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CM 021004 Modernising Mental Health11 May by pghr43eN


									                                                                 Agenda item 7
                                                               Ref: CM/02/10/04

                  BOARD MEETING - 19 MAY 2010



1. The purpose of this paper is to seek the Board’s endorsement for the
   proposed scope, objectives and success measures for the programme of
   work to modernise the approach and outcomes for the work of CQC’s
   Mental Health Act operations.


2. The Board is asked to comment upon scope, high level objectives and
   success measures of this programme as detailed in paragraph 10 below.


3. The bringing together within CQC of the regulatory powers contained in
   the Health & Social Care Act, CQC’s commitment to give due weight to the
   user voice as a key element of its way of working as a regulator, along
   with the statutory functions under the Mental Health Act provides a need,
   but also a real opportunity, to make a step change in providing protection
   for patients detained under the Mental Health Act, and improve the
   efficiency with which those services are provided.
4. There are three separate but related challenges. The first is to bring into
   alignment and coordinate effectively what are, at present, three separate
   areas of activity:
           Regulating both NHS and independent providers of mental
            health services; the process of making risk based regulatory
            interventions, including visits and inspections to ensure
            compliance with quality and safety standards under the Health
            & Social care Act;
           Protecting people’s rights by monitoring the lawfulness of the
            care and treatment provided under the Mental Health Act: the
            programme of visiting by Mental Health Commissioners of
            patients subject to the Act, investigating complaints and
            reviewing the death of detained patients;
           Providing for qualified medical second opinions of the quality,
            lawfulness and nature of the treatment (including Community
            Treatment Orders) provided to those detained under the Mental
            Health Act; the management of the statutory Second Opinion

                                Page 1 of 7
                                                                     Agenda item 7
                                                                   Ref: CM/02/10/04

               Appointed Doctor (SOAD) scheme, including appointing
5. Unless properly coordinated there are risks that activity is duplicative and
   therefore inefficient for both the CQC and those regulated. There is also
   the risk that important information generated from one activity is not
   provided to those conducting the other; for example that information
   gathered by Commissioners and SOADs is not input to the CQC Quality
   and Risk profiles which will be a key tool for informing the regulatory field-
   force’s activity. In turn the Commissioners and SOADs may benefit from
   being aware of wider regulatory information about a service.
6. The second challenge is to modernise the related administrative and
   business (including IT) functions and align and simplify processes that
   better support improved coordination, and to do so in a way that also
   ensures that data, in particular patient sensitive data, is handled
   appropriately to ensure its security, and adherence to other Data
   Protection Act requirements.
7. There are of course also constraints imposed by current and future
   budgetary limits.
8. The third challenge is to find ways effectively but efficiently to gather and
   give due weight to the experience of users of mental health services to
   better inform what CQC does, when and how.
9. The CQC Board has already agreed a Mental Health Position Statement
   and Action Plan, (see Annex 1) for 2010-2015 which seeks to embody
   CQC’s 5 strategic priorities;

   1)   Ensuring care is centred on people’s needs and protects their rights
   2)   Championing joined-up care
   3)   Regulating effectively in partnership
   4)   Acting swiftly to help eliminate poor quality care
   5)   Promoting high quality care

   Our mental health action plan identified three key areas for improvement
   where we plan to make a difference over the next five years:

       Prioritising a focus on rights, equalities and values within our regulation
        of mental health services, paying particular attention to access to, and
        experience of, services for people from black and minority ethnic
        groups, younger people, and older people with mental health problems.
       Ensuring that people with mental health problems receive care that is
        effective and safe.
       Improving the outcomes of the commissioning of services for people
        with mental health problems to meet individual needs, and promote
        social inclusion and recovery.

