Dudley & Walsall Mental Health Partnership NHS Trust Board

Date of Board Meeting:

28th January 2009

Subject:

Healthcare Commission Action Plans and updates

Trust Board Lead:

Jacky O’Sullivan, Director of Performance & Strategy

Presented by:

Jacky O’Sullivan, Director of Performance & Strategy

Aim of the report: To inform the Board of how the Trust will be assessed this year by the Healthcare Commission To inform the Board of performance and action plans against the Healthcare Commission Indicators To inform the Board of changes to national regulation Key points: Method of assessment this year clarified with Healthcare Commission Trust not expecting to achieve all indicators this year Care Quality Commission bringing together independent regulation of health, mental health and adult social care in 2009/10 Recommendation: The Board are asked to note the ongoing work and the contents of this report Board action required (please tick) Information □ Approval □ Other (please state)

Discussion □

Key Standard(s) for Better C5, C6, D7 Health: Implications: Financial: None additional noted at present time HR/Personnel:

None

Community/user:

Improved quality of care

Equality & Diversity:

None

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1.0

Introduction

The Healthcare Commission (HCC) are an independent regulator of healthcare in England, set up in 2004 to assess and report on the quality and safety of services provided by the NHS and the independent healthcare sector. The HCC carry out an annual health check that looks at: The quality of services, including areas such as patients’ safety, cleanliness, dignity in care and waiting times. How well organisations are managing their finances – use of resources As a part of this work, the HCC ask trusts to assess their performance against the Government’s core standards for the NHS. The HCC cross-check their self-assessments against a range of information, including what patients and the public tell them. They then give each trust an annual rating that consists of two parts: A score for quality of services A score for use of financial resources Ratings are on a scale of: Excellent Good Fair Weak 2.0

Performance in 2007/08

During 2007/08 Walsall and Dudley mental health services were rated as part of their respective PCTs and it is not possible to pull out performance ratings specifically for mental health. The ratings for both PCTs can be seen in the table below along with ratings of other mental health providers within the West Midlands Strategic Health Authority: -

Healthcare organisation Walsall Teaching PCT Dudley PCT Wolverhampton City PCT Birmingham & Solihull Mental Health NHS Trust Sandwell Mental Health NHS & Social Care Trust South Staffordshire & Shropshire Healthcare NHS Foundation Trust

Quality of Services Fair Fair Fair Excellent

Use of Resources Good Good Good Good

Excellent

Good

Excellent

Excellent

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Worcestershire Mental Health Partnership NHS Trust Coventry & Warwickshire Partnership NHS Trust North Staffordshire Combined Healthcare NHS Trust

Excellent

Weak

Fair

Fair

Good

Good

Table 1: Annual health check Ratings 2007/08

It can be seen that Trusts whose core business is the delivery of mental health services performed much better in relation to quality of services. The only organisation that achieved excellent on both ratings is the only mental health foundation trust within the West Midlands Strategic Health Authority. 3.0

How the Healthcare Commission will assess the Trust 2008/09

Given that the Trust only came into existence half way through the current financial year, the HCC have been asked how they will make their assessment for the Trust. They have responded that they will directly map activity to the new Trust and hold the Trust fully accountable for all activity and planning inherited. Where this is not possible, it would require unjustifiable resource to accurately complete, they will take a pragmatic approach and use most recently available data that can be accurately mapped to the Trust. Therefore, as a general rule, they will look to assess the Trust on a full years of activity, where this is not possible, they may apply category of ‘data not available’ to an individual indicator or indicators, meaning that The Trust will not be assessed against it through no fault of the Trust. 4.0

The Healthcare Commission Indicators 2008/09

As a part of the HCC annual health check for 2008/09, the HCC will be using 14 indicators to assess the performance of mental health trusts against the new national targets (as described in National Standards, Local Action: Health and Social Care Standards and Planning Framework 2005/2006-2007/2008 (DoH, 2004). The HCC have stated that of these 14 indicators, 3 are existing ones and 11 are new for this year. In reality, only 2 were existing indicators for mental health and the construct of one of these has been changed this year. The 14 indicators were originally issued in July 2008, four months into the year. The indicators were incomplete and construction of the majority of the indicators was only made available on 24th October 2008. The full construct for the indicator for Child and Adolescent Mental Health Services (CAMHS) was released on 14th January 2009 and the indicators ‘Patterns of care from MHMDS’ (Mental Health Minimum Data Set) and ‘Delayed Transfer of Care’ are still under construction.

