Mental Health BenchmarkingI

(1)

Psychiatry by Numbers

Mental Health Benchmarking

I

Stephen Watkins, 17

^th

May 2017

1

(2)

 UK NHS

 Benchmarking context

 Comparing provision & quality

 Adult comparisons from the UK

 International

 Discussion points

Overview

2

(3)

• Population 65m

• England 55m

• Scotland 5m

• Wales 3m

• Northern Ireland 2m

United Kingdom

³

(4)

United Kingdom

⁴

(5)

United Kingdom

⁵

(6)

Sweden

⁶

(7)

• National Health Service (NHS)

• Founded in 1948

• Free universal healthcare for all 65m people

• Funded through general taxation

• World’s largest publicly funded free healthcare system

• Spends £130b p.a.

• Around 10% of this is on mental health

• £12b - £13b

United Kingdom NHS 7

• NHS = world’s 4^th largest employer @ 1.7m staff

• 3^rd = McDonalds @ 1.9m staff

• 2^nd = Walmart / Asda @ 2.1m staff

• 1^st = Chinese Peoples Liberation Army @ 2.3m

(8)

 One of, the World’s largest healthcare benchmarking groups

 Member led topics advised by:

o

Steering Group

o

Sector based Reference Groups

 High quality products and services

 Critical mass achieved through 330+ organisation membership

 Unique data views, aims to fill gaps not covered by central NHS information sources

NHS Benchmarking Network

(9)

NHS Benchmarking projects

 Urgent Care

 Pharmacy and Medicines Optimisation (Commissioner)

 Planned Care

 CCG Functions

 Total System Benchmarking

 Primary Care

 Mental Health Inpatients and Community

 CAMHS

 Learning Disabilities

 Corporate Functions

 Pharmacy & Medicines Optimisation (Provider)

 Emergency Care

 Radiology

 Older People’s Care in Acute Settings/ DToC

 Operating Theatres

 Outpatients

 Acute Therapies (SLT, Dietetics, Physio and OT)

 Community Services

 Enhanced Monthly Community Indicators

 Community Hospitals

(10)

Benchmarking Structure

Quality

Finance

Activity

Workforce

“Benchmarking is the use of

structured

comparisons to

help define and

implement good

practice”

(11)

Annual UK benchmarking project process

1. Project initiation with

reference group

2. Data

collection and validation

3. Project outputs; reports

and software

4. Next steps;

good practice sharing & next

cycle

(12)

 Mental health reference group direction and content management

 Chief Executive consultation

 Definitions development

 Collection process May – July 2017

 Telephone helpline, e-mail, and Q&A support to members

 Data validation – consistency review, outlier feedback, member review

 First draft reports

 Changes, updated reports and sign-off*

 Publication 2

^nd

November 2017

 NB – This is a voluntary process

Background and Process 2017

(13)

Adult Inpatient and

Community Mental Health Benchmarking

• 100% coverage across providers in England & Wales

• Scotland & Northern Ireland

• Additional independent sector &

Island providers

• International comparators on small number of measures

Mental Health Data context

13

(14)

Benchmarking reports and software tools for local analysis

Mental Health benchmarking products

14

(15)

23,000 inpatient beds

1m people on community caseloads

100,000 people employed in Adult mental health services

Mental Health in England

¹⁵

(16)

What type of beds do we have?

Adult Acute (35%)

Older Adult (22%) Medium Secure (10%)

Longer Term Complex /

Continuing Care (8%)

Low Secure (7%) High Dependency Rehab (6%)

PICU (4%) High Secure (3.5%)

Mother and Baby (0.5%)

Eating Disorders (1%)

Other beds (3%)

(17)

• 70,000 inpatient beds in 1987

• 23,000 inpatient beds in 2017

• 1m people on community caseloads

• 100,000 people employed in Adult mental health services

Mental Health Data context

¹⁷

Balance of Workforce Balance of Care

(Admissions vs. caseload)

(18)

General Psychiatry / Adult Acute services

18

(19)

• Mental health inpatient bed capacity describes a

recognisable element of a country’s mental health

infrastructure and informs the likelihood of patients being admitted to a bed.

• The data reveals a mean

average of 51 General Psychiatry beds per 100,000 population in the working age adult group aged 18-64.

