South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
Introduction
The Health Act 2009 requires all NHS organisations to publish an annual report of quality, so we are delighted
to introduce the Trust’s second annual quality report for 2009/10.
The purpose of the report is to enable the Trust to be more transparent and accountable for its performance,
to engage both our stakeholders and staff in improving the quality of the services we provide, and to
demonstrate real improvements in service quality. The Trust’s annual quality report will develop in line with
the Trust’s strategy to improve quality of all services over the next five years, and to develop comprehensive
measures of quality across the whole range of care.
The Trust has many initiatives which are designed to improve quality: these include the AQUIP programme to
improve the quality of in-patient care, and the productive ward programme which aims to release staff time so
that they spend more time delivering direct patient care. Since the first quality report last year, we have
significantly increased the measurement of service user satisfaction, and have improved the collection and
analysis of clinical outcome measures so that we are in a strong position to be able to use this information to
make improvements to the effectiveness of treatments and interventions.
In order for the quality report to evolve we will ensure that our priorities align with those of service users and
commissioners. Our four main commissioning PCTs, our Local Authority Overview and Scrutiny Committees and
Local Involvement Networks have all been invited to comment on the report. Their comments are included in
section 10. The Foundation Trust’s Members Council have also contributed to this report. Quality accounts have
featured on the agenda of the Trust’s Partnership Time Events, where services users and carer’s representatives
have taken the opportunity to express their views on the form and content of this quality report. Indicators of
the quality of staff behaviour and interaction, measures of recovery and quality of life, and outcomes of care and
treatment are all seen as important issues. We have tried to include these in this report.
The current development of Clinical Academic Groups as part of our involvement in Kings Health Partners
presents an excellent opportunity to better define the interventions and quality of care that patients should
receive throughout their pathway through our services.
This quality report reflects our determination to develop our understanding and measurement of quality as
experienced by users of our services, and our ambition to deliver continuous quality improvement in all our
services. To our best knowledge the information presented in this report is accurate. We hope you will find it
enlightening and stimulating.
Madeliene Long
Chair
Stuart Bell
Chief Executive
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
3
Contents
Page
Part 1.
How we performed in 2009/2010
1. Performance against National targets and the CQC Annual Health Check
2. Data quality
11
3. Performance against the key priorities for improvement set for 2009/2010
13
Patient Safety
Patient Experience
■ Clinical Effectiveness
13
15
17
■
■
Part 2.
7
4. A review of performance against CQUIN targets
23
5. Quality initiatives in the Trust during 2009/2010
25
6. A response to issues raised by patients and carers, regulators and commissioners
27
7. Research, innovation, and audit
29
Looking forward to 2010/2011
8. Quality priorities for 2010/2011
33
9. Quality indicators for 2010/2011
37
Part 3. Commentary from commissioners and partners
10. Statements from PCTs, OSCs, and LINks
South London and Maudsley NHS Foundation Trust
38
Quality Report 2009/2010
5
Part 1. How we performed in 2009/2010
1. Performance against the Care Quality Commission (CQC) annual health check,
national targets, and the national staff and patients surveys
The CQC is the independent regulator of health and adult social care in England. The CQC assesses and
inspects organisations like South London and Maudsley NHS Foundation Trust (SLaM) to make sure that we
provide high quality care to patients. The CQC also monitors the care of people whose rights are restricted
under the Mental Health Act 1983 (MHA) to make sure that they are protected.
CQC Annual Health Check rating
SLaM’s performance over the previous three years is as follows:
Year
2006/2007
2007/2008
2008/2009
Use of financial resources
Excellent
Excellent
Excellent
Quality of services
Good
Excellent
Good
There are two reasons why we achieved a rating of ‘good’ for quality of services rather than ‘excellent’.
The first issue which affected our rating was the self-assessment we were required to undertake in April 2009
about access to and provision of learning disabilities services. We assessed ourselves as ‘amber’ in 11 out of the
12 areas and we assessed ourselves as ‘red’ in one area - having integrated workforce strategies in place with Local Authorities (LA) and Primary Care Trusts (PCT). We have now addressed all the issues which arose from
our self-assessment. Secondly, we under achieved in one area of the Mental Health Minimum Data Set
(MHMDS) – the basic set of information about care and treatment that all NHS mental health Trusts are
required to collate and maintain.
We were one of five, of the ten London mental health Trusts to receive a rating of ‘good’ for quality of services.
Three trusts were rated ‘excellent’ and two rated ‘weak’. Nationally, across all acute and mental health trusts,
58 were assessed as ‘excellent’, 186 were assessed as ‘good’, 128 assessed as ‘fair’ and 20 assessed as ‘weak’.
National Patient Survey - 2010 National Community Patient Survey
The 2010 National Community Patient Survey took place during January to April, 2010. The survey was sent
to a random sample of service users from all Mental Health Trusts in England. The survey sample included
service users aged 16 years or older who received services under the Care Programme Approach from 1st July
to 30th September, 2009. This year a total of 233 SLaM service users responded from a sample size of 850.
Following the previous National Community Patient Survey in 2008, the SLaM’s Patient Experience Group
(chaired by the Medical Director with representation from service users) identified three Trust patient experience
priorities; care plans, information and crisis contact numbers. Each Directorate was asked to respond to these
areas through the implementation of action plans.
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
7
Actions include care plan audits to establish the quality and level of involvement of service users in devising care
plans, increased information regarding the purpose of care plans, establishment of pharmacy sessions for service
users and carers, and in-depth reviews of crisis information and leaflets.
Care plans – provision of care plans to all service users and involvement of service users in the care planning
process. 30% of respondents said that they had been given a copy of their care plan in the last year,
82% said their views had been taken into account in the care plan.
Information – provision of information regarding medication, its side effects and employment and support
opportunities. 95% of respondents said they had been told the purpose of their medication, 69% said they
had been told about the possible side effects of their medication.
Crisis – individualised crisis information including provision of an out of hours support number. Only 33% of
respondents said they had an out of hours contact number for use in a crisis.
The 2010 results demonstrate an improvement in a number of these key areas, and further work to do in others.
We will continue to work alongside service users to ensure quality improvements in the above areas
Patient survey - Overall Rating of Trust Services
2004
2005
2006
2007
2008
2009
In-patient
2010
Excellent
20%
22%
23%
20%
18%
18%
27%
Very Good
26%
28%
26%
27%
31%
22%
33%
Good
26%
24%
23%
20%
23%
24%
21%
Fair
18%
15%
16%
19%
18%
19%
8%
Poor
4%
7%
8%
7%
7%
16%
5%
Very Poor
6%
5%
4%
7%
4%
1%
6%
Headline Finding: 81% of people rated services as good, very good or excellent in 2010 (compared to 72%
in 2008). Note: In 2009 in-patients were surveyed, all other years, patients in the community.
8
Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
CQC Indicators 2009/2010
The CQC assesses the Trust against a list of published indicators which link to existing commitments and national
priorities within the periodic review 2009/2010. They include:
CQC Indicators 2009/2010
CQC
SLaM results
2008/2009
CQC
National
Averages
2008/2009
SLaM
Performance
2009/2010
Target
1
Access to crisis resolution home treatment (HTT)
98.5%
94.1%
97.2%
90%
2
Care Programme Approach - 7 day follow-up
96.6%
96.9%
98.5%
95%
3
Drug users in effective treatment
86.5%
86%
85%
-
Access to Crisis Resolution Home Treatment (Home Treatment Team)
Home treatment teams provide intensive support for people in mental health crises in their own home: they
stay involved until the problem is resolved. Home Treatment is designed to provide prompt and effective home
treatment, including medication, in order to prevent hospital admissions and give support to informal carers.
The numerator here is the number of admissions to the trust’s acute wards (excluding admissions to psychiatric
intensive care units) that were gate kept by the crisis resolution home treatment teams, the denominator
being all admissions.
Care Programme Approach (CPA) 7 day follow up
Follow up within seven days of discharge from hospital has been demonstrated to be an effective way of
reducing the overall rate of death by suicide in the UK. All patients on the care programme approach (CPA)
who are discharged from a spell of inpatient care should be seen within seven days.
