Where next for the Quality Network for Forensic Mental Health Services (QNFMHS)? Dr Quazi Haque, Chair, QNFMHS & Executive Medical Director, Partnerships in Care 1 …

Who we are One of around 20 quality improvement projects at the Royal College of Psychiatrists Engages directly with services – those working in the service, those using the service and those caring for those using the service Supporting services to take responsibility for their own improvement

Community of Communities Forensic Mental Health Services ECT Accreditation Service Self-harm Project In-Patient CAMHS Multi Agency CAMHS Prescribing Observatory for MH Accreditation for Acute In-Patient MH Services Accreditation for Acute In-Patient MH Services - Older People Perinatal Quality Network Psychiatric Intensive Care Advisory Service British Psychological Society Welsh Assembly Government Mind Association of Therapeutic Communities College of Emergency Medicine Her Majesty’s Prison Service The Charterhouse Group The Royal College of Nursing The British Association for Psychopharmacology Young Minds The Royal Pharmaceutical Society of Great Britain Department for Children Schools and Families (DCSF) The College of Mental Health Pharmacists The National Institute for Mental Health in England’s National CAMHS Support Service (NCSS) The CAMHS Outcomes and Research Consortium (CORC) The UK Psychiatric Pharmacists Group The National Mental Health Partnership (NMHP) College of Occupational Therapists The Department of Health NCB LD Accreditation Memory Clinics Psych Therapies The Sainsbury Centre for Mental Health

QI Framework Reviews are based on Service Standards The cycle provides an iterative system for quality improvement Agree standards Self Reviews External Peer Review Local Reports Compiled Action Planning Annual Forum and Report

Accreditation Cycle Agree Standards Self Review Peer ReviewLocal Report Accreditation Decision

Why the need for QNFMHS? Variation VARIATION (we think…) 6 Forensic and secure care “Curiouser and curiouser!”

Standards published Medium Secure Services Low Secure Services Learning Disabilities in MSU Relational Security (supplementary) Deaf People in MSUs (supplementary) Psychotherapy MSUs (supplementary) Substance Misuse (supplementary) Community Forensic Mental Health Prison mental health services

The Quality Network  Medium secure services (launched in 2006) – Currently in year 10 – Membership: 60 services (257 wards) – Number of standards: 177  Low secure services (launched in 2012) – Currently in year 4 – Membership: 106 services (256 wards) – Number of standards: 224

Membership (2014/15) Participation: 100% of English, Irish and Welsh Medium Secure services 88 % of English Low Secure Services Number of units: 97 low secure members 61 medium secure members Total Membership 116 (42 are members of both low and medium) 61 cater for female patients; 4 cater for deaf patients and 38 cater for learning disability and autistic spectrum patients Membership of the Quality Network is written in to the commissioning contract for MSU services. Low secure enforcement of membership has been staggered to allow for meaningful research to be completed (evaluation of impact of participation in the network).

Key Achievements Medium Secure Standards Updated Medium Secure Standards Additional supplementary standards Forensic Pathway Standards (LS, Prison) Provider engagement and membership Service user and carer involvement Commissioner engagement Responsiveness to issues (e.g. CQUINs, relational security, workforce) Culture of support

Medium secure standards Patient SafetyPhysical security Procedural security Relational security Safeguarding children & vulnerable adults Patient ExperiencePatient focus Family and friends Environment and facilities Clinical EffectivenessPatient pathways and outcomes Physical healthcare Workforce Governance

Medium secure standards 1st edition2nd edition3rd edition Physical securitySafety and SecurityPhysical security Procedural securityPhysical securityProcedural security Relational securityProcedural securityRelational security Personal DignityRelational security Safeguarding children & vulnerable adults Core InterventionsSerious and Untoward IncidentsPatient focus Workforce Development and Training Safeguarding Children and Visiting Policies Family and friends Equality and DiversityClinical and Cost EffectivenessEnvironment and facilities Workforce, Recruitment, RetentionGovernancePatient pathways and outcomes Supervision and SupportPatient FocusPhysical healthcare Patient InvolvementAccessible and Responsive CareWorkforce AdvocacyEnvironment and AmenitiesGovernance Carer InvolvementPublic Health Interagency Working Management

Performance of units (MSU) Average percentage met criteria per section (cycle 4-8)

Medium Secure Standards

Performance of units (MSU) Average percentage met criteria per section (cycle 9, 2014/15)

Themes for quality improvement (MSU) Optimising patient pathways Staff supervision and wellbeing The role of frontline staff in patient recovery Healthy lifestyles within a secure environment Engagement of patients and carers in secure services Work opportunities within medium secure services Challenges in relation to the use of technology Relational security Physical security Smoke free services

Low secure standards Model of CareAdmission Recovery Physical health care Discharge A Safe Therapeutic Environment Physical security Relational security Procedural security Service EnvironmentEnvironmental design Risk assessment and management De-escalation and seclusion Access to external spaces Facilities for visitors WorkforceCapacity and capability Training and continuing professional development Governance and Equalities

