Delivering the Five Year Forward View for Mental HealthWhole systems approach to Mental Health Informatics, Information, Intelligence and Improvement Science (4Is)

#5YFV #MentalHealthDr Geraldine Strathdee @DrG_NHS

& Dr James Wollard

January 2015 v1

The 4 ‘Is’ is route map to better mental health services in England

Information & data

What are the national policies and priorities that

direct our work

What are the quality standards we need to

implement for evidence based best clinical

How do we agree what data to gather to assess baseline & to ensure we are making

progress

Informatics

How do we gather the data in a low burden way to free up time to care and improve

data quality

How do we achieve integrated care through

interoperability's & increased functionalities

Intelligence

How do interpret the data & turn it into intelligence for choice and improvement support for the public,

patients and clinical teams

Where do we find and share ‘What Good Looks Like’ to tackle the big problem of variation in standards and

17 year science to front line gap

Improvement

Implementation How do we create a Learning

Organization Model of leadership & improvement

NHS England’s The Five Year Forward View – Mental Health

• INVESTING IN MENTAL HEALTH NEEDS TO HAPPEN TO BENEFIT ALL OF US:

– Mental illness is the single largest cause of disability in the UK and each year about one in four people suffer from a mental health problem. The cost to the economy is estimated to be around £100 billion annually – roughly the cost of the entire NHS. Physical and mental health are closely linked – people with severe and prolonged mental illness die on average 15 to 20 years earlier than other people – one of the greatest health inequalities in England. However only around a quarter of those with mental health conditions are in treatment, and only 13 per cent of the NHS budget goes on such treatments when mental illness accounts for almost a quarter of the total burden of disease. Over the next five years the NHS must drive towards an equal response to mental and physical health, and towards the two being treated together.

• WE ARE ALREADY ON OUR WAY, BUT IT IS ONLY A START:

– We have already made a start, through the Improving Access to Psychological Therapies Programme – double the number of people got such treatment last year compared with four years ago. Next year, for the first time, there will be waiting standards for mental health. Investment in new beds for young people with the most intensive needs to prevent them being admitted miles away from where they live, or into adult wards, is already under way, along with more money for better case management and early intervention. This, however, is only a start.

• BEGINNING WITH TIMELY ACCESS TO THE RIGHT CARE:

– We have a much wider ambition to achieve genuine parity of esteem between physical and mental health by 2020. Provided new funding can be made available, by then we want the new waiting time standards to have improved so that 95 rather than 75 per cent of people referred for psychological therapies start treatment within six weeks and those experiencing a first episode of psychosis do so within a fortnight.

• CRITICAL STANDARDISATION OF CARE

– We also want to expand access standards to cover a comprehensive range of mental health services, including children’s services, eating disorders, and those with bipolar conditions. We need new commissioning approaches to help ensure that happens, and extra staff to coordinate such care. Getting there will require further investment.

January 2015 v1

The “I’ statements in 2014 for people who use mental health services – what they experience now and what they want

‘I cannot find good information on how to build my resilience for

whatever life throws at me

I look on NHS choices and i can’t see what services I can access

locally or on line

I am not sure if its safe to speak to peers on line in digital support

I have to tell my story over and over again in

every settings.

I am not sure my clinicians know what

each other has recommended

I don’t get any text reminders for

appointment or for my blood tests like I do

from the dentist & my physio

I don’t know what treatments will help me or how to judge

them

One of my psychiatrists uses an app to help me to do

mindfulness exercises as part of my therapy and its really helpful

I use crisis service often because i can’t seem to

get them all to work together to share my

crisis care plan

I can’t have my treatment at home although it is a struggle for me to get out because my CPN’s trust will not let her use

video-calls or skype

I wish I could have my physical health monitored at home, so I don’t have to travel to be told my blood pressure is normal

and to carry on with the same treatment

My mother has dementia and she is not safe as she wanders at night and we dont have technology to