Number of Drug Users in Effective Treatment (Drug misuse: 12 week effectiveness)
The percentage of drug users who were retained in treatment for 12 weeks or more, indicates the effectiveness
of the local treatment system in engaging drug users and minimising early drop out. Evidence suggests that
drug treatment is more likely to be effective if clients are retained in treatment for 12 weeks or more, reducing
drug use, reducing morbidity and mortality associated with misuse, reducing crime and improving health and
social functioning. Benefits include substantial financial savings in both the criminal justice system through
reduced offending and in the NHS through reduction in blood-borne diseases amongst drug users.
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
9
2. Data quality
The Trust submitted records to the CQC during 2009/10 for inclusion in the Hospital Episode Statistics and
Minimum dataset; these are included in the latest published data. The Trust has prioritised data quality over
the last year and achieved significant progress in the completeness and accuracy of the key data quality items.
The table below shows continuing improvements in the recording of ethnicity, GP coding, NHS number
and postcode.
Data Quality
100
80
Q1 %
60
Q2 %
40
Q3 %
20
Q4 %
0
Ethnicity
GP Code
NHS No
Diagnosis
Post code
Fig: CPA register – Data Quality Improvements 2009/2010
Data quality and Information Governance Toolkit attainment level
The Information Governance Toolkit is an annual national self-assessment procedure overseen by the NHS
Connecting for Health. The toolkit provides assurance in relation to the Trust’s compliance with the information
governance standards in six key areas covering information governance management, confidentiality and data
protection, clinical information, corporate information, secondary uses and information security. The Trust scores
for this year’s toolkit (version 7), which were independently audited, are at Level 2 or 3 (out of 3) for all standards
for 2009-2011, which represents 90% compliance.
The Trust was not subject to the Audit Commission’s Payment by Results clinical coding audit during the
reporting period.
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
11
3. Performance against the quality priorities
set for 2009/2010
In the 2008/2009 quality report we identified the following as quality priorities for the Trust in 2009/2010:
3.1 Patient Safety
Medication safety was identified as the patient safety priority for 2009/2010. Although our rate of reported
medication incidents had been comparable with other Trusts, we recognised that medication transaction
errors have the potential to have catastrophic effects for individual patients, and is preventable. Our goal for
2009/2010 was to reduce the number of untoward incidents involving the prescribing, dispensing and
administration of medication. That number has fallen significantly and can be seen below.
Patient Safety Indicator – PSI 3.
Number of reported medication prescribing/administration incidents [all grades of severity].
Year
E
D
C
B
A
Total
2008/2009
126
102
272
0
1
501
2009/2010
82
83
240
1
0
406
‘A’ grade incidents are those resulting in death, ‘E’ grade incidents result in no harm.
A number of specific work streams were identified as being key to reducing the risks of medication error.
■
E-prescribing uses the electronic patient records systems to generate prescriptions, this reduces errors and
omissions. There have been delays in starting this project. A six week pilot is planned for the end of
April 2010. If successful, a Trust-wide rollout programme will follow.
■
Participation in the Health Foundation’s national patient safety programme. The DB2 ward team at the
Maudsley have focussed on improving medication safety using various improvement techniques.
Improvements in, interruptions to medication administration, missed doses, checking drug charts, and
medication reconciliation on admission have all been measured. We plan to spread the learning from this
initiative to other in-patient units in 2010/2011.
■
Analysis of all medication errors, is a quarterly activity for the Medicines Management Committee (MMC),
Clinical Risk Committee and pharmacy review. Findings and lessons learned are disseminated through local
governance committees and the medicines bulletin.
■
Implementation of all relevant National Patient Safety Agency (NPSA) pharmaceutical alert bulletins.
Alerts are reviewed in the Trust’s medicines management committee. Recommendations are included in
the Trust medicines management bulletin.
■
Participation in the POMH-UK prescribing audits. POMH-UK is the prescribing observatory for mental health
which administers a number of annual national prescribing audits [see section 7 for full list]. POMH-UK audit
findings are fed back to prescribing clinicians in summary form, with recommendations on prescribing practice.
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
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Other Patient Safety Indicators
PSI1. Comparison between serious patient safety incidents [graded A, B and C severity].
Incidents are graded for severity using outcome criteria in the categories of injury [or death], service continuity,
statutory compliance. Using the injury outcome criteria; ‘A’ grade incidents are those resulting in death, ‘B’ are
those requiring immediate hospital admission, ‘C’ are those resulting in medical treatment or three or more days
sick leave - ‘D’ minor injury, ‘E’ no injury reported].
2007/2008
2008/2009
2009/2010
Attempted suicide - in-patient
37
24
42
Attempted suicide - community
26
33
34
Suspected/actual suicide - in-patient1
0
0
1
Suspected/actual suicide – community1
42
23
38
Self Harm2
42
49
46
Patient falls
25
41
36
Table: showing serious patient safety incidents - last three years
1 For statistical purposes including coroners’ verdicts of ‘Suicide’, ’Took own life whilst balance of mind
disturbed’, also ‘Open’, ‘Narrative’ and unknown verdicts where fatal actions appear to have
been patients’ own.
2 Excludes incidents reported from the Crisis Recovery Unit.
PS5. Health Care Acquired Infection rates – Clostridium Difficile, and MRSA.
Clostridium Difficile, is the most important cause of hospital-acquired diarrhoea and is an anaerobic bacterium
that is present in the gut of up to 3% of healthy adults and 66% of infants.
MRSA are varieties of Staphylococcus Aureus that have developed resistance to Methicillin and some other
antibiotics that are used to treat infection.
Table: PSI4. Health care acquired infection rates C. Diff and MRSA.
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
2009/2010
MRSA*
0
0
0
1
1
0
1
1
1
1
0
0
C. diff
2
0
0
0
0
0
0
0
0
0
0
0
2008/2009
MRSA*
1
1
0
1
0
0
1
0
1
0
0
1
C. diff
2
0
0
0
0
0
0
0
0
0
0
0
* There were no cases of bacterium or blood born infection with MRSA, all were cultured from localised swab
samples. The majority of these cases of MRSA were identified before the patient was transferred into the Trust
from other services.
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Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
3.2 Patient experience
The experience and satisfaction of people who use our services is central to our approach to quality
measurement. We recognise that a range of different approaches are required appropriate to the different
services in the Trust and the communication abilities of people who use these services. The most important
thing about collecting feedback is that we listen to it, reflect upon it and do something with it.
Regular monitoring of patient experience data allows the Trust to identify areas where patient satisfaction is
low and put in place plans to improve performance based on patient feedback. At present, SLaM has two
Trust-wide tools that allow for patient feedback to be captured: the Patient Experience Data Intelligence
Centre (PEDIC), and the Patient Experience Tracker (PET).
PEDIC, provided in partnership with Fr3dom Health, is a system that provides a centralised approach to
collating patient experience data. The hub of PEDIC is its online data centre that integrates both internal and
external survey data. PEDIC has a range of interfaces including electronic handheld PDA devices, online surveys
and paper surveys. It enables us to collect the views of otherwise hard to reach groups through the display
of questions in five different languages, iconography, audio and video. PEDIC devices allow for qualitative
experiences of service users to be captured by either them speaking into the device or by inputting their
comments on a keyboard.
Patient Experience - Progress report.
During 2009/2010, we successfully piloted our Patient Experience Data Intelligence Centre (PEDIC) in over 80
teams across the Trust, including Southwark, Psychology, Productive Wards and CAMHS. PEDIC data contributes
to the patient experience score summaries on section 3. Additionally, we have continued to work with service
users and staff in other teams across the Trust to develop patient satisfaction surveys. This work includes
partnership working with service user voluntary organisations across our four geographical boroughs as well
as the involvement of service user interviewers.
Other patient experience development in 2009/2010 have included:
■
mapping patient experience metrics and activities across all of our teams to ensure routine involvement of
service users and carers and to embed, build upon and share best practice of engagement
■
continuation of ‘Partnership Time Events’ (PTEs) to inform and seek the views of service users, carers and the
wider public regarding the development of Clinical Academic Groups (CAGs), care pathways and the quality
accounts. We held three PTEs in 2009/2010, which attracted over 150 participants
■
development of a Trust-wide patient experience strategic framework and review and update of our Patient
and Public Involvement Strategy.