• England’s position of 26 beds per 100,000 population is comprised of Adult Acute, PICU, Perinatal and Eating Disorders beds.

General Psychiatry Beds

19

Taxonomy = Adult Acute, PICU, Eating Disorder and Perinatal beds for ages 18-64

1Also includes general old age psychiatry

1 0

20 40 60 80 100 120

NOR NLD SCO SWE CAN AUS ENG CYM

General Psychiatry Inpatient - Beds per 100,000 population (age 18-64)

Mean = 51 Median = 42

(20)

UK Adult acute beds per 100,000 registered population (16-64)

• Average bed numbers have stabilised this year

• National mean average = 21 per 100,000

registered population

• South East Region highlighted

(21)

Map of Variation – Adult Acute beds

Adult acute beds per 100,000 registered population (16-64)

Adult Acute beds per 100,000 registered population

Greater London

10 53

(22)

Mean length of stay in adult acute beds excluding leave (national increase)

• 2015/16 mean average length of stay = 33 days

• 2014/15 mean average length of stay was 32 days

• South East peer group = 36 days

• Region has longest and shortest stays nationally

22

(23)

Average Length of Stay

23

A number of factors can influence length of stay,

including bed availability, patient acuity, rates of involuntary detention and models of community care to facilitate a prompt discharge.

A three-fold variation is demonstrated, with England reporting the longest lengths of stay, and Australia and

Netherlands the shortest.

The data focuses on General Psychiatry admissions and explicitly excludes psychiatric intensive care unit provision in each country. The impact of authorised leave is also shown as a red area on the chart.

1LOS including leave across all general psychiatry beds

1

(24)

Which type of patients occupy beds?

24

Occupied Bed Days by Diagnosis Group General Psychiatry Beds for ages 18-64

(25)

25

Involuntary Treatment

Involuntary admissions are frequently subject to a minimum detention period which will impact on the length of stay in an inpatient bed. Where bed numbers are smaller, it is likely that the

percentage of admissions that are involuntary will be higher, as thresholds for admission rise, and patients detained under local Mental Health Act legislation make up a larger proportion of the inpatient cohort.

Patients who are sectioned under the Mental Health Act in England typically stay 50% longer than patients who are not detained. In England, mean length of stay for all Adult Acute patients is 33 days excluding leave. Mean length of stay for Adult Acute patients sectioned under the Mental Health Act is 46 days.

(26)

Admissions under the Mental Health Act (national increase)

• 2015/16 = 35%

of Adult Acute admissions are involuntary

• South East peer group = 40%

26

(27)

Adult acute bed occupancy 2015/16 excluding leave

• 2015/16 median bed occupancy 94%

• 2 Trusts in peer group at or below 85% occupancy

• RCPsych guideline recommends 85%

occupancy

• 103% occupancy in including leave

27

(28)

UK Adult Acute Summary Time Series

28

 Long term trend of bed reductions

 Length of stay increased

 Delayed transfers decreased

 Readmissions down

(29)

Benchmarking ALOS & Occupancy

Profiling average length of stay excluding leave

Bed Type Average length

of stay (days)

Bed Occupancy

% Child / Adolescent Eating Disorders 123 70%

Child / Adolescent Secure 271 55%

Child / Adolescent Other / Behavioural 72 74%

Adult Acute 33 94%

Older Adult 81 85%

PICU 50 86%

Low Secure - Forensic 584 89%

Medium Secure - Forensic 620 91%

Eating Disorders 108 77%

High dependency rehabilitation 499 86%

Longer term complex / continuing care 546 85%

29

(30)

Workforce

30

(31)

Consultant Psychiatrists per 100 Adult Acute beds

• 2015/16 average 5.8 WTE Consultant Psychiatrists per 100 Adult Acute beds

31

(32)

Qualified Nursing staff per 100 Adult Acute beds

• 2015/16

Qualified Nursing staff per 100

Adult Acute beds

= 74 WTE

• Unqualified Nurses and

Support Workers

= 73

• Total “Nursing” = 147

32

(33)

Therapy staff per 100 Adult Acute beds

• 2015/16

Occupational Therapy staff per 100 Adult Acute beds = 7.5 WTE

33

(34)

