Improving service user experience in adult mental health – NICE guidance and National Quality Standard

Patient Experience Annual Conference, 9 November 2011The King’s Fund Professor Tim KendallDirector of National Collaborating Centre for Mental Health, Royal College of Psychiatrists and Visiting Professor UCL

Medical Director and Consultant Psychiatrist for homeless people, Sheffield Health and Social Care Trust

NCCMH

• Evidence-based mental health clinical practice guidelines factory for the NHS (funded by NICE)

• Our guidelines are about the overall treatment of schizophrenia, depression, bipolar disorder, drug misuse etc (takes 2 years each)

• Review ALL treatments (drug, psychological, social, service level), including service user/patient experience of care

10 years of NICE guidelines in mental health in UK

• Schizophrenia* December 2002• Eating disorders January 2004• Self-harm* July 2004• Depression* December 2004• Post-traumatic stress disorder July 2005• Depression in children* September

2005• Obsessive-compulsive disorder* October 2005• Bipolar disorder July 2006• Dementia* November

2006• Ante and postnatal mental health February 2007• Drug misuse – psychosocial July 2007• Drug misuse – detoxification July 2007

10 years of NICE guidelines in mental health in UK

• ADHD* September 2008• Antisocial personality disorder January 2009• Borderline personality disorder* January 2009 • Schizophrenia (update)* March 2009• Depression (update) October 2010• Depression (chronic health problems) October 2010• Generalised anxiety disorder* February 2011• Alcohol dependency March 2011• Psychosis and substance misuse* March 2011• Referral /ident.n common MH disorders April 2011• Self harm – Longer term management November

2011

Overseas guidelines/national quality standards

• Caesarean section – no clinical indication* October 2010• Management of acute stroke* February 2011

Guidelines underway

• Improving the experience of care in adult mental health*• Autistic spectrum conditions in adults (with Holland)• Schizophrenia in children and young people (under 18 years)*• Conduct disorder in children and young people• Autistic spectrum disorder in children (treatment and management)

(with SCIE)*• Mental health impact of abortion (for Academy of Medical Royal

Colleges)*• Schizophrenia in adults (update and QS)

NICE and service user experience• NICE and clinical and cost effectiveness?

• Incorporating service users/carers in the first NICE guideline– atmosphere and focus of GDG– language

“People with schizophrenia should be cared for in an atmosphere of optimism and hope”

• Mental health: chapter on service user and carer experience - in all guidelines

Finding out about the experience of service users – NICE mental health guidelines

• The service user/carer chapter

– Testimonies/stories from service users and carers

– Qualitative studies and reviews

– Service user literature review

– NHS staff attitudes

– Focus groups and interviews

– National surveys (eg CQC)

Self-harm in the emergency department• Both service users (but not carer) left the guideline!

– Focus groups (self-harm network)– Service user literature (internet and service user

organisations)– Systematic review of health care staff attitudes to self

harm (emergency room, GP, psychiatric units)

“Don’t sew up service users without an anaesthetic!”

ADHD and ritalin

• SU (ADHD as a child) and two carers on guideline

• Reviews of literature on parents and teachers views/experience of Ritalin – nothing on children

• New interviews with children taking Ritalin undertaken by LSE

• Children take Ritalin in the way they want to – mainly to help keep friendships and stave off school boredom

Depression in adultsThematic qualitative analysis of www.healthtalkonline.org

• Experience of depression• Accessing help• Stigma of depression• Experience of psychological treatments • Experience of drugs • Experience of ECT• Experience of health care professionals• Experience of services, families and coping

NICE Quality Standards for Patient Experience• Quality standards on patient experience:

– Patient experience in generic terms

– Service user experience in adult mental health

• Project started: November 2010• Anticipated publications: November or December, 2011• Patient and professional chairs; GDG members mainly SUs

and carers

What is a quality standard? A set of specific, concise statements that: act as markers of high-quality, cost-effective care

across a pathway or clinical area; are derived from the best available evidence such

as NICE guidance or other NHS Evidence accredited sources; and

are produced collaboratively with the NHS & social care, along with their partners & service users

Methods for developing the guidance and quality standards (1)

1. Design a framework for the experience of care – based on a matrix created using:– Dimensions of person-centred health care (Picker Institute Europe)– Key points on the pathway of care

2. High quality care for service user experience – GDG developed qualitative statements that describe key requirements for the provision of high quality service user experience, and the desirable or expected outcomes

Methods for developing the guidance and quality standards (2)

3. Identify key problems – Review key problems in current service user experience by triangulation of:– Existing qualitative reviews (themes extracted from existing NICE MH

guidelines) – Existing + new qualitative analyses (eg, Healthtalkonline – Experiences

of schizophrenia/psychosis)– Surveys (e.g., CQC Community mental health survey , 2010)

4. Identify interventions to improve the experience of care – Review interventions for improving service user experience.

