National Clinical Audit of Psychosis (NCAP) Specification and Development Meeting Minutes of the meeting Tuesday 10 November, 2.00pm - 5.00pm, Friends Meeting House, 173 Euston Road, London, NW1 2BJ Attendees Pauline Ong (co-Chair) Emerita professor of Health services research, Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University Geraldine Strathdee (co-Chair) National clinical director for mental health, NHS England Richard Arnold Clinical programmes lead, Medical directorate, NHS England Sarah Watkins Head of Mental health and vulnerable groups policy division, Welsh Assembly Government Alison Brabban National clinical advisor for SMI (IAPT) recovery lead, Tees, Esk and Wear Valleys NHS Trust Sue Coffee Associate director of AHPs & Health and wellbeing services
Catherine Dunn Head of clinical audit, Lancashire Care NHS Trust LG Service user David Kingdon Professor of Mental health care delivery, University of Southampton Jen Knight Clinical audit manager, Berkshire Healthcare NHS Foundation Trust Shubhra Mace Deputy director of Pharmacy, South London and Maudsley NHS Foundation Trust Angela Moulson Clinical specialist lead mental health and learning disability, Bradford City & District CCGs Caroline Parker Consultant pharmacist adult mental health & Independent prescriber Paula Reid Senior policy officer, Rethink Mental Illness
Alan Cohen Retired as Director of primary care, West London Mental Health Trust
Jo Smith Consultant clinical psychologist and Professor of early intervention and psychosis, University of Worcester
Mike Crawford CCQI director, Royal College of Psychiatrists
Nicola Vick Provider analytics manager, Mental health, Care Quality Commission
Kate Dale Mental and physical health project lead, NHS Bradford, District Care Trust
Krysia Zalewska Programme manager, NAS and PMH, Royal College of Psychiatrists
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HQIP Dr Kirsten Windfuhr Associate director, NCAPOP Dr Yvonne Silove Associate director, NCAPOP
Eleanor Mitchell-Heggs Programme support officer Linda Haines Minutes
Miranda Heneghan Programme manager, NACPOP Apologies Stephen Bleakley Operational lead pharmacist, Southern Health lead nurse, Northumberland, Tyne and Wear NHS Foundation Trust Nick Black Professor of Health services research, London School of Hygiene and Tropical Medicine Shaun Chainey Major health conditions policy team, Welsh Assembly Government Steve Cooper NCA proposal co-applicants Fiona Lecky Clinical professor of Emergency medicine, University of Sheffield, NAGCAE
Sean Rellick Health and social care quality programme director, Health and Clinical Excellence David Shiers Clinical advisor, National Audit of Schizophrenia Julie Taylor Physical health lead nurse, Northumberland, Tyne and Wear NHS Foundation Trust David Taylor Director of Pharmacy and pathology, Head of pharmaceutical sciences, Clinical Academic Group, King’s Health Partners, South London and Maudsley NHS Foundation Trust Denise Taylor Senior lecturer in Clinical pharmacy, University of Bath
Introduction and Welcome The Chair welcomed the group and the purpose of the meeting was outlined. o The purpose of the meeting is to inform HQIP in writing the specification for the new national clinical audit for psychosis o The National Clinical Director for Mental Health England (GS) summarised relevant work in England where a range of new standards have been implemented to drive improvements for patients with psychosis across seven core areas. The core areas are: • Information about treatments and services • Physical healthcare • Psychological therapies • Medicines –patients have the right support and information • Support for employment, only 4-12% of people with psychosis are in work
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Support for families and carers Crisis care – psychosis episodes are not currently captured
o Recent initiatives include: • New estimates of prevalence of psychosis which is significantly underestimated • Early intervention psychosis service standards introduced for all ages • Mental health payment systems including payment by outcomes so services have to collect patient reported experience measures (PREMS), patient reported outcome measures (PROMS) and clinician reported outcome measures (CROMS) • Using digital technology, e.g. digital dictation; patient tablet and self management apps; direct data entry; clinical team dashboards for continuous quality improvement (QI) o The Head of Mental Health and Vulnerable Groups Policy Division for the Welsh Assembly Government (SW) then summarised the situation in Wales. There is a key strategic intent around measuring services and giving all those in secondary care a service user care plan. Wales has also introduced a primary care support service where GPs can refer patients to specialists. Access targets have also been set Presentation, Royal College of Psychiatrists o The contract holder for the National Audit of Schizophrenia (NAS) described the key features of the current audit, and what