS Board 2009/10
900
800
700
600
500
400
300
200
100
0
NHS Fife
NHS
Dumfries &
Gallow ay
NHS Forth
Valley
NHS
Grampian
NHS
NHS Lothian
Ayrshire &
Arran
NHS
Tayside
NHS
Western
Isles
NHS
Greater
Glasgow &
Clyde
NHS Board
G4 - Psychiatry of Old Age
Scotland G4 Total
NHS
Borders
NHS
Lanarkshire
NHS
Highland
Next steps nationally
• Coding of beds so can benchmark acute,
rehab, intensive care and continuing care
from April 2013.
• Mental Health Strategy, Commitment 23
– Core data set to allow comparison of different
crisis resolution/home treatment models
– Identify key components of crisis prevention
approaches
Effective and Efficient
Community Mental Health Services
Efficient and Effective CMHTs
• Reliable implementation of evidence based practice
• Effective Team Working (addition following recent
research)
• Reducing DNAs (and CNAs)
• Reducing unwarranted variation in new to follow-up ratios
• Reducing time spent on non-value adding activities
• Remove duplication of work between professionals, teams,
sectors and agencies
• Appropriate skill mix
• Better use of technology
Effective and Efficient
Community Mental Health Services
Nine-fold variation in DNAs as a % of new outpatient appointments for
General Psychiatry
DNAs as % of New Outpatient Appointments for General Psychiatry ( 2009/10)
Just new DNAs moving to mean represents approx £1million
productive opportunities across Scotland.
40.0
35.0
30.0
% DNAs
25.0
20.0
15.0
10.0
5.0
0.0
B o rders
Western
Isles
Grampian
Shetland
Islands
Fife
Orkney
Islands
Dumfries
and
Gallo way
A yrshire and
A rran
NHS Board
Lo thian
Tayside
Greater
Lanarkshire
Glasgo w and
Clyde
Highland
Fo rth Valley
Effective and Efficient
Community Mental Health Services
Seven-fold variation in DNAs as a % of new outpatient appointments
for Old Age Psychiatry
DNAs as % of New Outpatient Appointments for Psychiatry of Old Age (2009/10)
20.0
18.0
16.0
14.0
%DNAs
12.0
10.0
8.0
6.0
4.0
2.0
0.0
Borders
Grampian
Tayside
Lothian
Dumfries and
Gallow ay
Fife
NHS Board
Greater
Ayrshire and
Glasgow and
Arran
Clyde
Forth Valley
Lanarkshire
Highland
Effective and Efficient
Community Mental Health Services
Three-fold variation in ratio of new to returns for General Psychiatry
outpatient appointments
Return to New Ratio for General Psychiatry (2009/10)
12.0
8.0
6.0
4.0
2.0
Bo
rd
er
s
pi
an
ra
m
G
La
na
rk
sh
i re
ig
hl
an
d
H
Va
l le
y
Is
le
s
NHS Board
Fo
rth
an
d
sh
i re
Ay
r
W
es
te
rn
Ar
r
an
ly
de
C
an
d
Is
la
nd
s
la
sg
ow
re
at
er
G
G
s
um
fri
e
D
Sh
et
la
nd
an
d
G
al
lo
w
ay
Fi
fe
Lo
th
ia
n
Ta
ys
id
e
rk
ne
y
Is
la
nd
s
0.0
O
Return to New Ratio
10.0
Effective and Efficient
Community Mental Health Services
Five-fold variation in ratio of new to returns for Psychiatry of Old Age
outpatient appointments
Return to New Ratio for Psychiatry of Old Age (2009/10)
7.0
6.0
Return to New Ratio
5.0
4.0
3.0
2.0
1.0
0.0
Lothian
Lanarkshire
Dumf ries and
Gallow ay
Fif e
Greater
Glasgow and
Clyde
Ayrshire and
Arran
NHS Board
Grampian
Forth Valley
Borders
Highland
Tayside
Effective and Efficient
Community Mental Health Services
Indirect
Clinical
Role Agency
Tasks
Activity
Direct Clinical
Percentage of average hours per week by activity - All Charge Nurses
Individual Follow-up
Other
Assessment
1%
Case Review (inc. CPA)
Group Therapy 0%
Clinical Admin
45%
Other
Clinical Meeting Attendance
Telephone - other agency
Travel
29%
Meetings (non-clinical)
Training/CPD
2%
Supervision
1%
Other
14%
26%
0%
6%
5%
24%
10%
6%
5%
14%
7%
5%
5%
10%
15%
Percentage of Hours
20%
25%
Next steps nationally
• Effective and Efficient CMHT Toolkit –
prototype being launched today
• Database to reduce analytical time needed for
activity trackers
• Address quality of national staffing data
so have credible comparative info on costs
• Producing example set of Quality and
Productivity Reports (QDCAQ) for
Community Mental Health Services
Telehealth/Telecare
(Making better use of new (and not so new) technologies)
Telehealth/Telecare
• Video conferencing to improve access and
reduce travel
• Telephone/Webex to improve access & reduce