keep her safe at home

I am psychological resilient and use on line

tools to help have a better quality of life

I use a series of on line self assessment and

management tools as part of my ‘mental health

‘reading

I can safely use an on line peer support platform to

get support when a bit shaky

I can access psychological therapy for my conditions

on line

I can have my treatment as a combination of on

line, face to face, groups, by skype

I get text reminders to remind me to go for blood tests, see my

doctor for monitoring, take my medication,

inspirational lines

I love to hold my own records and get my blood

tests and track my own improvement and self

monitoring

I feel more in control as I am more knowledgeable

My doctors and professionals all get the test results so I feel safe

that treatment is not interacting badly

I feel safe that when my records are shared, the very confidential issues

are well safeguarded

I can get most of my treatment at home

I now get my blood tests at home

I can monitor my blood pressure and weights on

my iPhones the trust gave me

The ambition for 2020:“I’ statements for people who use mental health services in the future

The 4I’s behind meeting the #5YFV:

Intelligence

Information

Informatics

Improvement Science informed

change

January 2015 v1

In order to meet the vision of the five year forward view we need to engage in a whole systems approach that makes the best use of the Informatics, Information, Intelligence and Improvement Science available and being developed. These 4 “I’s” form a reinforcing cycle that will drive the system towards better more effective care, for more people, in more communities, in more personalised, technology enabled ways.

4I’s sit at the centre of delivering effective policies that lead to better commissioning and better, personalised care

January 2015 v1

Activity and Outcome Based Tariff Models

Effective Patient Choice

Access and Waiting Time Standards to Evidence-Base Care

Information,

Intelligence,

Informatics &

Improvement

Science

Quadri-lingual Leadership

At the heart of the strategy to meet the five year forward view for Mental Health, we need four areas of co-ordinated leadership brought together in effective forum:

– Policy and Healthcare Economics

– Patient/Person using services

– Technology and Data

– Clinical and Improvement Science Evidence

• Identifying and bring together the core leadership in these areas will be critical

• Maintaining and developing the right skills and knowledge in emerging leaders will also be critical to continuing progress through to 2020

January 2015 v1

Aims of a 4I strategy for Mental Health

January 2015 v1

• To implement the “No health without mental health”, Better Access & Crisis Concordat policies, and support the implementation of the CYP taskforce recommendations & dementia

• To determine & develop the transparent metrics to inform Ministers, policy makers, the public, patients, commissioners & clinicians of the levels of access, standards, outcomes & Value of the NHS, Las, & wider system collaborative communities functioning

• To inform the development of an information, informatics, intelligence & improvement highway to support the implementation of the 5YFV aims

• To steer the development of digital maturity in the mental health sector to• a) ensure the commissioning of electronic care records systems that maximise the functionalities &

interdependencies of Electronic care record across primary & specialist sectors & social care sectors, • b) enables modern integrated, safe, NICE/SCIE concordant effective treatment & care, & routine

outcome measurement, fed back to front line clinicians and teams to drive improvement & transformations in care,c) improves data quality through reduced burden of data collection for clinicians &, delivers a digital revolution in data access, decision support systems for patients & clinicians,

• To identify through our mental health networks, SCNs , AHSNs, CLARCs, ‘What Good looks like’ in commissioning, provision & empowered patient self care & disseminate through improvement programmes & to ensure sustainability through establishing an independent, robustly funded mental health intelligence network collaborative ( like cancer IN)

10

Policy• 5 Year Forward View • No health without MH’• Cross Govt Commission • Better Access & Choice• Crisis Concordat• Care pathways & CFV• PHE prevention agenda • Workforce modernisation• Generational ambition• Tariff & economic

modelling• Funding allocation

formula

Better, safer, modern care• NICE /SCIE HTAS, PH &

care guidelines, quality stds

• Generational • Outcome measurement• Research programme• CPRD• Prevalence project• CFV design • RCPsych/BPS Better

/MIND better formulation

• ICD/ smowmedintroduction

Systems Programs• SOS transparency prog.• Jon Rouse T & F & PID• MHSB sub group• 13 agency programme• HSCIC, MHMDS spec.