aspects might be improved in the re-specified National Audit of Psychosis (NCAP). Key points included: • NAS had 100% NHS trust participation in 2013 and a relatively good response to the survey of service users and carers. The NCAP will aim to replicate excellent local provider engagement (i.e. all sector trusts providing data and going forward) • NAS data have been used widely, including the 2 annual reports published by the audit providers. Two areas of focus in the NAS were: 1. The physical health care of mental health patients 2. Access to evidence based treatment. Both of these areas will likely continue to be a focus as part of the NCAP, along with the provision of crisis care o The new NCAP audit should use the same core variables as used in the NAS to ensure continuity for the audit. However, the number and type of data items will need to be reviewed as part of the development of the NCAP. The dataset should be rationalised in line with stakeholder requirements and new emerging national standards o There was broad consensus around key components of care and NICE standards for a national clinical audit of psychosis. This includes the following: • Within the first 3 years of the NCAP audit, the audit providers should develop the audit methodology upon which the NAS is currently based. Currently, the audit is National Clinical Audit of Psychosis, Specification and development meeting
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reliant on sampling case records for patients that meet the audit criteria. Data is collected by clinicians and audit department staff from the patients’ case records, and supplemented where appropriate with information from primary care services The NCAP should move towards developing continuous, routine data collection mechanisms. However, some sampling may be necessary, given limitations of available data on all patients. The data quality improvement plans in progress led by the Department of Health (England), the arms length bodies (ALBs) and professional bodies should be noted and tenderers should have regard for developments as part of the audit programme A core dataset should be succinct, e.g. 10 or 20 key variables, and should be related directly to standards and guidelines, and the quality improvement questions upon which the audit is based Providing consistency in relation to the data items collected would encourage trusts to invest in systems to collect the data items; however there were concerns that more frequent reporting would be a burden for trusts without electronic case notes The change in methodology should help to reduce the burden to trusts, and improve timeliness of reporting. This in turn will more effectively support continuous local quality improvement In addition, the NCAP should carry out in depth ‘spotlight ’ audits, e.g. service type and diagnostic sub-groups
Stakeholders discussion The discussion was opened up to the group. The following is a summary of the discussion. o The audit needs to collect patient level data and audit services across a pathway o The most important driver should be what service users want from the audit, and whether their areas of concern are being addressed. Five issues of concern to service users were summarised by one of the stakeholders, these are: • Being listened to • Not being given the context of services • Validation of peoples experiences • Choice and shared decision making • Being seen as a person o From a service user perspective, the audit should cover: • Psychological therapies - the NAS showed a gap between the offer of therapy and therapy take-up by service users; the NCAP could explore reasons for this • Legal use of the Mental Health Act, e.g. police involvement in detention • Thresholds for access to care coordination and community services – there are concerns these are set too high
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o Diagnostic data collected for the purposes of benchmarking would be useful. For example: • The psychosis supra-cluster could be used for those without a diagnosis • Interventions such as the number of patients given information, prescribed specific psychotropic drugs, and who have been given physical health checks and employment support could be identified • The audit should drive improvement in how these data are recorded (in the patients’ records) and used to improve clinical practice o Stakeholders felt crisis management and home treatment care for people with psychosis should be addressed in the audit. These services often only offer one contact with a professional and patients’ needs go unaddressed. o Physical health care is an important issue for patients, clinicians and commissioners. o The value of the NAS audit was that it looked at whether quality standards were being delivered to patients – this aspect should be retained. o Increasing the frequency of data feedback should be a focus for the new NCAP o The development of the NCAP should consider other data sources and monitor changes to theses, including the following: • Mental