The following pie charts illustrate the results of amalgamated responses from all services surveyed over the year
to the core five questions:
1. How well was your treatment explained to you?
2. How successful is the team in helping you achieve what you want in your life?
3. How well does the environment of the buildings meet your needs?
4. How well do you trust the people providing your care?
5
Ho w well have staff listened to you today?
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
15
Treatment Explanation
7%
9%
49%
Very well
PEI 1.
To some extent
2008 SLaM Patient Survey result:
57% Yes definitely
29% Yes to some extent
Not at all
35%
Not stated/Don’t know
Source: Amalgamated data from PEDIC surveys, April 2009-2010
Sample size: 201 respondents
Staff Support and Effectiveness
12%
6%
53%
29%
Very successful
To some extent
Not at all
Not stated/Don’t know
PEI 2.
No comparable data from 2008/09
Source: Amalgamated data from PEDIC surveys, April 2009-2010
Sample size: 495 respondents
Environment and Furnishings
14%
1%
53%
32%
Very well
To some extent
Not at all
Not stated/Don’t know
PEI 3.
No comparable data from 2008/09
Source: Amalgamated data from PEDIC surveys, April 2009-2010.
Sample size: 220 respondents
Trust of Staff Team
7%
7%
Very well
To some extent
27%
59%
Not at all
Not stated/Don’t know
Source: Amalgamated data from PEDIC surveys, April 2009-2010
Sample size: 291 respondents
PEI 4.
2008 SlaM survey result:
63% Yes definitely
28% To some extent
[Question: Did you have trust and
confidence in the last person you saw?]
Staff Team Listening
3%
2%
16%
79%
Very well
PEI5.
To some extent
2008 SlaM survey result:
73% Yes definitely
22% To some extent
Not at all
Not stated/Don’t know
Source: Amalgamated data from PEDIC surveys, April 2009
2010 Sample size: 496 respondents
Caution: Comparisons with data from different patient experience surveys need to factor in the variation in the
way that questions are phrased in different surveys. PEDIC groups responses to similar survey questions, however
the questions may not be identical.
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Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
3.3 Clinical Effectiveness
Our clinical effectiveness priority in 2009/2010 was to focus on the collection and use of outcome measures
across all services. We made a pledge to:
■
Work to embed the recording of outcome measures in all services and increase the percentages of collection,
in services where routine collection is established
■
Focus on the use and analysis of outcome measures to enhance clinical practice, in reflective practice
and clinical team meetings. Using analysis to enhance effective practice and discard ineffective practice
■
Establish the use the Childrens Global Assessment Score (CGAS) outcome measure within Child and
Adolescent services at assessment, discharge and six monthly intervals where appropriate
■
Develop the programme of psychological therapy outcome measures (CORE-OM) data analysis and feedback
reports to each service, and develop our ability to benchmark internally, comparing the results of different
services. This will support services to make changes on the basis of analysis of factors that might result in
different outcomes
■
Encourage the sharing of outcomes data with stakeholders
Progress in 2009/2010.
Considerable progress has been made over the year in the collection of clinical outcome data in most services.
The use of data for comparing performance, and service improvement is beginning to gain momentum,
indicators show improvements in the completion of paired outcomes scores and the effect size which
demonstrates the degree to which patients are improving following treatment or intervention.
There are three principal outcomes score used in the Trust. They are;
■
HoNOS - Health of the National Outcome Scales for adult and older adult services
■
CGAS - Child Global Assessment Score for child and adolescent services
■
CORE-OM - Clinical Outcomes in Routine Evaluation Outcome Measure for psychological therapies
HoNOS
HoNOS contain 12 scales which are used to estimate severity in a range of problems that commonly affect
people with severe mental illness. The scales are sometimes grouped into four domains and provide a broad
view of health need and social functioning. The scales are rated 0-4 in severity. The crudest measures of
outcomes are paired scores; two total scores for the same patient, one scored at the start of an episode of
care and a second at a later point, usually the end of an episode with the same team.
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
17
The table and chart below show the steady increase in the numbers of paired HoNOS total scores being
collected. Strategies are being put in place to improve performance on this. When reports by care spell are
available performance is likely to increase by 10-15%. The Trust is also working on different ways to motivate
staff to see the collection and reporting of HoNOS as a priority.
CEI 1. The table below shows the percentage of paired scores completed of all eligible patients
in adult service by quarter over the past two years 2008/09 and 2009/10.
Q1
08/09
Q2
08/09
Q3
08/09
Q4
08/09
Q1
09/10
Q2
09/10
Q3
09/10
Q4
09/10
Eligible Patients
21493
24003
25125
26748
30079
30046
29997
31155
Paired HoNOS
3707
5109
6511
7884
12308
12759
13318
14055
Target %
40.0%
40.0%
40.0%
40.0%
60.0%
60.0%
60.0%
60.0%
Achieved %
Paired HoNOS
17.2%
21.3%
25.9%
29.5%
40.9%
42.5%
44.4%
45.1%
Target
70.0%
Paired HoNOS
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Chart: Paired HoNOS scores against target for 2008/09 and 2009/10 [adult services]
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Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
The table below shows the mean shift in total scores (patient improvement) for different service types.
With this scale a lower second score indicates overall improvement of the aggregated sample. The mean shift
gives an indication of service user recovery in large aggregated data samples across Trust clinical services. These
samples are not yet fully representative of the work of all clinical teams but do provide a baseline view of clinical
effectiveness for reference in future years.
Service Type
Number in
sample
Mean starting
HoNOS score
Mean second
HoNOS score
Mean
shift
Psychiatric Intensive Care Unit - PICU
273
15.64
9.1
-6.5
Support and Recovery [at crisis review]
85
16.7
10.2
-6.5
Acute in-patients
549
12.97
7.14
-5.8
Inpatients with depression
448
13.64
8.02
-5.6
Assessment Teams (community)
1123
10.8
6.2
-4.6
Home Treatment Teams
2472
11.01
6.82
-4.2
Street homeless with mental illness
116
16
12.7
-3.3
Early intervention in psychosis
115
9.9
8.8
-1.1
Assertive Outreach
301
11.0
10.0
-1.0
Support & Recovery team
1468
9.1
8.6
-0.5
CEI 5. Table: Aggregated mean paired HoNOS total score change [adult services]
Current developments will ensure that outcome data samples increase and become fully representative of all
treatment episodes for all adult and older adult services.
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
19
CGAS
CGAS is a numeric scale (1 to 100) used by mental health clinicians to rate the general functioning of children
under the age of 18. The broad score intepretation is as follows:
100-91
90-81
80-71
70-61
60-51
50-41
40-31
30-21
20-11
10-1
Superior functioning in all areas
Good functioning in all areas
Slight impairments
Some difficulty in a single area but generally functioning well
Variable functioning with sporadic difficulties
Moderate degree of interference in functioning in most social
areas or severe impairment of functioning in one area,
Major impairment of functioning in several areas
Unable to function in almost all
Needs considerable supervision to prevent hurting others or self
Needs constant supervision (24-hour care)
Improvement
in functioning
In 2009/2010 30% of eligible cases (1,952 out of 6,229) had at least a paired CGAS during 2009/10 which is
recorded at initial assessment, 6 monthly and at case closure. It’s important to note that 30% recording is a
significant achievement considering the stage of implementation. The target for paired CGAS in 2010/11
is 75% which will enable a more representative analysis of outcome measurement across CAMHS services.
The first and last CGAS in the team episode for eligible cases was compared. A paired sample test
was completed (this is a statistical test) and this indicated that there was a statistically significant change
within the sample.
The table below shows the mean first and last score across CAMHS services in the aggregated data sample.
On this scale a high score indicates improvements.
Service Type
Score 1
Last Score
Tier 4 outpatient
Mean
N
53.35
269
69.13
269
Tier 4 inpatient
Mean
N
34.58
73
54.64
73
Tier 3
Mean
N
52.77
1207
60.4
1207
Tier 2
Mean
N
61.04
363
67.88
363
Total
Mean
N
53.73
1912
62.83
1912
Tier 4.
These are essential tertiary level services
for children and young people with the most
serious problems, such as day units, highly
specialised outpatient teams and in-patient units.
Tier 3.