for ICD, bed+ team types,

effective interventions, Oats + coding alignment with A/E, ambulance, CEM, MH

• NHS Choices information

Fingertips pathways• Prevention, Social care

Primary care • Workforce data • New NHSE+ CQC, CCQUI

• Website dev’t

NCD team work • JSNAs• Psychosis reports etc• Atlas of variation • Outcome metrics • Quality metrics urgent• Crisis concordat

metrics• Crisis Concordat

assurance checklist• CQUIN

Governance WGLL programmes

Digital maturity optimization • Electronic records

(interdependency &

functionality

• Digital data collection • Empowered self

managing patients• Use of NHS number,

ODS 5 digits, ICDs• SPN notifications for

111 frequent attenders • Clinician decision

systems • Bradford SMI template• Capacity man’t system • 111 clinical pathways

Information sharing Caldicott protocols crisis

Digital governance• Digital Apps

accreditation• Digital therapies

accreditin• London platform

Current programs

• SCN manuals

• AHSN programmes

• CCG leaders programmes

Key products to commission

• Model JSNA + LGA/PHE

• Aligned coding for UEA

• Data demand & capacity modelling

• Economic modelling

• Workforce modelling

• In vivo live for every clinical team data set

• LCCG commissioner data set

Leadership & improvement programmes

1. What Good Looks Like Repository

2. BBC & journals comms• Timetable of products

• Slide share packs

3. MHIN funding

• Improvement offer 2 pager for 5 funders

• Establish blind trust

5. NCCCH access and waits programme + MHIN ERGs

6. AHSN & Education

• JSNAs

• AHSN psychosis pathway

• East London course

• Educational products e.g. slide share

• Commissioning for value

• Newsletter to CCGs/ SCNs

What directs our work Getting & sharing good data

How to agree & assure the data indicators & analysis

Turning data into intelligence and improvement programs

How do we develop leaders with literacy to drive sustainable transformation & improvement

Policy & clinical best practice developments Digital developments

Governance &Innovation

An overview of the 4I programs in place or being developed to meet the #FYFV

Why we need a 4I’s strategy group to deliver it

• There are already multiple programs internally and externally to NHS England that are trying to achieve the same ends, leading to partial and incomplete solutions being reached

• The number of existing and potential data streams is expanding and will continue to expand. There needs to be an agreed, structured approach to organising and analysing those streams of data – this is critical in closing the loop of: data – information – intelligence –transformative change

• The increasing use and desire to use technology in self-care and care co-produced with Healthcare serviced must be backed by co-ordinated, effective and safe policy – this cannot be achieved if the relevant experts and stakeholders and not brought together in a sustained and organised way.

• Specifically to Mental Health services: There is wide recognition that they are not meeting the needs of the population, both in terms of the level of services available, but also in their current models of delivery. However evidence for effective model of service and care exist and need to be implemented in an intelligence driven way to bring about the changes desired by all parties.

January 2015 v1

The Critical 5 W’s of data that will drive the 4I’s

• To accurate describe the pathways of care we need to collect data about 5 critical aspects of the processes involved at every stage:– Who - Patient and HCP - NHS number and National Staff codes

– Why - Diagnosis Codes – ICD-10, SnoMed

– What - Intervention codes

– Where - ODS codes, standardised taxonomy of services across data streams

– What Happened - Outcome measurements

• Many of the W’s are already collected but need greater coordination across data sets.

– The NHS number provides a key part of this and hence the importance of it as a “Primary Identifier”

– Intervention codes are the least developed area of data

– Use of Outcome measures needs to become embedded in clinical practice beyond IAPT services.

– There is no current standardised taxonomy of services to define “where” care took place

January 2015 v1

“Global” Mental health Taxonomy of service types and accurate

Directory of Service based on it

Tariff ModelsOutcome or Acitivity

based models require clear evidence of

where care took place

Enabling Choice through choose and book – services

registered appropriately

Standardised information for patients to make informed choice and access services appropriate

Transparency and comparability of services – drives service improvement

Allowing standardised collection of data and aggregation of data across sources

Where? – A standardised taxonomy and maintained Directory of Service are a critical part of delivering other policy areas

Access and Waits – Clarity and standardisation about what these mean

Admission/Attendance

Referral

Assessment

Care Planning

Investigations Treatments

Discharge

I can only receive information by fax or over the phone and then have to transcribe this into an electronic record system

I have to write duplicate entries in the medical records, often still paper based, and the mental health records system

I cannot use technology based interventions and monitoring routinely in

care planning

I have to rely on colleagues in acute trusts to access pathology results otherwise I have to call the pathology lab and receive the results manually over the phone

I have to rely on paper systems to transfer results of investigations between acute settings and mental health outpatient and community clinics

I cannot routinely contributed to an integrated discharge summary that is electronically distributed.

