1. International Mental Health Comparisons Results Presentation
28th May 2018, Stockholm

2. Overview A brief history… Project scope and process Data definitions
Analysis structure & headline comparisons
Finance
Children
Adults
Outcomes
Reporting
And next…?

3. Background
Ongoing collaboration between a group of countries, facilitated by Prof Harold Pincus and team from 2008
Organises systems for international innovation sharing, networking and problem solving across countries and agencies
Aims to provide better outcomes for people who use mental health and addiction services and their families
Range of papers published and initial data analysis presented at 2015 seminar in New York

4. Deep-Dive Project Timescales
Interest in collaboration – September IIMHL New York / Vancouver
Data specification developed for 10 high value areas, collection during 2016/17, presented at Canberra seminar in 2017
Local reports issued for all countries
Value of collaboration demonstrated, agreed to undertake a further cycle of analytics
Virtual project group established
Enhanced data specification developed for 2017/18 collection
Wider content
Inclusion of finance and access metrics
Opportunity to extend to other countries via OECD encouragement
Next cycle of data collection took place from November 2017 to April 2018
Data validation

5. Deep-dive; project scope
Strategic benchmarking topics were agreed, to cover main headings;
Inpatient services for Adults
Community based care
Quality indicators
Data transparency arrangements in each country
System expenditure on mental health
Access to specialist care
Forensic care
Rehabilitation
Mental health prescribing
Children and young peoples care
Participants agreed that the project would attempt to use the most up to date information, for most countries this relates to data collected during 2016/17.

6. Interpreting project findings - caveats
The project’s aims are ambitious given the scope of the work and the extent to which objectives can be influenced by a range of factors present in the characteristics of each country’s health system.
Data quality
Service scope & models
Service definitions
Service scope
Case mix
Resource levels
Clinical processes
Validation

7. Finance

8. Total health expenditure
Standardised currency of US dollars $
Data is standardised for year 2016/17
Median value of $3,893 healthcare expenditure per capita.

9. Mental health expenditure per capita
$ spend per capita on all mental healthcare per annum / total population.
Data is standardised for year 2016/17 wherever possible.
Mental health spending has a median average of $260 per capita.

10. Mental health as % of total health expenditure
Mental Health spending averages 6% of overall health spending across the participant group, where data is available.

11. Comparisons of Children & Young Peoples Mental Health Services
Hospital Inpatient Care

12. CYP MH beds per 100,000 population
Median average of 8 CAMHS beds per 100,000 population in the CYP age group (0-18). The mean average is skewed to 10 beds per 100,000 children by the large number of beds reported by Belgium at 31 per 100,000
The lowest bed numbers are reported by Wales and New Zealand (4 each) and Australia (5).

13. CYP MH Admissions per 100,000 population
Median average of 116 CAMHS admissions per 100,000 population (0-18). Mean average is 105 admissions per 100,000 children.
The data splits into two broad groups with high admission rates evident in countries with high bed numbers (Belgium), and short length of stay (Sweden and New Zealand).
The lowest admission rates per annum per 100,000 children are reported by Wales (13), Republic of Ireland (26) and England (33).
Growth evident in commentaries

14. CYP MH occupied bed days excluding leave per 100,000 population
Median average figures are 1,711 occupied bed days per 100,000 population, with mean average values of 1,797 bed days per 100,000.
Bed numbers, length of stay and bed occupancy all impact on the total number of occupied bed days a country will report.

15. Bed occupancy excluding leave
Bed occupancy is a mean average of 67% excluding leave, with all countries reporting bed occupancy below the 85% guide outlined by the UK Royal College of Psychiatrists.
Occupancy = 81% including leave
Ireland figure is including leave

16. Average length of stay excluding leave
An 11-fold variation is evident in the data, from Australia with the shortest stays (10 days) and Wales the longest (99 days), with England reporting the second longest length of stay (72 days excluding leave) and Wales the longest (98 days). Mean average length of stay is 41 days (median 42 days).

17. Illustration of intra-country variation UK ALOS for General CAMHS
The mean average length of stay in the UK (all 4 countries) for NHS General Admission CAMHS beds was 74 days (excluding leave) in 2016/17, an increase from the mean of 72 days seen in 2015/16.
Substantial variation is evident in the data from shortest average length of stay of 10 days through to longest length of stay of 310 days.

18. Illustration of intra-country variation Sweden ALOS for CAMHS
The mean average length of stay in Sweden is 11 days
Variation evident between regions but from a smaller base length of stay

19. Inpatient CAMHS: Workforce
Workforce groups
Staffing on Secure CAMHS units
Registered Nursing (24%)
Support Workers and unregistered nursing (47%)
Psychology = 1.5%
Medical = 3%
Explore other bed types in the toolkit

20. Community Workforce Workforce groups – Total Registered Nursing = 29%
Psychology = 17%
Medical = 9%
Nursing and Psychology same as 2015/16
Medical in 2015/16 = 10%
CAM243 = ELFT (east London)

21. Comparisons of out of hospital care
Community Care
Comparisons of out of hospital care

22. Children seen by community CAMHS
Nine of the thirteen countries could quantify the level of community care provided in terms of the number of children who access services each year.
Median average position occupied by the USA of 3,221. Sweden provide the highest level of community care in terms of population coverage (5,671 children per 100, ), and Australia and the Republic of Ireland the lowest levels.
Please note that data for Republic of Ireland relates to children seen for first appointment only

23. Contacts delivered by community CAMHS
The mean position reported is 25,504. Locally determined policies and procedures may impact on contact levels, and there is variation in duration and frequency of contacts that a service may offer.
New Zealand (58,884) and Sweden (40,778) support the highest number of contacts in the community environment.