This is usually a multi-disciplinary team
or service working in a community mental health
clinic or child psychiatry outpatient service, providing
a specialised service for children and young people
with more severe, complex and persistent disorders.
Tier 2.
Practitioners at this level tend to be CAMHS
specialists working in community and primary care
settings in a uni-disciplinary way (although many
will also work as part of Tier 3 services).
CEI 7: CGAS changes in paired scores
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Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
CORE-OM
The CORE-OM is administered routinely to all clients seen by psychology services or by psychological therapists
working in multi-disciplinary teams (MDTs). As of 31 March 2010, for working age adults, 5329 clients had
at least one valid CORE-OM entered onto ePJS, with 1395 providing paired ratings (a CORE-OM pre- and
post-therapy). The effect of therapy was statistically significant, and moderate in size (see Table). 55% of
clients with clinically significant pre-therapy scores demonstrated reliable improvement between their preand post-therapy CORE-OM Global Distress scores (see Table 2); 40% showed ‘clinical recovery’, moving from
a ‘clinical’ to a ‘non-clinical’ category following therapy (see Table 3).
For older adults, 1040 clients had at least one valid CORE-OM entered onto ePJS, with 436 providing paired
ratings. The effect of therapy was statistically significant, and moderate in size (see Table 1). 47% of clients
with clinically significant pre-therapy scores demonstrated reliable improvement between their pre- and
post-therapy CORE-OM Global Distress scores (see Table 2); 43% showed clinical recovery (see Table 3).
Table. CEI 6. Mean Global Distress scores, pre- and post-therapy
Pre-therapy Global
Distress score
Post-therapy Global
Distress score
Effect
Size*
Working Age Adults
(N = 1395)
1.85 (SD 0.74)
1.32 (SD 0.76)
0.72
Older Adults
(N = 436)
1.44 (SD 0.62)
1.00 (SD 0.60)
0.71
*An effect size is a standard way of reporting significant treatment effects (which takes account of the variability
occurring naturally in the population) – there are conventions for determining effect size (0.2 and above is
indicative of a small effect, 0.5 a medium and 0.8 a large effect size (Cohen 1992).
Table 2 – Reliable change in CORE-OM Global Distress scores between pre- and post-therapy (for clients with
clinically significant pre-therapy scores)
Working Age
Change
MHOA
Number
Percent
Number
Percent
Reliable Improvement
594
55.4%
157
47.3%
Non-reliable Improvement
311
29.0%
129
38.9%
Non-reliable deterioration
147
13.7%
41
12.3%
Reliable deterioration
21
2.0%
5
1.5%
1073
100%
332
100%
Total
To summarise, the results demonstrate that, for those individuals assessed using the CORE-OM, psychological
therapies delivered in SLaM are effective in both adults and older adults, with a moderate effect size.
Approximately half of those assessed showed reliable improvement, with 40% showing recovery
i.e. moving from scores typical of a clinical population to those typical of a non-clinical population.
These findings are extremely encouraging, viewed in the context of therapy occurring in secondary care
settings where clients predominantly have severe and long-term conditions.
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
21
4. Performance against 2009/2010 CQUINs
The DH document High Quality Care for All included a commitment to make a proportion of providers’ income
conditional on quality and innovation through the Commissioning for Quality and Innovation [CQUIN] payment
framework. Goals were agreed with Lambeth, Southwark, Lewisham and Croydon PCTs and London Specialist
Commissioning Group through the Commissioning for Quality and Innovation payment framework.
A proportion of Trust income in 2009/2010 was conditional on achieving quality improvement and innovation
goals agreed between SLaM and commissioning PCTs that we entered into contracts for the provision of NHS
services, through the CQUIN framework.
Further details of the agreed goals for 2009/2010 and for the following 12 month period are available on
request from the Trust’s performance and contracts team at Tabard House, Guys Hospital, London SE1 9RT.
4.1 CQUIN Patient Safety – Serious Untoward Incidents
The levels of reported incident of violence and aggression across Trust services have increased.
For this reason, the Trust has made violence and aggression a quality priority for next year.
See page 33 - quality priorities for 2010/2011.
4.2 CQUIN Delayed discharges
Information on delayed discharges can highlight areas of blockage and gaps, which the commissioner and
provider can jointly review and implement appropriate changes. The Trust has made good progress on this,
particularly in Lambeth. The directorate agreed a protocol for signing off all delayed transfers of care and have
seen an overall improvement on previous weeks through regular monitoring of manual reporting systems.
Table: Delayed Discharges 1 April 2009 – 25 March 2010
Delays in
period
Days Lost
in period
OBDs in
period
% Days lost
in period
Discharges
in period
Discharges
that were
delayed
in period
% Discharges
that were
delayed
in period
Croydon
2
78
27,111
0.3%
659
1
0.2%
Lambeth
14
872
34,405
2.5%
890
15
1.7%
Lewisham
0
0
30,663
0.0%
776
0
0.0%
MHOA
27
1906
31,870
6.0%
304
24
7.9%
Southwark
6
557
36,798
1.5%
821
6
0.7%
Specialist
0
0
58,516
0.0%
1007
0
0.0%
Total:
49
3413
219,363
1.6%
4457
46
1.0%
Directorate
MHOA - There are delays with service users waiting for places to become available in care homes and
continuing care beds in Lambeth Southwark and Lewisham. The Trust is addressing this problem with
commissioning PCTs. There are also placement issues for those patients who are no longer fit to return home
without support which requires a reliance on social services, housing and other partner agencies. Individual case
conferences are arranged to attempt to resolve obstacles. The directorate has instigated a fortnightly discharge
group which includes action planning around delayed discharges.
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
23
4.3 CQUIN Recording of HoNOS Scores
See pages 18, and 19.
4.4 CQUIN Equality monitoring reports
SLaM has regularly provided commissioners with monthly ethnicity data (both in-patients and out-patients) by
borough for the last six months. The Trust will continue to develop these reports and move towards the creation
of comprehensive data sets for age, gender, disability, religion and sexual orientation. The overall intention is
to ensure that disability, sexual orientation, race, ethnicity, gender, age, religion, socio-economic class does not
hinder users being able to access and benefit from services and to ensure that all service users accessing services
receive equitable treatment
4.5 CQUIN Patient experience
See page 24.
24
Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
5. Quality initiatives
The Trust has many active quality improvement initiatives, both large and small scale.
These are some of them:
Accreditation for Acute Inpatient Mental Health Services (AIMS) for adult acute and older people
in-patients wards (AIMSAA and AIMSOP)
AIMS is an initiative from the Royal College of Psychiatrists which, along with other professional groups and
services users, devised the standards required to achieve accreditation. These cover five areas: environment;
safety; admission and discharge; therapeutic interventions; health and safety. Service users are involved in the
assessment process.
The last wards in the AIMS project for Acute and Older People’s wards have been enrolled onto the programme
and will commence self assessment in June 2010. AIMSOP [AIMS for older people’s services] commenced in the
Trust in October 2009 and three wards are currently in the review stage. The outcome of their peer reviews will
be announced in summer 2010. To date, nine out of the twelve wards that have completed the accreditation
cycle, have been accredited, three with excellence. Two were deferred for a period of three months to improve
on some of the mandatory standards.
Releasing Time to Care (RTTC) – Productive Services Programme
This initiative aims to empower staff to drive quality improvements by improving the efficiency of ward systems
and processes so that staff can spend more time with services users. Areas covered include safety and reliability
of care, carer satisfaction and staff wellbeing.
Twenty of our 65 wards are currently involved in the RTTC project and all services are now represented.
New cohorts of wards are recruited every six months and improvement facilitators work with teams during the
foundation modules and the first process module. It is expected that after this intensive support, teams will
be familiar with the tools and the methodology and will be able to proceed with the project with
minimum support.
Nursing Practice Assurance Assessments
This year, all community and inpatient teams were subject to the annual nursing [and other professions] practice
assurance assessment. Assessments are conducted by a team of senior nurses who assess practice across a wide
range of indicators, including safety and security; professional standards; policy implementation, record keeping
and medication management. These assessments provide a rich source of information of the quality of each
service and this material is used to identify both good practice and areas where improvement is required.
Actions plan for improvement are agreed with senior nursing staff who conduct the assessments.