Multi-disciplinary team comparisons

Adult Acute Staff Groups

All Participants 40.9%

0.0%

0.1%

3.9%

0.7%

0.3%

2.9%

2.4%

1.1%

0.1%

3.8%

36.1%

1.0%

5.7%

1.1%

Other HCPC (Health and Care Professionals) Total Nursing

Peer support workers (Paid) Social Workers

Occupational Therapists (OT) Clinical Psychologists Psychology - Other Psychiatry - Consultant

Psychiatry - Training Grades (Assoc Specialist, SpR, Trust and Staff Grades) Psychiatry - Trainees (FY1 & FY2)

Mental Health Practitioners

Support Workers and Other Unqualified Clinical Staff Management

Administrative and Clerical Other Staff

(35)

Workforce – what works best?

Hypothesis testing 1 - Does the level of therapy input

impact on average length of stay?

(36)

Benchmarking Specialist Beds

Profiling clinical input against length of stay

• PICU analysis

• Higher

staffed

units have

marginally

shorter

length of

stay (3%)

(37)

Benchmarking Specialist Beds

Profiling clinical input against length of stay

• PICU analysis

• Units with

higher

Psychiatry

input have

marginally

shorter

length of

stay (5%)

(38)

Benchmarking Specialist Beds

Profiling clinical input against length of stay

• PICU analysis

• Units with higher therapy input

(Psychology

& OT) have

shortest

length of

stay (-20%)

(39)

Agency staff usage in Adult Acute Mental Health services

• 11% of all NHS jobs are currently vacant

• UK wide, 19% of Mental Health pay costs are on

temporary / agency staff

• Emergency

departments in UK spend 25% of pay costs on temporary / agency staff

39

(40)

Community services

40

(41)

Community Mental Health Teams - Caseload levels per 100,000 registered population 2015/16

• 1 million people are on the

caseloads of specialist mental health services

• 1.8% of UK population

• 2015/16 = 1,803 patients on the caseload per 100,000

population

41

(42)

Total caseload per 100,000 registered population

42

(43)

43

Community Services

* 7-14 day community based follow-up post discharge

• Countries typically aim to offer a first follow up appointment for patients discharged from inpatient care within 7 days or 14 days of discharge.

• England reports the highest rate of community based follow up care with 96% of patients followed up by a specialist mental health practitioner within 7 days of discharge.

(44)

Community Mental Health Teams - Contact levels per 100,000 registered population 2015/16

• 2015/16 = 34,053 contacts per 100,000 population for all

Community Mental Health Teams

• Each patient

averages 19 contacts per annum if they stay on caseload for a

year…

• Only 4 of 9 countries quantified the level of community care p.a..

• Wales 17

• Australia 22

• Sweden 8 p.a.

44

(45)

Map of Variation – Community Contacts

Community MH Team contacts per 100,000 registered population

All CMHTs - Total contacts 2015/16 per 100,000 registered population

Greater London

16,204 82,591

(46)

Caseloads, contacts and waiting times

2

^nd

Appointment waits for community MH services

Contact rates per person

Contact Rates per person p.a.

Contacts Early Intervention 25

Older People 12 Mother and Baby 9 Assertive Outreach 49 Assessment & Brief

Intervention 6

General Community

Team 14

Eating Disorders 15 Memory Services 5

(47)

Mental Health Finance & Economics

47

(48)

Community Finance comparisons

Community Mental Health Service Costs

Annual cost per service user on CMHT caseload 2015/16

 General Community Mental Health Team cost per service user on caseload = £2,880 p.a.

