What you can do to bring about its findings and why you
Anniversaries are great. Excuse for a party. An excuse for
attention. Also an occasion to review work and monitor how it’s
We have a one-year anniversary to celebrate. One year ago the
independent Commission that we set up to review the provision of
acute adult psychiatric care published its findings.
Gosh, that was ponderous. Let me try again.
The Crisp Commission on Beds, as we definitely don’t call it but
let’s be honest that’s what it was all about, hit headlines a year
ago. I hit local radio (“Good morning Professor, this is Radio
Three Rivers, please let the people of LoamShire know what your
report means for them, before the traffic news”). Lord Crisp, who
ran the NHS and is still a Big Cheese and thoroughly decent bloke,
did the top billing on the Today Programme. He scored a blinder
when John Humphrys tried to change the subject, only to be firmly
put in his place: “No, this is what always happens when we talk
about mental health – you try and change the subject”.
OK, what did it conclude?[i] A lot, all on how to improve access
to and quality of acute mental health care, as you
can see here)
And what has happened since? Again, a lot - you can find our progress report here -
and we expect even more to come, with a formal response to the
report from the central NHS bodies expected to land on our desks in
the next few months.
For those with short attention spans here are some of the
Commission’s key recommendations and the progress made so far
towards their implementation:
- Recommendation: Out-of-area-placements (OAPs) to be
Progress: The Government has committed to
eliminating OAPs by 2020/21. A national definition of OAPs has been
agreed at long last and national data is now collected.
- Recommendation: Introducing four-hour waiting time
targets for access to acute mental health care
Progress: An evidence based treatment pathway (our
favourite sort) for acute mental health care is currently being
developed and will be published this Spring, including clear
recommended response times and quality guidelines and
- Recommendation: Ensuring Crisis Resolution and Home
Treatment Teams (CRHTs) are well enough resourced to offer
alternatives to inpatient admissions
Progress: More that £400m for CRHTs will be introduced
over 4 years from April 2017.
- Recommendation: Better collection and availability of
mental health data and transparency around funding
Progress: More dataset changes will be implemented
this Spring to provide more robust information on acute care
services including use of different types of bed and delayed
transfers of care.
But those of you who haven’t retired, left the country or joined
a quango, must have noticed that despite this progress pressures
upon acute adult services have not disappeared.
One of the most visible symptoms of this is out-of-area
placements, where unwell patients have to travel long distances for
care due to lack of local beds or appropriate care in the
community. Last December more than 500 patients still had to travel
out of area to receive care.
Don’t despair. Skilful footwork meant that we got many of our
recommendations incorporated in the Five Year Forward View for
Mental Health, which has been accepted by NHS England (Five Year
Forward Views are all the rage at the moment, and if you haven't
got one you are not just at the back of the class, you are outside
the school gates pressing your nose against the bars). This means
that the implementation of these recommendations really will be
pushed with support of central bods, or at least they should if we
continue to keep our beady eyes peeled.
But it’s not all about government, NHS England and a jumble of
quangos. Frontline efforts are equally important when it comes to
changing things and stopping OAPs. And that means you. So what you
And for those who still have a sentimental liking for the
printed word, read on. I do apologise if unacceptable levels of NHS
jargon slip in
1. Achieving the right balance of provision between
inpatient and community care
As the Commission stated, the solution to pressures in adult
acute care is not necessarily more beds. Sometimes it is, sometimes
it isn’t. Delivering accessible, high-quality care requires
sufficient local beds but is also reliant on sufficient
alternatives to admissions, including crisis resolution and home
treatment teams, rehabilitation services, community mental health
services and supported accommodation.
Robust service capacity assessments are crucial for determining
care needs, eliminating OAPS, reducing waiting times, and
high-quality assessments. Good models of service capacity
assessment are already used by many Trusts across the country. Now
is time to do this systematically.
You can help your local area deliver the right balance between the
different elements of the acute pathway by encouraging your Trust
to undertake a service capacity assessment with commissioners, and
to act on this.
Once capacity is assessed, encourage your Trust to undertake a
quality assessment. The College Centre for
Quality Improvement (CCQI) is developing a scheme to allow your
areas to self-assess against access and quality guidelines. These
guidelines – developed by our own National
Collaborating Centre for Mental Health (NCCMH) for NHS England
and NICE - will be published this year and recommend a four-hour
standard for accessing acute care. Exactly what the Crisp
Commission recommended. What a coincidence.
2. Improving services through better data
As psychiatrists, we spend hours inputting data and can be
disheartened if they are not well used. Nonetheless, better data is
essential to improving services and accountability. As mental
health has long lagged behind physical health data this is doubly
important. I have bored for England on this before.
But before you yawn, remember - robust data is a Good Thing. It
can be used to hold commissioners and providers to account. We can
tell when they are being naughty, not eliminating OAPs, or
implementing guidelines and benchmarks. And Lord be Praised, the
data we need to torment and chastise them will be available from
April. And we sure will torment and chastise.
You can help. Please encourage your Trust to: (1) submit OAP
data monthly; and (2) return data to the Mental Health Services
Data Set (MHSDS) which will be annually reviewed to ensure
information is fed back to you in a way that makes sense.
This will mean a bit of your time. So whilst you are at it,
continue to encourage your Trust to implement streamlined IT
systems. Some do, some don’t. Those that do make your life
3. Revolutionising ways of working through Quality
While you might be familiar with clinical audits and peer
reviews, it’s less likely that organisational Quality Improvement
(QI) approaches are part of your team’s day-to-day. QI techniques
can revolutionise ways of working and help reduce bed occupancy,
length of stay, OAPs, sickness absence and patient complaints.
This is why the College is supporting development of QI
knowledge and skills amongst members, mapping learning needs,
setting up a network and ensuring QI is embedded in the curriculum
of future psychiatrists. Pedanticus may point out that QI seems
very similar to “clinical audit cycles”, and Pedanticus might have
a point. But for a thing to keep happening, it has to change its
name once in a while. Remember, “standing still is not an option”
even if it’s the right thing to do.[ii]
Again, you can lead by highlighting to your Trust the importance
of implementing a system-wide approach to QI and setting up QI
training for inpatient staff. Your Trust can work with
commissioners and clinical networks to share good practice which
other areas less fortunate than ourselves (your neighbouring
service, not your own of course) can learn from.
You may find it hard to believe, but psychiatrists, indeed all
doctors remain incredibly important in bringing change. One mental
health CEO recently said to me – “I am not a great fan of doctors,
but if you want change, you have to bring the doctors with you, or
it won’t happen”. Most CEOs really do like us – they wish we got
more involved in these issues, not less. Like it or not, as leaders
within your local services, you are well-placed to spot triggers
for action, and to take action. By doing so, you will play your
part in bringing about the changes suggested by the Crisp
Commission on Beds, sorry, the Commission on Acute Adult
Psychiatric Care. And then we will invite you to the champagne
second anniversary party next year.
Our animation to mark the report’s
anniversary contains a checklist of actions you can take to improve
acute care in the areas discussed above.
Further information about the progress made so far can be found
on our website.
To find out more about the Commission, visit http://www.caapc.info/.
Join the discussion on social media using #CAAPC.
[i] My old friend Pedanticus has popped up to remind us
a) the Commission didn’t cover Scotland or Wales.
b) it did cover Northern Ireland, but in a separate report and I’m
afraid its first anniversary isn’t for a few months, so it doesn’t
get the champagne and flowers 'til the summer.
[ii] To be fair, which I rarely am, QI isn’t quite the same as
clinical audit, but I like to have a rant from time to time.
Professor Sir Simon Wessely
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