Low secure standards

Performance of units (LSU) Percentage of core criteria met between cycles 1, 2 and 3

Themes for quality improvement (LSU) Optimising patient pathways Staff supervision and wellbeing Engagement of patients and carers in secure services Self-catering and meals within a low secure environment The physical environment Relational security Police, communication and liaison in low secure services Facilities in low secure services Access to community services Education within low secure services

Prison mental health high profile in news and political agendas Proposal from Forensic Faculty to develop standards Standards published in June 2015 Domains: Admission and AssessmentPatient Safety Case Management and TreatmentEnvironment Referral, Discharge and TransferWorkforce Patient ExperienceGovernance Currently piloting 18 prison mental health services in England and Ireland

23 “Everybody has won and all must have prizes”

Limitations Do we have strong evidence for sustained QI? Rigour Duplication and potential for contradiction across networks Pathways The changing landscape of quality Value for the service user and provider

Landscape for Quality Healthcare Providers’ internal governance systems Commissioners (Regions) Regulators – Care Quality Commission – Professional regulation (GMC, NMC, BPS etc) Other national organisations – Professional Bodies (Royal College of Psychiatrists) – NICE (Clinical standards) – NHS Trust Development Authority National Quality Board

Regulation 26

27 Our new approach

Sheldon: Juggernaut of Quality (2005) Computers are driving an obsession with measurement to find deviant behaviour Quality is used in a normative, coercive way Can annihilate the worst and best of services Need “more trust promoting approaches rather than trust eroding ones” “combination of oversight and active professional self-regulation is probably the best way forward”

Characteristics of Quality Indicators used for Judgement and Improvement Judgment/ Compliance Unambiguous interpretation Unambiguous attribution Good data quality Statistical reliability necessary Cross-sectional Use for punishment/reward Stand-alone Risk of unintended consequences Quality Improvement Variable interpretation possible Ambiguity tolerable Poor data quality tolerable Statistical reliability preferred Time trends Use for changing practice Allowance for context Lower risk of unintended consequences

30 Figure 1 The distribution by year of the total use of each of the10 common QI terms in citation titles / abstracts on Medline / HMIC 1998–2007 (see online supplementary material for a colour version of this figure).

31 Choose an approach and stick to it!

ACCREDITATION

The Accreditation Decision Accreditation Commitee reviews a report and makes a recommendation A separate senior committee checks and formally accredits “Not Accredited”, “Deferred”, “Accredited”, “Accredited with Excellence” Accreditation is prospective for 3 years

College Centre for Quality Improvement Work with nearly all mental health trusts in UK Accreditation work started in 2000 Have accreditation programmes for most specialised mental health services, n = 17 About 1000 peer reviews in 2013 Services pay about £2000 per annum Each project costs about £100,000 to start, then they are self financing Gives patients and professionals more c ontrol

Does Accreditation Work? David Greenfield UNSW (2012) Accreditation improves organisations in some circumstances Consistent findings: Promote change and professional development Inconsistent findings: Quality measures; Financial impact; Organizational impact

What the advocates claim...

What the critics say...

ECT Clinics’ Performance against 10 standards 3 Clinical audits: 1981; 1992; 1998 Accreditation:

Solomon et al., (2013) Does sustained involvement in a quality network lead to improved performance? Prospective cohort design 48 QNIC members between 2005/ /10 Increase in units reaching ‘excellent’ overall compliance (14.6 →37.5%) Decrease in units with ‘poor’ compliance (22.9%→12.5%) 4.2% of units deteriorated over period

Key Ingredients for Successful Accreditation Schemes Local ownership and leadership Sensible recommendations Benchmarking capability Feeling connected Leverage after being accredited Taking a strategic view

2016 A New Approach

Preparatory Steps Development of core standards Review of QNFMHS standards performance and relevance International comparisons Expert consultation meetings and workshops Drafting of core and specialist standards and refinements to the peer review process Membership consultation through April and May 2016

2016 – MS and LS Standards Pathway standards 172 standards Item descriptors to improve consistency of recommendations Key domains: Safety; Patient & family experience; Effectiveness and outcomes; Physical healthcare; Workforce well-being & effectiveness; and, Governance. Outcome focussed Reinforces involvement of services users, carers and families Potential for refinements to the review process Benchmarking data

Topics for Medium Secure Annual Forum, Thursday 19 May 2016 Review of 10 th Annual Cycle Least restrictive care: Views from the CQC Outcome measures Technology in secure settings Engaging family and carers Physical healthcare and workforce capabilities Future standards and the peer review process.

Annual Forum Information Annual Forum – MSU: Thursday 19 th May 2016 Annual Forum – LSU: Thursday 9 th June 2016 Both events are taking place in London at the Royal College of Psychiatrists The booking form can be downloaded from the QNFMHS’s website: Quazi Haque –