                                   Page 2 of 7
                                                                   Agenda item 7
                                                                 Ref: CM/02/10/04

10. We have identified a range of outputs and outcomes that we believe are
    key to our objectives. These are as follows:

   i) Defining and implementing the new processes and vision for all statutory
   duties of CQC under the Mental Health Act (Section 120(1)) to deliver;
        a. A Patient visiting function that is better aligned and consistent with
            CQC’s regulatory model, providing clarity to all stakeholders about
            our respective roles.
        b. A Mental Health Act monitoring role that incorporates the care
        c. A Second Opinion Appointed Doctor service that is modern,
            efficient and meets future professional requirements.
        d. A complaints function relating to the powers and duties of the Act
            that is modern and efficient
        e. Report annually to Parliament
   ii) A modern information system which supports the modernised mental
   health act function and CQC’s regulatory assessments.
        f. Implement the Information Security requirements
        g. Revised policy and procedures
        h. Revised organisational structure & resources
   iii) A set of revised key performance indicators to support these new
   processes and engage all key stakeholders during the process

11. We have commenced a programme of work which involves 5 key
    engagement with key stakeholders (internal and external- see Annex
      2) – to help shape our modernisation work and influence the outcomes
    communications plan - to ensure that our stakeholders are kept
      informed and involved in the change process and have the ability to
      discuss how the programme will be implemented
    development – we have two key projects underway, one focusing on
      future ways of working and the second improvements to our
      information system.
    consultation – there are a series of planned workshops with targeted
      stakeholders (these are currently work in progress) to help examine
      and advise on specific parts of our duties under the Act
    delivery – following the completion of a fully costed option appraisal
      and approval by the Board we plan to deliver these changes in the

   A Mental Health Modernisation Programme Board has been established to
   oversee this work.

12. Our work to date has produced the following considerations;
            Mental Health Act Commissioner visits - Currently
      commissioners focus overwhelmingly on detention (inpatient settings),
      but there are also significant concerns about assessment and after
      care. We want to rebalance our approach to cover the whole pathway,
      better reflecting people’s experiences and safeguarding of rights
      overall. There is strong support for this approach particularly as it helps

                                  Page 3 of 7
                                                           Agenda item 7
                                                         Ref: CM/02/10/04

realises the benefits of being a part of the Health and Social Care
       The Commissioner resource is already quite limited, but we can
release some for additional monitoring of assessment and after care,
by refining and developing methods for inpatient settings, and
removing duplication with compliance monitoring. However, visits to
inpatient settings will remain both regular and the clear majority of our
       Work is already in progress to share information between MHA
monitoring, and the compliance and performance functions. Methods
for each stage of the pathway now need to make sure we are
generating and using that information effectively; that we can map
findings across the different regulations, risk models and judgement
tools; and that we are clear about roles (particularly the boundary with
        Second Opinion Appointed Doctor Service – The way in which
doctors are regulated is changing. The General Medical Council (GMC)
has set out proposals for a new process to assure patients and the
public, employers and other healthcare practitioners that licensed
doctors are up to date and fit to practise. The process is called
revalidation. In future, all licensed doctors will need to revalidate
regularly if they wish to keep their licence to practise.
       CQC is at considerable risk in terms of discharging its duties
under the MHA if there is no mechanism for assuring the ongoing
competencies of its SOADS.
       Revalidation is a new way of regulating the medical profession
that will provide a focus for doctors’ efforts to maintain and improve
their practice; facilitate the organisations in which doctor’s work to
support them in keeping their practice up to date; and encourage
patients and the public to provide feedback about the medical care they
receive from doctors. In these ways, revalidation will contribute to the
ongoing improvement in the quality of medical care delivered to
patients throughout the UK.
       What are the risks? - CQC appoints consultant psychiatrists to
undertake second opinions under the Mental Health Act 1983. These
doctors will be affected by these new requirements and CQC therefore
needs to consider the best arrangements for the future delivery of this
service. CQC is at considerable risk in terms of discharging its duties
under the MHA if there is no mechanism for assuring the ongoing
competencies of its SOADS.
       At present a significant number of SOADs are either retired or
due to retire from their substantive post as a consultant psychiatrist.
The SOAD panel currently consists of 116 doctors and approximately
just under half fall into this category. Consequently it is not clear how
their Continuous Professional Development (CPD), annual appraisal
and Revalidation functions will be provided. In addition to this as a
result of the introduction of Community treatment Orders (CTOs) under
the Mental Health Act and the gross under-estimation by the
Department of health about the likely number of CTO cases the SOAD
service has been placed under considerable pressure. Despite CQC’s

                          Page 4 of 7
                                                                  Agenda item 7
                                                                Ref: CM/02/10/04

       robust recruitment drive to appoint more SOADs the increase in
       appointed panel members is modest and we are aware that there are
       wider issues in the sector and system that affect the support provided
       to consultant psychiatrists to become a SOAD. These need to be
       addressed to ensure that this important safeguard is delivered
       effectively and to a high standard.
              This requires action by CQC in collaboration with the
       Department of Health, Royal College of Psychiatrists (RCPsych) and
       the NHS Confederation.