I can only use technology in a limited way to keep patients up-to-date with follow-up arrangements

There is no place for an collaborative shared care plan between the medical team, mental health team and the patient/their carers

Information about attendance or admission is not automatically sent to mental health trusts systems

The current use of technology in Mental Health Care is far from what it could or needs to be to meet the vision of the #5YFVLiaison Services – example “I statements” for professionals now

Admission/Attendance

Referral

Assessment

Care Planning

Investigations Treatments

Discharge

I can receive referral electronically that integrate into the electronic records system reducing duplication of work

I can write one entry in one record system and it is shared with other linked records systems, or there is one record systems across trusts

I can recommend technology-enabled care that integrates well with

other IT systems – e.gApps or remote sessions

using videocalling.

I have access to pathology systems within the electronic patient record for mental health service. I can order investigations online and remotely

Information about t physical health investigations is shared with primary care and community services electronically

I can contribute to an electronically integrated discharge summary

Discharge plans (eg. appointment times) are routine shared and updated through an electronic system . Notifications are sent about changes to staff who will see the patient

Care plans are shared in real time across systems and can be updated and) accessed by all involved (including patients.

My team are able to receive timely alerts through an integrated system that enable us to respond quick and triage our work more effectively

In to the future...Liaison Services – “I statements” for professionals in 5 years

Wider Consensus Needed On Difficult Issues:

• Who own’s data generated by individuals – how do we agree policies that ensure we can make the best use of this for the individual, communities and the whole healthcare system

• How do we manage (both in terms of policy and technically) the balance between confidentiality of data and the need to share information (such as care plans) to ensure better care, particularly in urgent or emergency care and working with other agencies. Not addressing these will lead to barriers in making progress. Allowing local decision to be made on this will lead to a myriad of solutions that will continue that post-code lottery of care

• Due to the sensitive nature of many narratives in mental health, potential vulnerability for those suffering from mental health difficulties in negotiating these issues, and the relevants laws, these issues required specialist consideration beyond that which may agreed for other areas of healthcare

January 2015 v1

AppendicesMapping the Complexity in the system

• The following slides illustrate the complexity of the systems we are working with and the need for a consistent 4I’s strategy across the mental health care system.

• That the systems we are trying to influence and change are complex only underlines the need for a co-ordinated national mental health strategy around informatics, information, intelligence and improvement science.

January 2015 v1

Local/FrontlineP

ub

lic S

ecto

rIn

du

stry/Private Secto

r

National/International

NHS England

Tim KelseyBeverly BryantMonitor

PHEGregor

HendersonCQC

Paul Lelliot

Benchmarking Club

NHS Trusts

Private Health Care

Providers

CCIOs

RCPSYCH

Simon Wessley

CCGs

Informatics CommitteeJonathon

Richardson

MHINJames Seward

Transparency – Emma

Doyle

CCG Leadership Program –Data and

Tech Themes

Apps Library Kite Marking Technology –Simon Dixon

DHKathy

SmethurstPeter Burke

Charlotte Lilliford

Wildman

HSCICAndy

Williams

EHI CCIO NETWORK

EHI

Digital Maturity Index

Technology Strategy –Paul Rice

TDA

Pathways –Jackie Shears

NHS Choice

s –Nicola

Gill

AHSNs

CSUs

NICE

The 4Is Organisational Map – there is more to go on this!!