Practice Assurance Visits were undertaken to all inpatient wards and community services during a four week
period between January and February 2010. The inpatient visits were conducted by the senior nursing team led
by the Director of Nursing and Education. The community visits were lead by Nurse Advisors and accompanied
by specialist nurses.
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
25
Physical
Healthcare
Medication
Management
Care Planning
& Care Provision
Risk, Safety
& Security
Information
& Communication
Professional
Standards
Service
Innovation
Total
mean Scores
2010
Community
87%
80%
95%
81%
91%
97%
76%
96%
77%
87%
2010
In-patient
85%
74%
93%
81%
87%
96%
72%
96%
70%
84%
2008/09
Community
79%
86%
94%
90%
93%
78%
80%
94%
69%
84%
Workforce
Policy
Implementation
The overall inpatient Trust scores showed an improvement from 77% in 2007, 84% in 2008 and 87% in 2010.
A breakdown of the inpatient scores 2008 compared to 2010 is shown in the table below.
Table: Nursing Practice Assessment In-patient scores [Green = >85%]
The fall in scores for physical health care, care planning and provision and professional standards can in part be
explained by more rigorous scrutiny of the quality of recording in the areas of involving patients in their care
planning, health assessments and observations, and clinical supervision.
26
Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
6. A response to issues raised by regulators
and commissioners
Information relating to registration with the Care Quality Commission (CQC) and
periodic/special reviews
The South London and Maudsley NHS Foundation Trust achieved registration for all of its services with the CQC
from 1st April 2010, without compliance conditions.
The CQC has not taken any enforcement action against the Trust during 2009/2010.
The Trust has not been subject to CQC special review during 2009/2010.
Safeguarding the rights of patients detained under the Mental Health Act (MHA)
The CQC regularly visits all services which detain people under the Mental Health Act 1983. In a presentation of
their annual Mental Health Act report to the Board of Directors in March 2010, the CQC praised the quality of
leadership and administration relating to the Mental Health Act within the Trust, and its commitment to ensuring
that detained patients’ rights were properly respected. The development of River House, the funding of Black
History Month, the accreditation to become an Academic Health Sciences Centre, and a continuing commitment
to improving services to patients were all welcomed.
There were however some areas of concern;
■
The prescribing of medication not approved by a form T2 and T3
■
Failure to record discussions concerning consent and capacity
■
Record of statutory consultees views
■
Provision of timely information as required by Section 132.
What action is being taking to address these concerns?
■
Clinical staff have been reminded that only medications authorised on T2 or T3 form can be given,
or emergency powers S62/S64 (for Community Treatment Orders) used. Further audit of this is planned
for 2010/2011
■
A recording form for the purpose of recording discussions concerning consent and capacity is to be added
to the electronic clinical record so that consistent recording will be expected. This facility is expected to be
live from August 2010
■
A proforma is to be added to the electronic clinical record so that consistent recording of statutory
consultees views will be expected
■
Provision of timely information as required by Section 132. Associate Hospital Managers check this on
ward visits and report back to the MHA teams. There is a form for this on the clinical records system.
Leaflets explaining legal rights are available in a variety of languages with DVDs. MHA trainers emphasise
the need to give rights in timely manner.
MONITOR
There were no issues raised by Monitor in relation to service quality in 2009/2010.
The Health and Safety Executive [HSE]
The HSE issued no improvement or prohibition notices to the Trust during the last year.
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
27
7. Research, Innovation and Audit
The number of patients receiving NHS services provided or sub-contracted by the South London and Maudsley
NHS Foundation Trust for the reporting period, 1 April 2009 - 31 March 2010, that were recruited during that
period to participate in research approved by a research ethics committee was 7630.
This level of participation in clinical research demonstrates SLaM’s commitment to improving the quality of care
we offer and to making our contribution to wider health improvement. SLaM and its closest academic partner,
the Institute of Psychiatry (King’s College London) (IoP), are committed to working together to promote mental
wellbeing and to establish the best possible treatment and care for people with mental illness and their family
members. In a pioneering global collaboration between King’s College London, SLaM, King’s College Hospital
and Guy’s & St Thomas’ Hospital NHS Foundation Trusts, ‘King’s Health Partners’ was formally accredited in
March 2009 as one of the UK’s first five Academic Health Sciences Centres (AHSCs). King’s Health Partners has
the core aim of aligning clinical services, research and training much more closely for direct patient benefits for
a large and diverse population. Further, the National Institute for Health Research (NIHR), Biomedical Research
Centre (BRC) for mental health was awarded to the partnership between SLaM and the IoP. The aim of the BRC
is to conduct best quality translational research to deliver better mental health care, working in partnership with
other academic groups and industry to complement its expertise, shape its research and improve the practical use
of research work and development of products for service users’ benefit.
SLaM was involved in conducting 207 clinical research studies, 112 of which were adopted onto the NIHR
Portfolio and active during the reporting period. SLaM is fully compliant with and is using national systems
(Integrated Research Application System – IRAS, and the Coordinated System for gaining NHS Permission - CSP)
to manage these studies in proportion to risk.
All of our NIHR Portfolio studies have been conducted under NIHR Topic Specific Networks, the majority of
studies being under the Mental Health Research Network.
Contracts for our commercially-sponsored studies have been negotiated and managed by the Joint Clinical
Trials using the national model clinical trials agreement (mCTA).
The joint R&D office of SLaM and the Institute of Psychiatry, KCL, uses the national NIHR HR Good Practice
Resource Pack. The R&D Office has issued 153 honorary contract or letters of access based on the Research
Passport during the reporting period.
In the last three years, 2552 publications have resulted from our involvement in ethically approved research,
helping to improve patient outcomes and experience across the NHS.
Clinical Audit Program 2009/10
The SLaM Corporate Trust wide Clinical Audit Program in 2009/10 was divided into three areas to reflect the
dimensions of quality highlighted in ‘High Care Quality for All’:
■
Patient Safety: This is a programme of audit and re-audit of NHSLA clinical policies in preparation for
NHSLA level 3 assessment in December 2010. Completed projects include audits of Clinical Supervision,
Safeguarding Children, Patient Information, Workplace Stress, Safeguarding Adults, Observation, AWOL,
Rapid Tranquilisation and Physical Healthcare. A SLaM Suicide audit has also been completed as part of
monitoring NSF standard 7 and the National Confidential Inquiry recommendations
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
29
■
Clinical Effectiveness: This included a series of audits of NICE guidance drawn from the NHSLA list of key
NICE guidelines included in the 09/10 assessment standards: including violence (2 audits on physical
intervention and supervised confinement), dementia prescribing, bipolar disorder prescribing, OCD, PTSD
and Anxiety and Depression (participation in national audit pilot).
■
Patient Focus: Completed audits include patient rights (Section.58/Consent to Treatment) and carers rights
(right to carers assessment), nutrition and the new CPA policy implementation.
Process for monitoring actions to improve the quality of healthcare provided
The audit programme for 2009/10 included many re-audits of topics selected in 2008/9 to monitor
implementation of audit recommendations. In addition, progress reports/updates on actions arising from audit
report recommendations are fed back quarterly to the Clinical Audit and Effectiveness Committee. The audit
program in 2010/11 will also include re-audit of the majority of audits undertaken in 2009/10.
Examples of improvement work that the Clinical Audit & Effectiveness Team have engaged in following
publication of audit reports include:
30
■
Patient information – the Patient Information Manager has been following up teams who scored poorly in
the audit to ensure that they produce a leaflet aimed at service users which describes their service coherently.
This will be re-audit in 2010.
■
Supervised confinement - Following the audit, an in-depth review of wards with supervised confinement
rooms is being conducted. This review will feed into a policy review planned for mid April 10.
■
Stress in the workplace - Following this audit report, the Audit Project Officer and the Occupational Health
Physician are meeting the eight team leaders who participated to feedback each team’s individual stress audit
results and produce action plans to address stress and engage further support if necessary.
Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
Participation in National Audits and National Confidential Enquiries
During April 2009- March 2010 SLaM participated in data collection for 2 national clinical audits: Pilot of the
National Audit of Psychological Therapies for Anxiety and Depression (Royal College of Psychiatrists) and the
National Audit of Continence Care (Royal College of Physicians). SLaM also participated in the National
Confidential Inquiry into suicides and homicide by people with mental illness.
