A Critical Evaluation of the implementation of NICE Quality Standard 80 in a specialist Early Intervention Service

The aims of the project are to:

• Work with the EIS service and all other services currently working with service users subject to the standard (primarily adult mental health community and inpatient services) to map out demand and capacity in line with new guidance to establish how to meet the new standards and establish effective referral pathways.
• Develop and implement a new clinical model that ensure the trust meets the two wait targets and provides appropriate treatment delivered in accordance with NICE guidelines and quality standards
• Ensure an effective reporting mechanism is in place to evidence compliance against both measures and ensure standards are met.

The project will be delivered through the objectives given below:

1. To improve and streamline the referral, assessment and treatment pathways into and within EIS to support the new standard of more than 50% of people experiencing first episode psychosis being treated with a NICE approved package of care within two weeks of referral.
2. To streamline referrals into EIS working particularly closely with the Adult Mental Health network, reducing internal delays and achieving better integration across networks.
3. To ensure clear and robust referral management protocols are in place, which are underpinned by good data quality principles enabling referral to treatment performance to be monitored and reported for both internal and external purposes.
4. To establish and embed a process for managing engagement and disengagement from the service to adhere to the Referral To Treatment (RTT) technical guidance for potential rollout across Adult Mental Health Services (AMH).
5. To establish additional demands against current capacity to support business case to secure appropriate resources to deliver the standard.
6. Oversee the development of a clinical model, and clinical standard operating procedures to establish a care pathway that offers services in line with new standards.
7. To ensure the Trust's electronic care records and systems are able to support the reporting of this standard and systems, either retrospective or prospective through the Mental Health Minimum Service Dataset (MHMSDS), are in place to assess NICE concordance.

The new standards will drive significant changes in the referral pathways into service and clinical model for EIS services to reflect the new NICE standards and pathways.

In October 2014, NHS England and the Department of Health jointly published “Improving access to mental health services by 2020” (2014) which outlined a first set of mental health access and waiting time standards for introduction in 2015/16 and an ambition, subject to future resourcing decisions, to introduce access and waiting time standards across all mental health services.

Improvements towards meeting the first standards came into effect from 1 April 2015 for achievement by 1 April 2016, focusing on areas where timely access to evidence-based care is of particular importance in improving longer-term mental health, physical health and recovery-focused outcomes. Rapid treatment following referral for suspected first episode psychosis was one of the first access standards to be introduced in 15/16.

The purpose of the Referral to the NICE Concordant Care Project Group is to ensure the Trust meets the new access and waiting times standards for people experiencing a first episode of psychosis, which requires that more than 50% of people experiencing a first episode of psychosis are treated with a NICE approved care package within two weeks of referral and for a specialist At Risk Mental State (ARMS) assessment to have commenced for referrals for those with this presentation.

Within the standard are two conditions, which must both be met for the standard to be deemed as being achieved:

- A maximum wait of two weeks from referral to treatment

- Treatment delivered in accordance with NICE guidelines for psychosis and schizophrenia (NICE, 2015, 2014, 2013).

The NICE Quality Standard 80 provides the key standards for implementation for first episode psychosis services. A summary of baseline, challenges and actions against the 8 Quality statements is given in the supporting material.

A clear governance and assurance framework was agreed by both network and corporate management, to ensure that regular highlight and performance reports were provided, to ensure the project was on schedule to meet deliverables and agreed trajectories for meeting the referral to treatment standard. This included project meetings where the barriers to the implementation and local strategies to manage these were discussed.

A business case was written early in the project to map the expected additional resource required to meet the additional demands on services. It proved challenging to predict the expected numbers of service users who would access the service as research provides different incidence rates and this required considerable review of research, service data and discussion with clinical leads.

Dedicated project resources were allocated to support the project to achieve its objectives to meet the new NICE quality standards, within existing network resources. The objectives and key deliverables were agreed, and a project plan was developed with key milestones to monitor progress against.

Berwick (2015) speaks of how health services need to ensure managers mirror their delivery style with that they would want to be used when working with service users. In line with this, a collaborative design approach was utilised. Workshops used an Appreciative Inquiry approach using a 4 d format (Cooperrider et al 2007) (see below) to structure the discussion. This was continued in the focus groups used to evaluate the project. This process approach allowed for collaboration and also to promote Plan-Do-Study-Act cycles (NHSIII 2008).

The workshops focused on specific standards, grouping together themes and although all staff were invited, the focus was on the staff with the greatest interest and expertise in that area joining, for example, the Medical team were focused on when considering clozapine etc.