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The action plans that have been developed to map current position against the indicators and achieve improvements where possible this year can be found at appendix 1. Trusts do not know exactly what information the HCC will utilise in making their ratings on some of the indicators and what tolerances will be allowed. Sometimes tolerances are not set until after the evidence has been collected. Whilst the indicators have been rated by the Trust using the RAG system (Red, Amber, Green), this is not how the HCC will rate them as they use a 4-grade scale: Fully met Almost met Partly met Not met The Trust does not anticipate achieving all of these indicators within this financial year and would not have achieved them within their respective PCTs. There may also be some indicators that the Trust is not measured on this year due to the part year change, which will include the indicator for NHS staff satisfaction. 5.0

Monitoring Progress

The indicators are RAG rated on a monthly basis and form a part of the Corporate Dashboard which is submitted to Trust Board via the Finance and Performance Committee. Ratings are applied as follows: Green = fully compliant Amber = Action plan in place and on target to achieve compliance this year Red = Action plan in place but behind target/compliance will not be achieved this financial year or insufficient information available from the HCC on method of rating for the Trust to give an accurate rating. 6.0

Looking forward to 2009/10

2009/10 will see the HCC replaced by a new regulator – the Care Quality Commission (CQC). The CQC will bring together independent regulation of health, mental health and adult social care for the first time (Healthcare Commission, Mental Health Act Commission and Commission for Social Care Inspection (CSCI)). For NHS providers the CQC propose to make minimal changes to the indicator sets compared to those used in 2008/09 (i.e. two new indicators will be introduced, and one existing indicator will be withdrawn). This is currently subject to consultation as a part of a wider consultation exercise by CQC on periodic and special reviews (Care Quality Commission enforcement policy, Consultation, 2008). CQC will be responsible for registering, reviewing and inspecting services. Where providers fail to meet the legal requirements of their registration, CQC may take action against them. This includes those who are operating without being registered.

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The CQC will have enforcement powers under the Care Standards Act 2000 and new powers under the 2008 Act, summarised as follows: Issue a warning notice Impose, vary or remove conditions Issue a penalty notice in lieu of prosecution Suspend registration Cancel registration Prosecute for specified offences At the present time any organisation wishing to pursue a Foundation Trust application must be fully compliant with the HCC Indicators and meet the Core Standards. This position is not expected to change with the CQC but will be clarified at the earliest opportunity. 7.0

Recommendations

The Board are asked to note the ongoing work and the contents of this report. This report has been presented at Finance and Performance Committee and Trust Board to ensure all members receive a brief on current performance, potential position for this years rating and the changes in progress in terms of the Care Quality Commission and their enforcement powers.

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Appendix 1

Healthcare Commission Indicators 2008/2009 Action Plans Directorate Leads:

Performance & Strategy Jacky O’Sullivan

Reporting period:

December 2008

Overall Objectives:

Develop action plans to deliver improvements, where possible, against all Healthcare Commission Indicators for 2008/2009.

RAG Rating Summary Ref INDICATOR H1 H2 C1 C2 C3 C4 C5

Data quality on ethnic group Experience of patients - health and wellbeing domain(s) Patterns of care from Mental Health Minimum Data Set (MHMDS) Completeness of the Mental Health Minimum Data Set (MHMDS) Access to crisis resolution home treatment (CRHT) Child and adolescent mental health services (CAMHS) Experience of patients – clinical quality domain(s)

RAG Ref  S1  S2  P1

INDICATOR

RAG

Care Programme approach (CPA) 7 day follow up Experience of patients – safety domain(s) Delayed transfers of care

  



P2





P3

 

P4 N1

Best practice in mental health services for people with a learning disability (Green light toolkit) Experience of patients – patient focus and access domain(s) Numbers of drug misusers in effective treatment NHA staff satisfaction

  N/A

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Health and Wellbeing Ref Objective

Action

By whom?