Participation in National Quality Improvement Projects, managed by the Royal College of Psychiatrists Centre
for Quality Improvement (CCQI).
CCQI Programme
Service accreditation programmes
Participation by Trust
National Participation
ECT clinics
2 ECT clinics
105 ECT clinics
Working age adult wards AIMS
12 wards
159 wards
Psychiatric intensive care units
0 PICUs
15 PICUs
Older people mental health wards
3 wards
56 wards
Inpatient learning disability units
0 units
33 units
Memory services
1 service
37 services
Psychiatric liaison teams
2 teams
18 teams
Multisource feedback for psychiatrists (ACP 360)
58 psychiatrists
2,928 psychiatrists
In addition, SLaM also participated in the following national audits as part of the POMH-UK pharmacy audit
programme 2009 – 2010
■
Topic 1: Prescribing high dose and combined anti-psychotics on adult acute and psychiatric intensive
care wards
■
Topic 2: Screening for metabolic side effects of anti-psychotic drugs in patients treated by assertive
outreach teams
■
Topic 3: Prescribing high dose and combined anti-psychotics on forensic wards
■
Topic 5: Benchmarking the prescribing of high dose and combination anti-psychotics on adult acute
and PICU wards
■
Topic 6: Assessment of side effects of anti-psychotic medication
■
Topic 7: Monitoring of patients prescribed lithium
■
Topic 8: Medicines reconciliation
■
Topic 9: Use of anti-psychotic medicine in people with learning disabilities.
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
31
Part 2. Looking Forward to 2010/2011
8. Quality priorities for 2010/2011
Patient Safety Priorities for 2010/2011
PRIORITY 1. Medicines Safety
We recognise that medication error can cause serious harm and is avoidable. We will maintain our focus on
making patients safer as a result of better prescribing, dispensing and administration practice.
In 2010/2011 we will:
■
Pilot and evaluate e-prescribing, and if successful move to Trust wide rollout.
■
Establish a process of medicines reconciliation in all in-patient services.
■
Continue our commitment to the POMH UK audit programme for 2010/2011
Our aim will be to further reduce the number of medication incidents, and to reduce the harm done by
medication error.
The lead for this patient safety priority will be:
David Taylor – Director of Pharmacy and Pathology
PRIORITY 2. Tackling Violence and Aggression
The incident data below clearly shows a year on year increase in the number of serious violent incidents over the
past four years. While most of the violence is directed at staff, service users are also victims of violence.
PSI 5. Serious violent incidents by severity grade (by year).
A
B
C
Totals
09/10
6
40
316
362
08/09
10
26
231
267
07/08
4
29
197
230
06/07
8
21
167
196
Totals:
28
116
911
1055
PSI 2.
RIDDORS
Number of RIDDOR* reported incidents as a result of violence.
2007/2008
2008/2009
2009/2010
81
77
109
*RIDDORs are incidents of defined outcome in terms of injury, which are required to be reported to the Health
and Safety Executive under the ‘Reporting of injuries deaths and dangerous occurrences regulations’.
A number of actions have already been taken to reduce the risk of violence on in-patient units, and to support
patients, staff and others who are injured as a result of violence.
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
33
In 2010/2011 we will:
■
Agree a plan of action for reducing violence and aggression with each service
■
Review our promoting safe and therapeutic services training to ensure that it is effective in both de-escalation
of potentially violent situations, and in addressing the causal factors behind violence and aggression
■
With good police liaison, increase the number of sanctions taken against assailants, including cautions
and prosecutions
■
Closely monitor patterns and trends of reported incidents
■
Monitor the use of physical restraint and rapid tranquillisation events [on in-patient units]
■
Pilot the placement of dedicated Police Officers at the Bethlem and Maudsley Hospitals
■
Improve the support offered to victims of serious violence, including piloting the Trauma Management
‘TRiM’ system of supporting victims of violence within teams
Our aim will be to reduce the incidence of violence and aggression on in-patient units and reduce the number
of injuries to staff and patients.
This safety priority will be led by:
Cliff Bean - Deputy Director, Patient Safety and Assurance
PRIORITY 3. Patient Experience
The experience and satisfaction of people who use our services and their carers is central to our approach to
quality measurement and quality improvement.
In 2010/2011, we will:
■
Expand the use of PEDIC system and aim to capture all teams’ patient satisfaction data through our centralised
reporting data centre
■
Increase the number of tools available to gather feedback from our service users and carers to ensure that
we are listening to as many people as possible. These tools will expand upon the continuation of paper,
online and handheld technology surveys (through Personal Digital Assistants) as well as include SMS texting
and kiosk-based surveys
■
Ensure that Clinical Academic Groups develop the capacity and commitment to use patient experience data to
adjust care pathways and improve services
■
We will use the feedback we have obtained from service users and carers to inform the re-development of
the SLaM website in May 2010. The focus of the website will be to provide clear information about clinical
services, care and treatment
■
Produce a patient engagement strategic framework that will outline how the Trust, service user and
carer forums will produce a jointly owned programme of action
■
It will also continue to monitor its performance on patient satisfaction surveys and put in place plans to
improve results
Our aim will be to extend the coverage of service users surveys across all services, and to demonstrate real service
improvements as a result of acting on the feedback from our service users.
This quality priority will be led by:
Dr Martin Baggaley – Medical Director
34
Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
PRIORITY 4. Clinical Effectiveness
We recognise that the ability to measure the outcome of the care and treatment delivered by Trust services is
vital in order to demonstrate the quality of our service to users of our services, commissioners of services,
clinicians and service managers. Outcome measures are a crucial component in promoting reflective practice,
learning from treatment successes and failures, and enabling comparisons to be made of similar teams and
services in order that variance can be addressed and improvements made.
In 2010/2011 we will:
■
Ensure that all services collect routine clinical outcome scores.
■
Set higher targets for the routine collection of outcome score.
■
Develop patient reported outcomes scores (PROMS)
■
Develop consistent analysis of outcomes scores in all services in order to;
- demonstrate results for commissioners [PbR], and
- compare services (like for like) both within the Trust and in other Trusts.
- drive improvements in services
■
We will conduct programme of research to explore local GP perceptions of the quality of SLaM services and
their experience of using our services
■
With the increased collection of outcome data that are contained within the Mental Health Clustering Tool
and the required collection of intervention data for costing care packages it will be possible to provide
commissioners with increasingly representative and reliable evidence of the clinical effectiveness of Trust
services. NHS London and the SE sector commissioners are encouraging these developments by setting
CQUIN targets that support improvements in data collection and quality assurance.
Our aim is to provide routine outcome data to support the success of future commissioning systems of payment
by results. The ability to link information on diagnosis, treatment and outcome will support our work to
ensure that service users receive the best evidence based care as prescribed by the National Institute for Clinical
Effectiveness [NICE] clinical guidelines.
This quality priority will be led by the Trust’s Clinical Outcomes Lead:
Professor Alastair McDonald
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
35
CQUINs for 2010/2011
In 2010/2011 for the first time (for mental health Trusts) CQUINS will be linked to payment of a proportion of
contracted income (1.5% of total contract value). The CQUINs [for 2010/2011] agreed by London mental health
service commissioning PCTs are:
■
Routine collection of clinical outcome scores for payment by result commissioning - HoNOS PbR;
■
Establish baseline information, on prescribing of anti-psychotics for people with dementia.
■
Physical healthcare recording for those registered on the care programme approach - CPA
■
Improving patient experience and satisfaction levels
■
Improved Social Outcomes (PSA 16)
■
Personalisation
■
Improving the collection and reporting of clinical outcome measures
■
Developing patient reported outcome measures
Targets have been specified for each CQUIN as have the financial payment weightings.
Performance against these will be reported quarterly to commissioning PCTs.
36
Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
9. Quality Indicators for 2010/2011
We will use the following indicators during 2010/2011 to measure progress against the quality priorities
described in section 8.
Patient Safety Indicators
PSI 1 – Patient safety incidents [A, B and C graded].
PSI 2 - RIDDOR reported injuries as a result of violence and aggression
PSI 3 - Number of reported medication prescribing/administration incidents [all grades].
