Acute inpatient mental health service review
A key aim of mental health care in England in recent years has been to support people to live more independent lives through better care and treatment in the community. One of the concerns arising from the emphasis placed on strengthening community services is that acute inpatient services have not always received the attention needed. The Mental health policy implementation guide for adult acute inpatient care provision (Department of Health, 2002), and other policy guidance published since then, has sought to encourage improvement in inpatient services. The five-year review of the National Service Framework highlighted the need for continued improvement in this area and the Healthcare Commission identified it as a priority on which to focus a service review.
Our service review assessed the quality and safety of care given by NHS providers of acute inpatient mental health wards (sometimes called acute admission wards) and psychiatric intensive care units in England. We gave all mental health provider trusts a score, as part of our annual health check for 2006/2007.
We asked services a set of questions that service users, carers and other key stakeholders helped us to develop into an assessment framework. The overall focus of the review assessed whether admissions to inpatient mental health services were appropriate, purposeful, therapeutic and safe. The four key criteria against which we assessed performance were:
- There is an effective care pathway that ensures admission to hospital is appropriate and that discharge from hospital is timely.
- Inpatient services focus on the needs of the individual and provide care that is personalised and promotes recovery and inclusion.
- Service users and carers are involved in care planning, in how the ward is run and in operational and strategic planning, evaluation and development.
- The ward has systems, processes and facilities in place to ensure the safety of service users, staff and visitors.
Details about the focus of the assessment and how the assessment framework was developed can be found below.
We conducted this assessment in relation to 69 NHS trusts that provided mental health acute inpatient services during 2006/2007. These trusts registered 554 acute mental health wards within the scope of the review, providing a total of 9,885 beds. A profile of the services registered within the scope of the review can be found below.
Profile of the services registered for the review (xls 90kb) (opens new window)
Publication of results of the review
The results of this review were published on 23 July 2008 and included the first of two national reports. The first report and its recommendations are aimed at NHS providers of acute inpatient mental health services, health and social care commissioners, and those responsible for assessing and monitoring policy. The second report, due for publication later in 2008, will present our findings on the issues of most concern to people who use mental health services, and their carers. It will identify ways in which they can encourage improvements in local services.
Our review showed that there were marked variations between trust performance and, in some places, marked differences between wards within trusts in relation to the quality of acute inpatient services provided. The general breakdown of the overall results showed that:
- We scored most trusts as “fair” (30 trusts, 43%), followed by “good” (20 trusts, 29%).
- Almost as many trusts were scored as “excellent” (8 trusts, 12%) as “weak” (11 trusts, 16%). The trusts that were scored excellent on this assessment demonstrate that personalised, safe and good quality acute care is both achievable and is being achieved.
On the four key criteria against which we assessed performance, our findings were:
- No trust was scored excellent on all four of the key criteria, suggesting there is room for improvement for all service providers.
- Almost two-fifths (39%) were scored weak on involving service users and carers – this was the area with the highest proportion of weak scores.
- Around one in every nine trusts was scored weak on the criteria for providing individualised whole person care and for ensuring safety.
- No trust was scored excellent for the effectiveness of the acute care pathway, although fewer trusts were scored weak here compared with the other three criteria.
Based on our findings, we have identified four key priority areas where improvements are needed to achieve better outcomes for services users and their carers. These are:
- Putting a greater focus on the individual and care that is personalised
- Ensuring the safety of service users, staff and visitors
- Providing appropriate and safe interventions
- Increasing the effectiveness of the acute care pathway
In order to address these issues we made some key recommendations for commissioners, providers of services, strategic health authorities, the Department of Health and regulatory bodies.
Copies of the full report, summary and press release can be found below.
The pathway to recovery - A review of NHS acute inpatient mental health services (pdf 1023kb) (opens new window)
The pathway to recovery - A review of NHS acute inpatient mental health services - Summary document (pdf 481kb) (opens new window)
Results of the review
All trusts assessed as part of the review have received a detailed report outlining where they have performed well and where they can improve.
To coincide with the publication of the results for this review, we have launched a new mental health website. This website provides access to the detailed findings of the review: the website can be searched by trust name, place name or postcode. Please follow the link below to this website:
www.healthcarecommission.org.uk/mentalhealth.cfm
A summary of the overall scores by trust, the breakdown of these scores and a summary of the national results can be found here:
Acute inpatient mental health service review scores table (xls 1303kb) (opens new window)
Acute inpatient mental health service review breakdown of scores for all trusts (xls 126kb) (opens new window)
Acute inpatient mental health service review summary data (xls 1302kb) (opens new window)
Further explanation about how we scored the assessment can be found in the guidance document here:
AIMH final detailed scoring guidance (pdf 626kb) (opens new window)
We have also collated the national results from the audit of care records that trusts carried out as part of the data collection for the review. These can be found here:
Acute inpatient mental health service review results of the care records audit (xls 1318kb) (opens new window)
Plan improvement
We have almost completed follow up visits to 11 trusts whose performance was identified as weak on this assessment. Action plans are now being implemented to improve services, which will be monitored by the strategic health authorities.