Timescale / milestones

Interdependencies/ comments

RAG 

Full construction details are finalised. There are two components both referring to the ethnic origin of patients having a finished consultant episodes and a care spell for inpatients (bed days greater than zero days) for Q1 to Q3. % score for Dudley and Walsall Q1 – 99%

H1

Data quality on ethnic group

MHMDS Q2 waiting submission for Dudley and Walsall, provide analysis that will identify hotspots by team. Repeat for Q3

Dave Harding Makhan Singh Neil Gage

Mid Dec 2008

Monthly data quality reports produced and shared with service to ensure all patient’s ethnic origin is captured

Information team

Monthly scorecard

Data will be locally refreshed to substantially reduce the incidence of ‘Not Known’ coding The HCC will use data from the Mental Health Inpatient Survey in Spring 2009

H2

Experience of patients - health and wellbeing domain(s)

Waiting on Connecting for Health bureau to process data

All Users



Rosie Musson Wendy Pugh

CSIP to audit DPH and BFH against standard/questions within inpatient survey.

Feb 2009

Action plan to be developed and implemented through Director of Operations and Nursing Group

Mar 2009

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Data source and period H1 H2

Mental health minimum data set (financial year 2008/09 (quarters 1 to 3)) Hospital Episodes Statistics (April to December 2008) Healthcare Commission mental health inpatient survey (subject to ethical approval) (fieldwork to be undertaken in spring 2009)

Clinical Quality Ref Objective

C1

C2

Patterns of care from Mental Health Minimum Data Set (MHMDS)

Completeness of the Mental Health Minimum Data Set (MHMDS)

Action

By whom?

Timescale / milestones

The HCC will assess how services are implementing policies that support better outcomes of care, as set out in the Department of Health's guidance 'Effective Care Coordination in Mental Health Services - Modernising the Care Programme Approach'. MHMDS will be utilised. Analysis of MHMDS Q1 and Q2 specific to care co-ordinator’s occupation, CPA level and CPA reviews in a specific period It is expected that all service users will have a copy of their care plan Of the 8 data items that the trust will be measured on, Marital Status is of concern. The HCC has released a new system of coding for marital status which will have to be mapped on new & existing data. PEAK, SEPIA, IPM, CARE Plus to be modified to accept the new coding structure Existing data to be mapped to new codes

Makhan Singh

Interdependencies/ comments Ratification of revised CPA Policy

RAG 

Jan 2009

Care Coordinators IPM & Care Plus – Existing codes are compatible Information Team

Jan 2009

Information Team Dudley Users of

Jan 2009 Mar 2009



SEPIA – Baum & Heart have adjusted the coding which

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C3

Access to crisis resolution home treatment (CRHT)

As Married\Separated is now split into two separate codes, all service users with this Marital Status on PEAK will be reviewed and the correct code inputted All users to ensure a valid Marital Status code is recorded on respective systems. Healthcare Commission have clarified that all admissions without exception should be gate kept by CR/HT.

PEAK

Systems changes have been put in place to ensure all admissions, with no exclusions, go through the gate keeping process. This will need to be monitored to ensure compliance and effectiveness.

Wendy Pugh

Dec 08

Monthly reports will be produced for monitoring purposes.

Neal Lamb

Jan 09

All Users 

Assessment will be made from Adult mental health service mapping. This indicator will be based on a HCC Special Data Collection on 31st March 2009 and will be considering year on year improvements on NSF standards.

C4

Child and adolescent mental health services (CAMHS)

Both localities have an NSF action plan. To clarify what information is reported where in relation to CAMHS. To evaluate where the Trust is against NSF standards and action plans.

will be available in the next SEPIA release (imminent)



Philip Hogarth Karen Williams Neal Lamb Wendy Pugh

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Data will be obtained from HCC Mental Health Inpatient Survey spring 2009.

C5

Experience of patients – clinical quality domain(s)



Rosie Musson Wendy Pugh

CSIP to audit DPH and BFH against standards/questions within inpatient survey.

Feb 2009

Action plan to be developed and implemented through Director of Operations and Nursing Group.