PSI 4 - Health Care Acquired Infection rates - C.difficile and MRSA.
PSI 5 - Incidents of violence and aggression
Patient Experience Indicators
PEI 1 Responses to the question – How well was your treatment explained to you?
PEI 2 Responses to the question – How successful is the team in helping you achieve what
you want in your life?
PEI 3 Responses to the question – How well does the environment of the buildings meet your needs?
PEI 4 Responses to the question – How well do you trust the people providing your care?
PEI 5 Responses to the question – How well have staff listened to you today?
Clinical Effectives Indicators
CEI 1 - HoNOS paired scores completion rates
CEI 5 - HoNOS -Effect sizes
CEI 9 - Change in HONOS scores
CEI 2 - CORE- OM paired scores completion rates
CEI 6 - CORE-OM effect sizes
CEI10 - Change in CORE-OM scores
CEI 3 - CGAS paired scores completion rates
CEI 7 - CGAS effect sizes
CEI11 - Change in CGAS scores
CEI 4 - TOPS paired scores completion rates [addictions services]
CEI 8 - TOPS effect sizes
CEI12 - Change in TOPS scores
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
37
Part 3 Commentary from commissioners
and partners
10. Statements from commissioning PCTs, Local Authority Overview and Scrutiny
Committees and Local Improvement Networks LINks.
PCTs, OSCs, and LINks from the four Boroughs of Lambeth, Lewisham, Southwark and Croydon were invited to
comment on the report. The responses received are published here in full. There have been some amendments
to the report on the basis of these responses.
Statements from Commissioning PCTs
1. NHS Lambeth
In line with the NHS (Quality Accounts) Regulations 2010 (1/4/2010), the draft South London and Maudsley NHS
Foundation Trust (SLaM) Quality Report 2009/10 was considered by NHS Lambeth. We welcome the opportunity
to feed back on this document.
NHS Lambeth enjoys an excellent relationship with SLaM and are committed to working closely with sector
colleagues to ensure the ongoing delivery of high quality services. NHS Lambeth has defined monitoring
arrangements agreed with SLaM which currently consist of contract and quality monitoring meetings.
NHS Lambeth also has a process for regularly reviewing quality issues at Board level with each of our main
providers through our Quality and Governance Committee meeting and received a presentation from SLaM in
December 2009.
The Trust has made good progress on key priorities selected for 2009/10. Medication incidents have reduced
throughout the year and it is encouraging to see this work continuing as an objective for 2010/11. Healthcare
acquired infection rates have met the trajectories for MRSA and clostridium difficile. Additionally, progress in
developing the Patient Experience Data Intelligence Centre (PEDIC) over the year has been impressive and with
continued emphasis as an objective this year patient feedback will continue to inform the development of
quality services.
CQUINs were in shadow form during 2009/10 with those areas requiring further improvement to be developed
this year. The priorities identified for 2010/11 namely medicines safety, violence and aggression and clinical
outcomes are welcomed although the report does need to make explicit how these were decided and who was
involved in the decision-making process.
The Care Quality Commission’s Mental Health Act Annual Statement highlighted good practices within SLaM
including the quality of leadership and commitment to ensuring that detained patients’ rights were properly
respected. However, there are clearly challenges to be met in respect of documentation and consent issues
which are currently being actioned.
SLaM has participated well in national clinical audits and national confidential enquiries and demonstrates
commitment to improving quality through participation in clinical research.
NHS Lambeth has checked the information contained in the draft document and can confirm the accuracy of
the data provided. SLaM need to be aware that the nationally mandated information as set out in a series of
statements within the Regulations should be completed in full with identified gaps around service provision and
income, data quality and clinical audit addressed.
Marion Shipman, Assistant Director Clinical Quality and Governance
NHS Lambeth
28 May 2010.
38
Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
2. Southwark PCT
NHS Southwark welcomes South London and Maudsley Foundation Trust’s first quality report in line with the
NHS (Quality Accounts) Regulations 2010 (1/4/2010). The South London and Maudsley Foundation Trust Quality
Report for 2009/10 will be formally presented to the Integrated Governance Committee of NHS Southwark on
24th June 2010. It will also be reported to the Southwark Mental Health Partnership Board (LIT) at its meeting
on 10th June 2010.
We welcome the progress that has been made during year in disaggregating the quarterly quality reports on a
borough basis, but we are disappointed that the quality report is largely a generic report, rather than one which
responds to borough specific situations. It would likewise be helpful if there was more detail and categorisation
of untoward incidents in the report.
The stated CQUINS for 2010-11 (#8 Quality Priorities for 2010-11) need to be amended in line with the final
national mandated CQUINS. Instead of “Compliance with prescribing guidelines for older people - POMH-UK”,
should be “Establish baseline information on prescribing of antipsychotics for people with dementia”
We would have valued more detailed action plans in the report. However, significant work has been done in
the preparation of the new standard contract between NHS Southwark and SLaM in preparing appropriate
quality indicators and reporting for 2010-11 (schedules 3, 4 and 5 of the new contract) and we expect these
to be incorporated into the proposed Quality Indicators for 2010/2011 (#9).
We will be working with SLaM both on a contract level to assess progress in achieving the performance
objectives, and together with NHS Lambeth, Lewisham and Croydon to benchmark performance across the
four boroughs through 6-weekly four borough meetings (with revised terms of reference to use the quality
improvement opportunities of the new standard contract).
We recognise that the next two years will represent a challenging environment in which to achieve quality
improvement and have developed, in partnership with SLAM, a system-wide sustainability programme which
will be closely and independently monitored to ensure that change does not result in loss of quality.
Gwen Kennedy
28th May 2010
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
39
3. Lewisham PCT
NHS Lewisham welcomes South London and Maudsley Foundation Trust’s first quality report in line with the NHS
Quality Accounts. We embrace the publication of this report in order to demonstrate the ongoing quality cycle.
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We wish to ensure that local commissioners influence the plans and priorities reflected in the account.
Lewisham would wish further 4 Borough discussions over the Quality Account for 10/11.
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We recognise that this report is Trust wide however local reporting would be welcomed in order to
demonstrate particular areas of excellence or areas that may need improvement.
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We fully support the Trust priority areas. As a local commissioner Lewisham would wish to be involved in
setting the Trust priorities for the 10/11 Quality Account.
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It would be helpful to demonstrate thematic reviews, action plans and lessons learnt for improvement for all
areas in addition to reporting baseline information. The action plan in relation to No. 6 A response to issue
raised by regulators and commissioners, is most helpful.
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Demonstrating targets next to levels of achievement is welcomed.
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Very helpful information is detailed in regard to Clinical Effectiveness priority with outcome scores.
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We welcome demonstrating performance in relation to CQUIN.
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It would be beneficial to evidence performance against Schedules 3: Quality requirements and Nationally
Specified Events and 4: Quality Performance Incentive Schemes of the New Standard Contract as these areas
have been agreed jointly by commissioners and SLaM.
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It would be helpful to have more information in regard to method of grading Serious Untoward Incidents.
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Comparisons to national Mental Health Trusts are very helpful.
Eleanor Davies
1st June 2010
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Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
4. Croydon PCT
Thank you for your letter on the development of your annual quality report for 2009/10 the thoughts on quality
priorities for the year ahead. As you state in your letter, the Health Act 2009 requires all NHS organisations to
publish an annual account of quality alongside the financial accounts in the annual report. Please accept my
apologies that the response from Croydon has missed your deadline. I hope that the comments below are
nonetheless of some value.
1. How the Trust has performed against the quality priorities that you set for 2009/10
We support the Trust’s choice of priorities within the parameters set by the Department of Health, and the fact
that the Trust has reported positive achievements in all three areas. Progress in respect of the recording and
collation of paired outcome scores is especially welcome and has also been monitored through CQUIN
requirements in the 2009/10 contract with the PCT. It would be helpful to hear of examples where feedback
from services users has informed measurable improvements in services.
2. The priorities being considered for the year ahead - 2010/11
We welcome your intention to continue to focus on the three 2009/2010 priorities:
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improving medicines safety,
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measuring clinical outcomes,
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increasing our coverage of surveying patient’s experiences.