Health and Learning Disability Data Set (MHLDS) – soon to change to the Mental Health Services Data Set (MHSDS). This dataset will collect data on service users with psychosis and support the ‘parity of esteem agenda’ • Physical health and mental health CQUIN audit data sets. There is always uncertainty around whether CQUINS will continue year on year although the audit should encompass these data where possible. Further, CQUIN data may not be continuous, but the CQUIN indicators will be built into the new datasets and can be used to demonstrate trends • The need to avoid duplication of data collection is important. For example, data on employment, accommodation, and crisis plans are collected elsewhere o The group discussed what data items could be dropped from the current NAS dataset and what data were available from other sources. One suggestion was to drop pharmacotherapy items to streamline the collection of data o It was agreed that the audit should move to 6 monthly or quarterly reporting, and should try to develop a user friendly way to support local quality improvement, e.g. a dashboard o There was discussion around the lower age limit for inclusion in the audit, with broad consensus that it should be 16. There was also a view from some stakeholders that where young people aged 14 were in an adult ward, they should be included too. There should continue to be no upper age limit National Clinical Audit of Psychosis, Specification and development meeting
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o The inclusion of service users 16+ could provide information on early intervention services, which would help to improve clinical services o The overlap with the early intervention (EI) psychosis audit was discussed. This is a standalone audit which is due to end. It was agreed that HQIP should seek NHS England’s view about their intentions for the EI psychosis. In principle, this work should be part of the audit, or at least aligned with the audit work o The specification should include the requirement to explore how to link with the national diabetes audit and other NCAPOP audits o YS highlighted that successful national audits are those where the individuals providing the data are also in a position to improve the system, and there is a shared understanding of what good care looks like o Stakeholders were invited to comment on whether the audit should focus on a large group of patients at different stages of their illness, or should start from a specific point in the patient pathway. Stakeholders view included the following: • The original audit focussed on secondary care specialist providers as should the NCAP, but it will be essential to include primary care when feasible • NICE standards provide a good basis for the audit • The first two rounds of the NAS showed there were still areas of concern which should be reflected in the NCAP • The new programmes and national standards need to be included going forward • Auditing pathways is happening locally and is complex. A one day census would also be difficult due to the large numbers so trusts should be asked to sample • As the external landscape changes there is increasing pressure on services. Patient groups would prefer the audit to have an in-patient cohort, include those in forensic settings, and in the majority of community teams • Substance misuse is a common co-morbidity and is not included in any standards. It should therefore be included in the audit, as should detention rates. Health of the Nation Outcome Scales (HONOS) includes substance misuse but the NAS audit providers reported this was dropped from the second round of the audit as the data did not relate to any NICE standard. There is a NICE cooccurring psychosis and substance misuse standard which should provide detail • There are between 5000-6000 patients in medium secure units who could be included as part of the audit. YS confirmed that approval from NHSE was not needed to include specialised commissioning service in the audit. This could be a good example of a ‘spotlight’ audit topic o The meeting was summarised as follows: • The core of the audit should continue as described in the proposal
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The sampling methodology of the NAS should move to continuous data collection Data flows need to come together in the lifetime of the new audit Spotlight audits should incorporate the experience from the early intervention in psychosis audit (EIP) in relation to the areas where NICE standards can be assessed There will be one ‘spotlight’ topic per year Tenderers would need to define psychosis for the purpose of the audit Child and Adolescent Mental Health Services (CAMHS) services would not be part of the audit The lower age limit should be 16 with no upper age limit If auditing EIP is incorporated as a ‘spotlight’ audit then the lower age limit should be 14
The Chair thanked the group for their contributions and part 1 of the meeting was closed.
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