24. Contacts per child
Data on the number of contacts per child shows wide variation reflecting different levels of service intensity between countries.
The mean average is 9, with Australia and New Zealand operating above this with 17 and 15 contacts per child during the year. The Republic of Ireland reports 14 contacts per child.
All 4 UK countries have an average input of between 5 and 6 contacts per child, followed by Sweden at 7 contacts per child per annum.

25. CAMHS Workforce

26. Workforce
The CAMHS workforce is typically an MDT involving Child and Adolescent Psychiatrists, specialist Therapists and Nurses.
Sweden reported the largest workforce figure at 378 per 100,000 population in the 0-18 group. This figure includes consultant psychiatrists, registered nurses, clinical psychologists and other clinical therapists and practitioners.
The mean value of 97 is skewed by the high numbers of staff reported by Sweden, the median value is 59 WTE per 100,000 population aged 0-18.

27. Consultant Psychiatrists

28. Access and scope of services
Adults and Older Adults

29. Access to specialist MH services
Incomplete position
Data looks at specialist secondary care services
Median average position of around 2,000 people per 100,000 population accessing specialist services.

30. Inpatient Comparisons General Psychiatry
Working age adult services

31. Beds per 100,000 population
Incomplete data from some countries re lack of available data from some private sector providers.
Mean average of 59 beds per 100,000 population aged
The median average of 41 beds per 100,000 population more representative?

32. Discharges per 100,000 population
A mean average = 655 discharges per 100,000 population p.a.
Median average = 400 discharges per 100,000 population p.a.
Netherlands and Sweden report the highest admissions
UK countries report low levels of admissions / discharges per 100,000 population which also links to higher length of stay across the UK.

33. Which type of patients occupy beds?
Occupied Bed Days by Diagnosis Group
General Psychiatry Beds for ages 18-64

34. Average length of stay Median average ALOS = 24 days
Five-fold variation is demonstrated, with Australia, New Zealand and the Netherlands reporting the shortest lengths of stay, & Czech Republic the longest length of stay.

35. Involuntary admissions
Detentions as a percentage of admissions
Where bed numbers are smaller, it is likely that the percentage of admissions that are involuntary will be higher, as thresholds for admission rise,
New Zealand’s figure of 63% is the highest amongst all participants, but should be considered against its small bed base.
Belgium reports the highest number of beds per 100,000 population alongside the smallest percentage of detentions.
Canada’s figure is based on all hospital beds (not limited to general psychiatry) and is limited to data from 5 out of 13 provinces/territories

36. Involuntary admissions
Detentions per capita

37. Bed occupancy

38. Emergency readmissions.

39. Use of restraint

40. Use of seclusion

41. Older People

42. Beds per 100,000 population
Bed numbers are shown here per 100,000 population (age 65+).
Scotland reports the highest number of old age beds and Canada the fewest. The median position is 38 beds per 100,000 people aged 65 and older.

43. Average length of stay
Old Age Psychiatry

44. Bed occupancy

45. Forensic care

46. Beds per 100,000 population
The mean average rate of provision is 7.5 beds per 100,000 population, with the highest number of beds provided by Sweden, England and Scotland.
Czech Republic (2) and Australia (3.5) report the lowest number of beds per 100,000 population.

47. Bed occupancy
Bed occupancy in forensic services averages 91% (median).
Leave is less used to manage bed capacity and typically accounts for 2% - 3% of bed days.

48. Discharges per 100,000 population
The long-term nature of forensic care generates a low discharge rate which has a median position of 8 discharges per 100,000 population. When compared to the average bed position at 7 beds per 100,000 population, this indicates an average length of stay of around one year.

49. Community based care

50. Community team caseloads
Sweden supports the highest number of people in the community setting at 4,245 people per 100,000 population. Australia occupies the median position at 1,827 per 100,000 population, and Wales the lowest position at 1,415 people per 100,000 population.

51. Community team contacts
Issues with the completeness of national datasets on community care.
The contact rate for specialist community mental health teams largely reflects the number of people held on caseloads. Sweden has the largest number of contacts at 55,827 contacts per 100,000 population.

52. Community Services * 7-14 day community based follow-up post discharge
Countries were asked for the period during which they aim to offer a first follow up appointment for patients discharged from inpatient care. This was typically reported as within 7 days or within 14 days of discharge. Countries are shown here for their attainment against their local measure.
Wales & England reports the highest rate of community based follow up care with 93% of patients followed up by a specialist mental health practitioner within 7 days of discharge.

53. Economic comparisons from UK
Why is this important?
Economic comparisons from UK
1 adult acute bed = 41 patients on a CMHT caseload
1 adult acute bed
= 17 patients on an EIP team caseload
1 older adult bed
= 32 patients on an
older adult CMHT caseload

54. Outcomes Suicide rates
Excess mortality for mental health service users (to follow)

55. Suicide rates Whole population suicide rate
There is variation on this metric with the Netherlands reporting the lowest suicide rates at 9 per 100,000 population, & Republic of Ireland the highest at close to 20 deaths per 100,000 people. The median average is 12 deaths per 100,000.

56. Conclusions
Project demonstrates the value of international comparisons
Data quality and completeness issues are evident, however...
Huge appetite for comparisons as political and policy levels
Financial and access data provides relevant context
Different service models shape care systems – balance of care between beds and community services very evident
CYP mental health emerging as a particular priority
Quality agenda becoming more evident
Outcomes discussion gaining pace
Thank you for contributing

57. Reporting & Next Steps
Commitment to provide a bespoke report to each country
Publication comments and timescales?
Planning for further work? (Tuesday pm)