 Increases to

£6,500 p.a. for service user with first episode

psychosis

(49)

Benchmarking Beds

Profiling inpatient costs

Bed Type

Average cost per admission £

Average cost per bed per annum £

Adult Acute £12,198 £131,267

Older Adult £34,027 £129,458

PICU £38,503 £230,552

Low Secure £455,361 £150,427

Medium Secure £412,170 £179,127

Eating Disorders £68,916 £166,956

High Dependency Rehabilitation £360,382 £116,858 Longer Term Complex / Continuing

Care £533,383 £136,302

(50)

1 adult acute bed

= 46 patients on a community team caseload 1 adult acute bed

= 20 patients on an Early Intervention in team caseload

1 older adult bed

= 33 patients on an older adult CMHT caseload

Economic comparisons

(51)

Safety and quality

51

(52)

Example benchmarking comparisons

Service Users in Settled Accommodation

• 2015/16 66% of service users (CPA) are in stable

accommodation

52

(53)

Example benchmarking comparisons

Service Users in Employment

• 2015/16 8%

(CPA) of

service users are in

employment

53

(54)

Example benchmarking comparisons

Incidents of violence to patients per 100,000 bed days

• 2015/16 286

incidents of violence to patients per

100,000 occupied bed days

54

(55)

Example benchmarking comparisons

Incidents of violence to staff per 100,000 bed days

• 2015/16 538

incidents of violence to staff per 100,000 occupied bed days

• Highest levels at 2 Trusts with highest detention rates

55

(56)

Example benchmarking comparisons

Incidents of restraint per 100,000 bed days

• 2015/16 954 incidences per

100,000 occupied bed days

• 2014/15 at 841

• 2103/14 at 781

• Reported use of restraint has

repeatedly risen in recent years

• Key indicator for some countries (e.g. New Zealand)

56

(57)

Example benchmarking comparisons

Incidents of prone restraint per 100,000 bed days

• Prone restraint reduced this year

• 2015/16 160 incidences per 100,000 occupied bed days. Reducing levels…

• 2014/15 at 199

• 2013/14 at 231

• “Positive and Safe”

campaign

encouraged by Ministers

• “No Force First”

57

(58)

Restraint – how do services compare?

3240

Incidents of restraint per 100,000 occupied bed days (median) on Learning Disabilities inpatient wards

2200

Incidents of restraint per 100,000 occupied bed days (median) on PICU (female wards highest)

3550

Incidents of restraint per 100,000 occupied bed days (median) on Child and Adolescent wards

954

Incidents of restraint per 100,000 occupied bed days (mean) on adult acute

(59)

Service User satisfaction

Benchmarking service user satisfaction rate 2015/16

 Annual surveys are conducted across England

 Community MH Team service user satisfaction rate 73%

 Range from 92%

to 63%

(60)

Staff satisfaction

Benchmarking service quality – Staff satisfaction rate 2015/16

 Annual surveys are conducted across England

 Staff satisfaction rate = 76%

 HONOS used as main outcome score

 International

interest in Mental Health PROM

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MH54 MH55 MH69 MH35 MH53 MH66 MH34 MH42 MH08 MH43 MH64 MH12 MH32 MH41 MH68 MH10 MH17 MH33 MH09 MH49 MH19 MH29 MH38 MH11 MH28 MH65 MH02 MH44 MH60 MH36 MH14 MH18 MH13 MH56 MH22 MH23 MH63 MH51 MH07 MH61

Quality Outcome Measures - NHS Staff Survey results % feeling satisfied with the quality of work and patient care they are able

to deliver

Organisations Region MH33 Mean

Lower Quartile Median Upper Quartile

(61)

61

Suicide – general population

Suicide data has been provided by countries for the most recent year available (2013 or 2014). This data is also generally consistent with that available from the World Health Organisation’s Global Health Observatory (2012).

This data considers whole population suicide rates and is not exclusive to those in contact with mental health services. Data from the UK suggests that approximately 26% of suicides annually are from those in contact with specialist mental health services

(62)

Benchmarking world city mental health London mental health dashboard

Online interactive dashboard launched across London October 2016

London’s most important mental health data

(63)

 Benchmarking provides evidence for understanding services, removes the need for anecdotes

 Incentivised involvement is required

 Has mapped UK historic reduction in adult inpatient bed provision

 UK has long average length of stay on Adult acute wards - 33 days, international outlier

 Adult acute bed occupancy high @ 94%, 103% including leave

 Adequate admission avoidance capacity?

 Patient preference and economic case for community care

 Balance of investment – inpatient care attracts most resource, slow shift towards community care

 Incident types show improvement, notable reduction in prone restraint

 International momentum exists for Mental Health PROM

 Make sure you are sighted on your data!

Conclusions

(64)

Discussion Points

Contact: s.watkins@nhs.net

64