The possible options are to:

            Commission a review of the SOAD and other related medical
             MH legislation workforce, policy and processes issues within the
             system e.g. SOAD role in relation to CTO patients, section 12
             appointed doctors, medical members of the First Tier Tribunal
             service. This could be done with input from our National Clinical
             Advisors but would need project management support.

            Develop the current interest from the RCPsych and NHS
             Confederation to explore with CQC, new and sustainable
             options to strengthen and embed the human rights and legal
             expertise required in CQC medical SOAD workforce into robust
             and accountable appointments from within current senior
             practising mental health clinicians (especially those with
             enhanced competency through MSc etc in mental health
             legislation) e.g. possible 3 year secondment from trusts. This
             option would significantly strengthen CQC’s medical workforce
             competencies, enhance public confidence in our legislation
             function and would ensure RO revalidation processes out with
             the Commission.


13 Before proceeding further however it would be helpful if the Board could
provide a steer on the following:
14. Whether the Board support seeking policy and, if necessary, legislative
change (for example in relation to the SOAD service) in order to improve the
current operation of this service.
15. Whether the Board support a move toward flexing the visiting MH
Commissioner role and shift the focus from the purely in-patient experience
toward an approach that looks at care pathways
16. Whether the Board thinks the current level of resource applied to the MH
functions is about right. It currently accounts for approximately 3% of the
CQC operating budget.
17. Whether the following success measures are the right ones
      Improved patient related outcomes in mental health

                                 Page 5 of 7
                                                                 Agenda item 7
                                                               Ref: CM/02/10/04

      Mental Health Act monitoring captures the patient experience across
       their pathway of care and not just the hospital experience.
      Mental Health Act information and data is much more prominent in our
       Quality and Risk Profiles for mental health services.
      Second Opinion Appointed Doctor service is modern, efficient and
       delivered to high professional standard in line with the new GMC
      Quality and skills of Commissioners, Assessors and Inspectors are
       developed to understand both the MHA and Health and Social Care
       Act requirements.
      More efficient business processes enable more value added activities
       such as management reports.


18. The aims of this programme will support;
    the CQC five year plan
    the IT/Business Systems ‘Mental Health Information Development
      Programme’ 4 projects (1. Update and secure MHAC database 2. E-
      Commission website 3. Office Information Security 4 New business
    government policy and our statutory duty under the Mental Health Act
      1983 and subsequent amendments
    better regulation principles
    the principles of equalities and human rights
    the needs of people in more vulnerable circumstances


19. The benefits that this programme will deliver include:
    A new approach that optimises the integration of registration, MHA
      monitoring and SOAD activity;
    A new organisation structure and processes that will best support the
      safeguards provided to mental health service users and carers;
    Data sharing and communication channels between CQC functions
      and externally too allowing better monitoring/inspections/reporting
      leading to improved patient care;
    Reduced costs through increased efficiency of process and personnel.


20. Following the Board’s discussion costed options for change will be
brought before the Board at a later date.


                                Page 6 of 7
                                                                  Agenda item 7
                                                                Ref: CM/02/10/04

21. In determining which is the best model for the future we will need to apply
a legal test to each option that ensures the CQC does not compromise its
statutory duty under the Mental Health Act.


22. The CQC’s mental health act monitoring function is in principle a human
rights and equality function. This programme aims to enhance CQC’s role in
protecting the rights of this vulnerable patient group.


   Annex 1 – Mental Health Position Statement and action plan – March
   Annex 2 – Multi-agency Stakeholder Workshop attendees

Anthony Deery
Head of Mental Health Operations
11 May 2010

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