Electronic Patient Record

Providers

British Computing Society –Specialist

Interest GroupDigital Maturity

Model For Mental

Health –Jackqui

McBurnie

Patient Information/Technology – Helen Rowntree

Oxford AHSN

– Sarah Amani

Composite indicators – Karina G

Data CataloguePaul Gavin

January 2015 v1

Health Foundation –Improvemen

t Expertise

Awareness/Acknowledgement of health related problem

Initial healthcare seeking activityEffective Choice is Enabled

Public Health/Preventative

Programs

Consultation and management in Primary care

Referral for further assessment/careby outpatient secondary care provider

Effective Choice is Enabled

Pre-consultation “wait” period

Specialist Consultation

Post consultation Wait/communication period

Further consultation/Investigations/

Interventions started

Individual generated data eg. From Fitness Tracker

Web searches results from Google etc

NHS Choices and its information and Data

“Quantified Communities” – Mental Health Intelligence Network (with participatory model)

Analysed by Geography

Accesses Urgent or Emergency Care Services (via 999/111)

Primary care record systems and generated data sets

Episode of Secondary Care Inpatient Treatment

Access and Waits standards data -monitoring

NHS Pathways systems data

Outcome Data

Data from self-management tools/technology and programs

KeyGreen –Information flowing away from the person using services

Blue –Information and Intelligence flowing back to the person using service

Secondary Record Systems

Secondary Record Systems

Initial 4I Flow Map – How Choice, A&W and Outcome link across the pathways

Awareness/Acknowledgement of health related problem

Initial healthcare seeking activity

Public Health/Preventative

Programs

Consultation and management in Primary care

Referral for further assessment/careby outpatient secondary care provider

Specialist Consultation

Accesses via Urgent or Emergency Care Services (via 999/111)

Episode of Secondary Care Inpatient Treatment

Continuation and modification of care package

Discharge from Secondary Care

Outpatient Care Package agreed and implemented

CPA Discharge from Secondary inpatient care

Community DischargesClinical Outcome Measure (e.g Honos)

7 day follow up

Inpatient Measures Admissions by bed type DischargesLength of StayBed Occupancy RateSeclusion RatesMedication ErrorsRestraintDeath RatesMedication AdherenceRates of Detention of MHAOutcomes of Detention

Community “In treatment” measuresGoals MonitoringInterventions CodesAttendance rates/missed appointmentsPrescription Changes

Medication Adherence

Outcome/RecoveryClinical Severity Measurese.G PHQ9Honos/HonosRates of EmploymentPrimary Care Data

Diagnosis rates in Primary Care by ICD-10 codeUse of psychotropic medications – prescription rates Use of Legal Right to ChoiceAccess to Primary Care

MH assessment in secondary care setting (e.g A&E, 136 suite)

Initial measures and dataAccess and Waiting timesClinical Severity ratingsICD Diagnosis ratesComplexity Measures – Social deprivation, rates of co-morbid conditionsInterventions codes Prescription Rates

Outcome and Activity Measures along the pathway

Awareness/Acknowledgement of health related problem

Initial healthcare seeking activity

Public Health/Preventative

Initial consultation with primary care professional

Referral for further assessment ?by secondary care provider

Pre-consultation “wait” period

Specialist Consultation

Post consultation Wait/communication period

Further consultation/Investigations/Interventions started

empowered self-monitoring

And data gathering

“Portal” website/app facilitating self triage – structured assessment tools

System that generate Co-constructed referrals

Online toolsthat inform consultation Apps, Websites, text message

Paper diaries

Preparing for consultation

Information websites/apps/videos

Comms systems around referral progress

ServicesVideos on YouTube

, Twitter, Virutal Wards

Text message acknowledgementsAnd updates

Good Guiding Systems Principles

• Every interaction is an intervention – “design” this in.• There should be no such things as “waiting time” • Processes should be adaptable to overcome barriers• Shared ownership of information where possible

Specific sites/Apps. E.g. “Docready”

Ongoing self-monitoringand data gathering

Co-Constructed and recorded outcomes

NHS Choices and other curatedinformation sites

The Potential of Technology to enhance person-centred care and pathway effectiveness

Technology delivered or enhanced

Therapy