travel
• SMS Technology
• Better use of technology to streamline admin
processes
• Better use of new technologies for self
management, peer to peer support, self
assessment, self referral and co-delivery of care
Main barriers to adoption of telehealth/care
• Awareness of potential opportunities
• Set up costs
• Cultural barriers
Next steps nationally
• National telehealth/care strategy
• Project Ginsberg
Early detection and
intervention in psychosis
Early Detection and Intervention
in Psychosis
Five-fold variation in bed days for admissions with a
primary diagnosis of psychosis for individuals aged 18-24 years
Bed days per 100,000 NRAC adjusted population for admissions 18-24 years old with a primary
diagnosis of psychosis by NHS Board 2009/10
Bed days per 100,000
population
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
NHS Greater
NHS
Glasgow & Lanarkshire
Clyde
NHS
Grampian
NHS Lothian
NHS Fife
NHS Forth
Valley
NHS
Ayrshire &
Arran
NHS
Dumfries &
Gallow ay
NHS Board
NHS Board 18-24's
Scotland 18-24's
NHS
Borders
NHS Tayside
NHS
Highland
Next Steps
Mental Health Strategy Commitment
• Identify key components that need to be in
place within every mental health service to
enable early intervention services to
respond to first episode psychosis and
encourage adoption of first episode
psychosis teams where that is a sensible
option
Other Issues for Consideration
/Further Work
• Dementia in General Hospitals
• Long Term Conditions and Mental Health
co-morbid mental health problems raise total healthcare costs
by at least 45%
• Borderline personality disorder
• Out of area admissions and independent
contracting
• Proactive management of medically unexplained symptoms
• Mental Health Promotion/Prevention
This work made considerable use of
benchmarking data…
• Help to identify opportunities for improvement
rather than the basis of judgements
• Needs to be complimented by other techniques
• Assessing practice against evidence base
• Process mapping
• Service User Experiences
Benchmarking data – not just the
scorecard
• Even more indicators are included in the
toolkit.
• Summary of all the indicators on each
table and an example of the type of
information in the toolkit (which is in
addition to the scorecard)
Table Discussions
• Have you been/do you think you can use the NHS
Scotland Variation in Mental Health Activity report to
inform work locally?
• Do you ever use the national benchmarking scorecard
and/or toolkit?
• If your answer to either of the above is no, what needs to
change so you can use national benchmarking data?
• Do you have any insights into the reasons behind any of
the significant variation highlighted in the NHS Scotland
Variation in Mental Health Activity report?
• What additional national data would you find useful to
support you in identifying unwarranted variation and
waste locally?
• What work are you progressing locally around balanced
scorecards/dashboards which will help in identifying key
quality and efficiency opportunities?
Quality and Efficiency Support Team (QuEST)
Directorate for Health Workforce and Performance
Feedback
Quality and Efficiency Support Team (QuEST)
Directorate for Health Workforce and Performance
Efficiency and Productivity
Mental Health Pathway
Meeting the challenge - delivering
better quality care with less
resource
Quality and Efficiency Support Team (QuEST)
Directorate for Health Workforce and Performance
Efficiency and Productivity
Mental Health Pathway
Meeting the challenge - delivering
better quality care with less
resource
Quality and Efficiency Support Team (QuEST)
Directorate for Health Workforce and Performance
Efficiency and Productivity
Mental Health Pathway
Meeting the challenge - delivering
better quality care with less
resource
Quality and Efficiency Support Team (QuEST)
Directorate for Health Workforce and Performance
Efficiency and Productivity
Mental Health Pathway
Meeting the challenge - delivering
better quality care with less
resource
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Opening Presentation - Quality Improvement Hub