Mar 2009

Data source and period C1 C2 C3 C4 C5

Mental health minimum data set (financial year 2008/2009) Mental health minimum data set (financial year 2008/2009) Adult mental health service mapping (subject to ROCR approval) (October 2008 to March 2009) Healthcare Commission special data collection (as at March 31 2009) Healthcare Commission mental health inpatient survey (subject to ethical approval) (fieldwork to be undertaken in spring 2009)

Safety Ref Objective

S1

Care Programme approach (CPA) 7 day follow up

Action The guidance states that it is the responsibility of the receiving trust to achieve this target, therefore where there is not a community element provided by this trust then this would be excluded. Additionally the HCC have indicated that it is unlikely that trusts will achieve 100% Unify both Walsall & Dudley systems for monitoring and investigating possible breaches Catalogue and apply exclusions within the reporting framework.

By whom?

Timescale / milestones

Makhan Singh Neil Gage

Monthly scorecard

Neal Lamb

Jan 2009

Interdependencies/ comments Thresholds will be set by HCC following assessment

RAG 

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Maintain a record of exclusions for HCC verification. Action to be taken as part of the local Performance Committee, all teams producing exception reports for discussion at Performance Review Group. Data will be obtained from HCC Mental Health Inpatient Survey spring 2009.

S2

Experience of patients – safety domain(s)

Philip Hogarth Karen Williams

Monthly scorecard



Rosie Musson Wendy Pugh

CSIP to audit DPH and BFH against standard/questions within inpatient survey.

Feb 2009

Action plan to be developed and implemented through Director of Operations and Nursing Group.

Mar 2009

Data source and period S1 S2

Healthcare Commission special data collection (financial year 2008/09) Healthcare Commission mental health inpatient survey (subject to ethical approval) (fieldwork to be undertaken in spring 2009)

Patient Focus and access Objective

P1 Delayed transfers of care

Action

By whom? All teams to complete Delayed Transfer of Care templates Monthly statistics reported to Information for inclusion on Balanced Scorecard Action to be taken as part of the local Performance Committee, all teams producing exception reports for discussion at Performance Review Group.

Makhan Singh Neil Gage Wendy Pugh

Timescale / milestones Monthly scorecard

Interdependencies/ comments

RAG 

Philip Hogarth Karen Williams

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Best practice in mental health services for people P2 with a learning disability (Green light toolkit)

Experience of patients – patient P3 focus and access domain(s)

Numbers of drug P4 misusers in effective treatment

Performance team to ascertain any external reporting requirements and implement same HCC special data collection (period to be finalised). Initial meetings to be held with Learning Disability Services in both localities to reach a common understanding of what has been commissioned against the Green light Toolkit. Data will be obtained from HCC Mental Health Inpatient Survey spring 2009.

Neal Lamb

Dec 2008 

Bill Conlon

Feb 2009 

Rosie Musson Wendy Pugh

CSIP to audit DPH and BFH against standard/questions within inpatient survey.

Feb 2009

Action plan to be developed and implemented through Director of Operations and Nursing Group HCC Assessment will be made on data obtained from NDTMS (NTA) (financial year 2008/2009) Set monthly targets that reflect the contribution expected from each team. Obtain routine monthly submissions to NDTMS from both Substance Misuse teams Scope provision of Halo System (used in Walsall) for Dudley Substance Misuse Team

Mar 2009  Neal Lamb

Jan 2009

Balanced Scorecard

Jan 2009

Neal Lamb

March 2009

Data source and period P1 P2 P3

Not yet finalised Healthcare Commission special data collection (as at 31st March 2009) Healthcare Commission mental health inpatient survey (subject to ethical approval) (fieldwork to be undertaken in spring 2009)

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P4

National Drug Treatment Monitoring System (National Treatment Agency) (financial year 2008/09) National Drug Treatment Monitoring System (National Treatment Agency) (financial year 2007/08)

NHS Staff Satisfaction Objective

NHA staff N1 satisfaction

Action

By whom?

Timescale / milestones

Survey is underway and will be extended into the new year. This survey will not be used for the HCC assessment but will be utilised to underpin and inform our action plan.

Mandy Shanahan

Jan 2009

Interdependencies/ comments

RAG N/A

Data source and period

N1

National NHS staff survey (fieldwork to be undertaken in autumn 2008)

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