A framework for person-centred health care

Involvement in decisions & respect for preferences

Involvement in decisions & respect for preferences

Clear, comprehensible information &

support for self-care

Clear, comprehensible information &

support for self-care

Emotional support,

empathy & respect

Emotional support,

empathy & respect

The relationship between individual service users and professionalsThe relationship between individual service users and professionals

Fast access to reliable health

advice

Fast access to reliable health

advice

The way that services and systems workThe way that services and systems work

Effective treatment

delivered by trusted

professionals

Effective treatment

delivered by trusted

professionals

Attention to physical &

environmental needs

Attention to physical &

environmental needs

Involvement of, & support for, family &

carers

Involvement of, & support for, family &

carers

Continuity of care & smooth

transitions

Continuity of care & smooth

transitions

Picker Institute Europe, 2009

Key points on the care pathway (Non-acute care)

Access AssessmentCommunity

care (including discharge)

Discharge/ transfer of care

Assessment and referral in

crisis

Hospital care

Assessment/ admission

under the MHA

Receiving compulsory treatment

under the MHA

Key points on the care pathway (Acute care)

Dimensions of person-centred care

Pathway of care

High quality care

Key problems triangulated

Possible interventions

Recommendations

Quality statement

A matrix for service user experience

NICE Quality Standard• 10-15 statements of good/excellent practice (aspirational)• Measurables (numerator and denominator)

– Structure (evidence of local arrangements that its happening and that this is being measured/recorded)

– Experience (surveys, interviews of SUs, showing its happening and this is a good experience)

• Action for– Commissioners– Providers– Health and social care professionals– Service users

Draft quality statements – community

1. People using mental health services, and their families or carers, feel optimistic that care will be effective.

2. People using mental health services, and their families or carers, feel treated with empathy, dignity and respect.

3. People using mental health services are actively involved in shared decision-making and supported in self-management.

Draft quality statements – community4. People using community mental health services are

normally supported by staff from a single, multidisciplinary community team, familiar to them and with whom they have a continuous relationship.

5. People using mental health services feel confident that the views of service users are used to monitor and improve the performance of services.

6. People using mental health services can access them when they need them.

Draft quality statements – community

7. People using mental health services understand the assessment process, their diagnosis and treatment options, and are emotionally supported with sensitive issues.

8. People using mental health services jointly develop a care plan with mental health and social care professionals, and are given a copy and an agreed date to review it.

Draft quality statements – community

9. People using mental health services who may be at risk of crisis are offered a crisis plan.

10. People accessing crisis support have a comprehensive assessment, undertaken by a professional competent in crisis working.

Draft quality statements – hospital

11. People in hospital for mental health care, including service users formally detained under the Mental Health Act, are routinely involved in shared decision-making.

12. People in hospital for mental health care can have daily one-to-one contact with mental health care professionals known to the service user and regularly see other members of the multidisciplinary mental health care team.

Draft quality statements – hospital

13. People in hospital for mental health care can access meaningful and culturally appropriate activities 7 days a week, not restricted to 9am to 5pm.

14. People in hospital for mental health care are confident that the use of control and restraint, and compulsory treatment including rapid tranquillisation, will be used competently, safely and only as a last resort with minimum force.

Draft quality statements – hospital

15. People using mental health services feel less stigmatised in the community and NHS, including within mental health services.

How standards will be used – communityExample – Quality statement 6: Timely and effective access to servicesPeople using mental health services can access them when they need them. Structure:a)Evidence of local arrangements to ensure agreed referral methods are in place between primary and secondary care.

How standards will be used – communityb) Evidence of local arrangements to ensure that people with

a non-acute referral to mental health services have a face to face appointment that takes place within 3 weeks of referral (and within 2 weeks of any service user request for change of date).

c) Evidence of local arrangements to ensure service users are seen within 20 minutes of the agreed appointment time.

d) Evidence of local arrangements to ensure that people in crisis referred to mental health secondary care services are seen within 4 hours.

How standards will be used – communitye) Evidence of local arrangements to ensure service users have

access to a local 24-hour helpline staffed by mental health and social care professionals.

f) Evidence of local arrangements to ensure all GP practices are aware of the local 24-hour helpline number.

g) Evidence of local arrangements to ensure crisis resolution and home treatment teams are accessible 24-hours a day, 7 days a week, regardless of diagnosis.

h) Evidence of local arrangements to ensure that people admitted to a ‘place of safety’ are assessed under the Mental Health Act within 4 hours.

How standards will be used – community• Process:a) Proportion of people with a non-acute referral for mental

health services who had a face to face appointment that took place within 3 weeks of referral (or within 2 weeks of a service user request for change of date).

o Numerator – the number of people in the denominator who had a face to face appointment that took place within 3 weeks of referral (or within 2 weeks of a service user request for change of date).

o Denominator – the number of people with a non-acute referral to mental health services.

How standards will be used – community• Outcome:• a) Evidence from experience surveys and feedback that

service users with a non-acute referral had a face to face appointment date that took place within 3 weeks of referral (or within 2 weeks of any change of date).

How standards will be usedExample – Quality statement 5: Using view of service users to monitor and improve servicesPeople using mental health services feel confident that the views of service users are used to monitor and improve the performance of services.Structure:a)Evidence of local arrangements to collect views of service users to monitor and improve the performance of services.

How standards will be used – communityb) Evidence of local arrangements to have service user

monitoring of services throughout the trust, for example using exit interviews undertaken by service users trained to do this.

c) Evidence of local arrangements to provide the executive board with reports on acute and non-acute care pathways, with a breakdown of the experience of care by culture, ethnicity, religion or other diverse minority groups using services.

How standards will be used• Outcome: Evidence from surveys and feedback that

service users feel confident that their views are used to monitor and improve services.