Integrated Care Pathways in Mental Health Sean Doherty NHS Quality Improvement Scotland

What is an ICP Integrated care pathway A system of continuous quality improvement Focuses on recording, analysing and acting on variances Put simply - a tool to compare planned care with care actually given

The policy context Commitment 6 - Delivering for Mental Health (2006) ‘NHS QIS will develop the standards for ICPs for schizophrenia, bipolar disorder, depression, dementia and personality disorder by the end of 2007. NHS board areas will develop and implement ICPs and these will be accredited from 2008 onwards.’

Links to performance management HEAT targets Benchmarking Single Outcome Agreements

Standards for integrated care pathways for mental health Developed collaboratively Consulted on widely Evidence based Published December 2007

Process Care – generic Care – specific Service improvement the essential foundations for development of ICPs Care – generic the framework for all mental health care Care – specific five mental health conditions Service improvement Ensuring that ICPs are making a positive impact on care

Condition specific care Bipolar disorder Borderline personality disorder Dementia Schizophrenia Depression

What now? - baseline scoping All NHS boards visited during April – June 2008 Local factual reports – NHS QIS Degree of development and implementation of ICPs – variable across NHS board areas Local action plans – NHS boards

What now? - ICP toolkit ICP resources – available online now Focus group sessions – what do you want from the ICP toolkit? All NHS boards invited to participate External web design company to be commissioned Piloting and launch

Crerar Review Looked at audit inspection and regulation of public services 42 recommendations to improve the role of scrutiny within the public sector

What now? - accreditation Complex System under development - but - this is NOT a barrier to ongoing local ICP development and implementation Facility for ongoing data collection Supportive and developmental The products of a functioning ICP will provide the evidence for accreditation

Our approach All NHS boards developing and implementing Continued support from NHS QIS ICP national co-ordinators Measuring and acting on variance

Mental Health Collaborative A brief overview

Collaborative Approach Providing the capacity (time) and capability (skills) to learn to see our systems afresh: Experiential – understanding how it feels to those on the receiving end of services Factual - using data to focus our attention Informed - using the evidence base and learning from experience

Systems Approach 95% variance is caused by the system We need to give front line staff the skills to understand why the system is failing and how to fix it Instead we have become self-taught experts in working around broken systems

Mental Health Collaborative 3 Workstreams & 4 HEAT Targets Better treatment for depression Improved inpatient processes and community mental health services Timely diagnosis of Dementia and appropriate follow-up support Each underpinned by: Improvements in the quality of the experience

Mental Health Collaborative We don’t have all the answers in advance We do have tools and techniques to help us find the answers together

Results delivered by… Developing links across other national programmes and organisations Allocating funding to NHS Boards for Improvement Infrastructures Providing training on improvement tools and techniques Generic Core Skills Training Customised to Mental Health and Local Needs

Results delivered by…. Providing toolkits for local use Generic Improvement Toolkits Customised to Mental Health (Simulation process improvement game and Demand & Capacity Model) Identifying High Impact Changes and Measures for Improvement Reference Group

Results delivered by…. Developing mechanisms for sharing learning and knowledge Web based resources Newsletters Networking events

“To change an organisation, the more people you can involve, and the faster you can help them understand how the system works and how to take responsibility for making it work better, the faster will be the change.” Marvin Weisbord,Training and Development Journal

Why do we need measurement in mental health? Information about delivery and outcomes of clinical and social care can make a vital contribution to facilitating the safety, efficiency and effectiveness of health care.

Who is the information for? Three Ps (in America 6 Ps) Patients Providers Policy makers

What do we need to measure? Our challenge is to select measures that matter in terms of Clinical outcomes Strategy Legislation

What are the key aspects of performance?

Key Aspects of Performance QUALITY – patient experience and health outcomes EFFICIENCY – How resources are managed and used SUSTAINABILITY – Whether the functions provided by services are sufficiently sized and appropriately positioned to meet needs of local communities COST – resources are limited so best value must be achieved from current investment

What are appropriate performance tools to measure the data? Benchmarking/Balanced score cards (indicators/definitions) HEAT (targets) ISD LDPs Review visits (templates) Joint Futures Outcomes (indicators) DoH – compendium of clinical outcomes

What do these tools measure? Benchmarking measures - Responsibility Benchmarking template reports annually try to achieve consistent definitions across the system Costing project – relates costs to definitions Balanced scorecard

What do these tools measure? Balanced Scorecards National Local Subspecialities

What do these tools measure HEAT – measures Accountability

What do these tools measure? ISD mental health information programme Inpatient returns SMR4, SMR1 (SPARRA) Outpatients returns SMR00 Prescribing information (monthly) Practice team information (GP plus nurse individual contacts) QOF

Performance tools not used MMI (monthly management Information) 18 week wait

Asprational PerformanceTools Data system (eHealth) – data sets IPACC versus PMS versus others eHealth supporting ICP data set IPACC core data set operating in some areas

What are the challenges? Robust, meaningful data sets and collection (definitions, IT, software, core data) Using the data appropriately

How it all fits together

Mental Health Collaborative Programme NES Psychological Therapies DRAFT – V3 NQIS ICP Programme Mental Health Collaborative Programme NES Psychological Therapies Programme Mental Health Benchmarking Programme Are we doing the right things Setting National Standards for ICP Development Identifying High Impact Changes – that if implemented will make a significant difference to outcomes What therapies should we be delivering to which diagnostic groups? Provide benchmarking comparisons to help to identify which services/functions may be less effective than others Supporting systems to process redesign to ensure evidence based care is being delivered in the most efficient way Providing evidence for most efficient pathway of care Competency Framework Agree model - stepped or matched care Review cost-effectiveness of therapies Provide benchmarking comparisons to help to identify where there may be inefficiencies Supporting systems to process redesign to ensure reduction of duplication and waste, removal of bottlenecks and efficient flow of work through system Modelling the demand for psychological therapies and capacity needed to respond Reviewing no of staff at different levels needed to meet demand with appropriately skilled staff Developing knowledge and skills of staff to develop and implement ICPs Funding Improvement Infrastructures in NHS Boards Developing knowledge and skills of frontline staff in improvement methodologies Supporting staff to put these into practice Developing a competency framework Providing training on psychological therapies and training for supervisors Funding NHS Boards to put in place governance arrangements Advice to boards on commissioning local training Provide benchmarking comparisons to help to identify where there may be skill mix issues and using information to review Reporting on variance analysis and using this to inform further service development Setting standard definitions to enable comparison Providing reports which show how health boards compare Accreditation of ICPs Developing the ability to collect and analyse information to inform service improvement Using variance analysis, outcome and impact assessment data to inform commissioning of psychological therapies training programme