Clinical outcomes and patient experience are covered very much by CQUIN and other requirements in the PCT/
SLaM contract for 2010/11, but medicine safety improvement and your additional fourth priority (to reduce the
level of violence and aggression on our in-patient units) are not really covered in the contract and should provide
a good opportunity to demonstrate quality improvements beyond stated contract aims.
It is worth noting that your patient experience priority for 09/10 was to measure the experience and satisfaction
of people who use your services and their carers. Obtaining representative samples of carers’ feedback is more of
a challenge and it would be a valuable addition to your reporting this year.
3. Comments on the list of quality indicators that you intend to publish in June.
Regular reporting on the proposed indicators would give us a better picture of quality improvements.
We recognise this is part of a wider attempt to report on the quality of services through the contract and the
National Mental Health Minimum Dataset.
Yours sincerely,
John Haseler
Assistant Director,
Mental Health Commissioning
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
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Statements from Local Authority Overview and
Scrutiny Committee
1. Southwark Overview and Scrutiny Committee
Dear Cliff,
South London and Maudsley Foundation Trust - Quality Accounts 2010
Thank you for forwarding a copy of SLaM’s draft 2010 Quality Account (QA), received 23 April.
Unfortunately, the DoH prescribed timescale for the 2009/10 QAs prevents a Southwark OSC review and
comment on this year’s QA from being feasible. In view of the need to provide feedback by 17 May, this
afforded only a short window of time in which the sub-committee could review the QA, agree and prepare
a response.
Under more ordinary circumstances, a request for swift feedback may be manageable by the committee
agreeing to a special meeting. During the recent Purdah period, however, this was not viable. In accordance with
Southwark’s Purdah rules, and advice from the council’s Monitoring Officer, no scrutiny meetings were scheduled
between 29 March and the 6 May election. Moreover, in view of the constitutional formalities required post
elections and new member induction, scrutiny members are not likely to consider actual scrutiny issues
until late June.
It may be reasonable to integrate a review process into the committee’s work programme for future annual
QA cycles (subject to members’ approval), and we look forward to discussing this with you.
In order to ensure that members can provide meaningful feedback on future QAs, we will want to discuss, for
example, the state of completion of the submitted draft account: It would not be appropriate to present a draft
QA to members that predominantly outlines the quality improvements aspired to and omits key performance
data from the previous year. We recognise again that the imposed timescale for the 2010 QAs has compelled
NHS providers to try to collate and process data considerably earlier than is customary for annual reports, and
that in cases it has not been feasible to complete the requisite QA data set within this timeframe. Members are
likely to strongly object, however, if requested to review a QA with such omissions.
As we understand that the imposed QA timescale is not something that you have been able to control, we are
forwarding a copy of this letter to the Department of Health. We would similarly welcome you to refer to our
concerns in feedback that you may provide to the DoH on the 2010 QA process.
In view of the reasons outlined above, we regret that Southwark’s OSC will not be submitting a statement on the
SLaM Quality Account for 2010.
Yours sincerely,
Shelley Burke
Head of Scrutiny
cc. Paul Calaminus, Southwark Service Director, SLaM Professor Sir Bruce Keogh, NHS Medical Director,
Department of Health
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Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
2. Lambeth Overview and Scrutiny Committee
Thank you for your letter to Cllr O’Malley, Chair Health and Adult Services Scrutiny Committee re SLaM’s Quality
Account. I thought it helpful to let you know where we are on this issue.
As you may be aware the local council elections are on 6th May; there are no formal meetings of the health
scrutiny committee until July. Unfortunately the very late guidance issued on QAs and the May submission
timeline has meant that there has been no opportunity to brief members on the new arrangement nor will there
be an opportunity at this stage for the committee to consider the content and priorities before trusts’ deadline.
Cllr O’Malley and I have discussed the matter and it has in principle been agreed that the committee will not
submit any comments this year but will include QAs in the work plan for next year and welcome early
engagement on the issue. I have forwarded the QAs received thus far to committee members (and will similarly
send on the SLaM letter) and sought their agreement that they are happy with the proposed approach. Subject
to that feedback, I will formally write to trusts on behalf of the committee acknowledging the invitation to
comment but decline etc.
Trust the above is fine for you but let me know if you wish to discuss further.
Best regards,
Elaine Carter
Lead Scrutiny Officer
Scrutiny Team
Finance and Resources
London Borough of Lambeth
3. Lewisham Overview and Scrutiny Committee
The Committee believe the SLaM Quality Accounts to be a well focused report that captured the key issues
around mental health. The Committee agreed with the quality priorities going forward.
8th June 2010
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
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Statements from Local Involvement Networks - LINks
1. Croydon LINk
Thank you for giving Croydon LINk the opportunity to feedback on SLAM’s Quality Account for 2009/2010.
At our last public meeting LINk members voted Mental Health to be one of six priority areas for LINk activity.
Accordingly a working group for mental health has been formed and begun operating since March 2010. This
consultation was passed on to members of the Mental Health Working Group for consideration and feedback.
The LINk also consulted with other mental health organisations in the field.
The priorities you listed were:
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Medication Safety
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Experience and satisfaction of people using the service and their carers
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Measuring Clinical Effectiveness
Medication Safety
We strongly welcome the fact that untoward incidents involving the prescribing, dispensing and
administration of medication have fallen significantly. However at this stage meaningful feedback may be quite
difficult. For instance we may be aware of a serious incident but it maybe unclear whether this is an isolated
event or an indication of a serious systemic weakness. We would need more information on the breakdown of
the incidents that have reduced. This would need to include some indication of the severity of incidents and the
seriousness of the incident/misdiagnosis.
Experience and satisfaction of people using the service and their carers.
In terms of Patient Experience Indicators, it may be advisable to add a question framed around the promptness of
the service being provided, for example, Was the rapidness of the response to your condition adequate?
In addition, Indicator PEI 2 may be simplified to a question such as: How happy are you with the overall
treatment experience?
We welcome the fact that this area was a priority for last year and will be again next year. However we would
like to be informed of some examples where consultation with patients has led to a direct and concrete
service improvement.
Measuring Clinical Effectiveness
Croydon LINk would request to be kept informed as progress is made with data specifically for Croydon as well
as the group SLAM data. For example under this priority area, the Touchstone Centre in Bethlem has only been
operating since October 2009. However as one of the aims is to prevent certain groups of people from having to
be admitted to hospital it would be useful to know how this compares to similar services in the other boroughs
outside of Croydon for us to give meaningful feedback.
Priorities for 2010/2011
In terms of the proposed priorities for 2010/11, one major priority we believe is missing, based on the
“Count Me In” census, is tackling the issue of the over -representation of people from BME groups in hospital
admissions. We think this is an important area to address for Croydon. On a separate level, working group
members have raised the issue of an investigation into whether language needs are being met adequately.
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Quality Report 2009/2010
South London and Maudsley NHS Foundation Trust
There has also been some concern voiced over the addition of the new priority to reduce violence and
aggression. Whilst we appreciate that the reduction of violence and aggression in the Hospital setting is a
positive thing there is no indication at this stage of how this area will be tackled. We would like to know what
this would mean in practice. For example, at a recent Croydon Rethink Carers Support Group, the issue of
SLAM’s Zero Tolerance policy was raised and anecdotal evidence indicated that punitive action was often taken
before fully exploring other avenues of resolution. Carers were not always kept informed through the process.
Therefore to know what the actual picture is it would be useful to know how many patients are actually arrested
whilst in Hospital as a result of the Zero Tolerance policy and what discussions were had with their carers
regarding the incidents.
I hope you will find this feedback helpful. I am afraid Rob Whitehead has moved on from Croydon LINk,
so please feel free to contact me if you require any further assistance.
Yours sincerely
Asma Choudhery
Community Involvement Worker
2. Southwark LINk
LINk Southwark would like to thank South London & Maudsley NHS Foundation Trust for providing a copy of
their draft Quality Account 2009/10. However, the LINk Southwark does not have any comments to submit.
The LINk looks forward to receiving the Quality Account for 2010/11 which will be presented to the LINk
Members for comment.
Alvin Kinch – Team Leader
South London and Maudsley NHS Foundation Trust
Quality Report 2009/2010
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South London and Maudsley NHS Foundation Trust
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