Following the completion of the workshops, the information about potential ways to achieve the standards was collated and feedback was sent out to all the staff team. A structure was developed to articulate the differences that would be required to meet the new standards whilst also acknowledging the positive work already completed by the service.

The development of the EIS pathway on SharePoint was made in order to provide accessible information to all staff ensure the opportunity for continuous improvement and management of critical information to support meeting the standards is as clear as possible within the service. This was based on the understanding that the patients and settings complexity required rapid access to complex information. The pathway structure and governance can be found in method section alongside an overview of the content related to each standard.

For an overview of the EIS pathway and details on the governance please see the supporting material.

Focus group review, discussion, data analysis and completion of a sustainability questionnaire have been used to evaluate the project.

Project closure meetings for the three streams of activity under the project (clinical outcomes, performance and workforce) have been utilised to complete a sustainability questionnaire (NHSIII 2007). The sustainability model (NHSIII 2007) has been utilised to evaluate the confidence in on-going delivery and any areas which need to be managed to ensure the project outcomes are maintained will be identified.

The initial aims and objectives have been reviewed at the Project Assurance Group. It was agreed that all the initial objectives had been fully or partially achieved, except for the last objective (7) which was agreed as not achieved. This objective was related to reporting through electronic records which was delayed due to the complexities of combining the MHMSDS and the trusts electronic systems.

Quantitative data has been gathered throughout the project. Data was gathered to respond to the Audit of Early Intervention in Psychosis (AEIP) which was coordinated by the Royal College of Psychiatrists. LCFT were required to completed audits on 100 service users from our total sample of 108 for the time period stipulated. In order to maximise the learning, the additional 8 service users were also audited and the results were collated to allow us to understand the baseline position and therefore the areas to focus on.

Detail of this evaluation is provided in supporting material document 1.

This evaluation is supported by review of the sustainability of the service improvement. The sustainability questions can be found at the NHS Institute for Innovation and Improvement

http://www.nhsiq.nhs.uk/resource-search/publications/nhs-inst-sustainability-guide.aspx

Through the completion of the sustainability questionnaires, six of the 10 areas considered were evaluated as meeting the maximum potential score for the project. The evaluation also highlighted that the development of the monitoring processes particularly is behind where it should be, this supported the review of the objectives.

The focus group feedback also supported the outcome of the sustainability questionnaire response around behaviours, and involvement & training noting that “it’s going to take a change of behaviour and culture”. This area was shown as having a marked gap between the project score and potential score.

The handover at project closure included discussion about ways of changing the way we talk about the clinical offer and ensuring the EIS Pathway in SharePoint is the central up to date place to get information on the service. The pathway format was noted as allowing for personalised care to meet individual service user need, however some of the staff team at the focus group had yet to embed the new way of working into their practice.

Local recommendations that resulted from our evaluation of the project included:

• To use the EIS Pathway on SharePoint as a central hub of all key information for the team and ensure the information remains current on the EIS pathway
• Other partner teams being able to access shared information would have been very helpful
• Continue to work with business informatics to establish clear reporting systems
• The involvement of carers was really helpful and we would propose that this should be continued to be developed going forward.
• We did not have an effective involvement with service users and this need to be established to review the clinical model and the experience for service users.
• Embedding the new clinical model into practice to build on the early adopters.
• Support the team to manage this change through ongoing involvement and training which will support behaviour change and engagement.

It is also acknowledged that there was wider learning to be gained from the project. The learning points to be shared for other areas are provided below:

• Having Senior Responsible Officer and organisation support was invaluable to the success of the project.
• The protected time provided for the Project Lead created the opportunity to think creatively about this complex offer and undoubtedly supported the success of the outcome.
• The separation of a Project Lead from the operational management of the service, however, did cause the project at times to be seen as an added on task not core to the service. This clarity of shared communication is essential.
• Having a dedicated Project Manager was a real asset to delivering the complex offer on time and in an efficient way.
• The project would have been improved if there had been a way of linking the EIS clinical pathway on SharePoint directly to the clinical record.
• The involvement of carers was really helpful and we would propose that this should have been done more within the development.

Overall the project has been successful, however there is clear evidence that the service improvement needs to be further embedded, owned and maintained in order for ensure NICE standard care is understood and delivered going forward. The key challenges remained around the completion of the reporting format and engagement with the staff team to support all the team working in line with the EIS Pathway on SharePoint not just the early adopters.