Queries about the service review
If you have any questions about the service review please email: feedback@healthcarecommission.org.uk or call our helpline on 0845 601 3012.
Sustaining improvement in acute care
The Care Services Improvement Partnership (CSIP) – National Institute for Mental Health in England (NIMHE) produced an electronic handbook to accompany the review. The handbook, Onwards and Upwards, aims to help local services to build on the review to sustain improvements in acute care. The handbook includes information and links to the key policies that provided the standards for acute care and it suggests action points for improving services. It also provides pointers to good practice and information about initiatives and approaches to sustaining improvements in acute mental health. The handbook can be found at:
Care Services Improvement Partnership - Standards (opens new window)
Background information – the assessment framework
The final version of the assessment framework and a general briefing about the review can be found here:
Final assessment framework (pdf 175kb) (opens new window)
General briefing on the acute inpatient mental health service review (pdf 66kb) (opens new window)
The content of the final assessment framework has been informed by:
- a literature review to scope the key issues for acute inpatient care
- mapping policy documents to identify the standards relating to acute inpatient services, supported by colleagues from the Royal College of Psychiatrists’ Accreditation for Acute Inpatient Mental Health Services
- fact-finding visits to 10 development sites to identify the priority issues for acute inpatient care from the perspectives of those involved in using, providing, managing and commissioning inpatient services
- a series of engagement events to identify the best possible outcomes at each stage of the acute care pathway and the indicators for outcomes having been achieved
- expert advice from our analytical and service review colleagues, members of the external reference group for the review, users of services and carer associates aligned with the core project team
- consultation on the draft assessment framework with the public, users of services and carers, service providers, national and local organisations, and other experts to assess the structure and coverage of the draft assessment framework, the validity of the proposed indicators and the robustness of the data sources suggested
- piloting of the draft assessment framework with development sites to evaluate the proposed data collection process and the extent to which the assessment reflects the provision of local services
We published the draft assessment framework for public consultation in November 2006. Click the link below to see a summary of the changes made to the assessment framework as a result of consultation feedback and piloting.
Summary of changes to assessment framework (pdf 54kb) (opens new window)
When we developed the assessment framework, we also carried out an equality impact assessment. This has included a review of the policy and literature and a meeting held to review the coverage of diversity issues in the assessment framework. Information from both of these can be found below.
Policy and literature review for the full equality impact assessment (pdf 109kb) (opens new window)
Data collection for the review
The review required the collection of both national and bespoke data. We collected the bespoke data during the summer 2007.The bespoke data collection had four elements:
- a questionnaire for trust acute inpatient leads
- a questionnaire for ward managers - to be completed for each relevant ward
- a questionnaire for service user groups - to be completed for each relevant ward
- an audit of care records - to be completed for a sample of 50 care records
Click on the links below to see copies of the final versions of the data collection tools and the accompanying guidance documents.
Copy of questionnaire for trust acute inpatient leads (pdf 26kb) (opens new window)
Guidance for the questionnaire for trust acute inpatient leads (pdf 54kb) (opens new window)
Copy of the questionnaire for ward managers (pdf 43kb) (opens new window)
Guidance for the questionnaire for ward managers (pdf 45kb) (opens new window)
Copy of the questionnaire for service user groups (pdf 45kb) (opens new window)
Guidance for the questionnaire service user groups (pdf 40kb) (opens new window)
Copy of the audit of care records form (pdf 324kb) (opens new window)
Guidance for completing the audit of care records (pdf 48kb) (opens new window)
Copy of questionnaire for trust acute inpatient leads (pdf 26kb) (opens new window)
Guidance for the questionnaire for trust acute inpatient leads (pdf 54kb) (opens new window)
Copy of the questionnaire for ward managers (pdf 43kb) (opens new window)
Guidance for the questionnaire for ward managers (pdf 45kb) (opens new window)
Copy of the questionnaire for service user groups (pdf 45kb) (opens new window)
Guidance for the questionnaire service user groups (pdf 40kb) (opens new window)
Copy of the audit of care records form (pdf 324kb) (opens new window)
Guidance for completing the audit of care records (pdf 48kb) (opens new window)
We had a list of frequently asked questions (FAQs), which was updated during the data collection process. The final version of the FAQs can be found here.
Frequently asked questions (updated 26/7/07) (pdf 81kb) (opens new window)
All 69 participating trusts submitted the questionnaires for service user groups for each of the 554 inpatient wards included in the scope of the review, and they all returned the audit of care records by the deadline. Ninety-nine per cent of the questionnaires for ward managers and for trust acute inpatient leads were returned by the deadline.
We also collected details of the main primary care trusts (PCTs) that commissioned services from trusts that took part in the review and used this information to calculate two indicators (out of 58 overall) that were based on national data collected at PCT level. We summarised the results of this exercise and the final version of the mapping of mental health provider trusts to commissioning PCTs can be found here.
Provider to commissioning PCT mapping (xls 2451kb) (opens new window)
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