Care quality data on mental health is too hard to pin down

Approximately seven million adults in this country suffer from a common mental health problem such as anxiety or depression and around 10 per cent of them require more specialised mental healthcare, often in an inpatient setting.

At any one time, about 32,000 people with serious mental illness are being cared for by mental health services as inpatients and many of these patients are long stay. Meanwhile, an increasing proportion of NHS-funded inpatient mental healthcare, particularly for people with complex mental health conditions, is commissioned from independent sector establishments providing mental health services.

The national data available on the quality of care these patients get is worth a look. What data is available from independent sector providers of mental health services and on how patients move through the mental health system?

And how can commissioners assure themselves they are commissioning services that provide good quality and value for money. How can the regulator effectively monitor this service provision?

Despite the scale of the issue and the amount of resources involved, national data about the care and treatment of people with a mental illness in independent services is inadequate.

NHS specialist secondary mental health services have been required to submit the mental health minimum data set since April 2003, in addition to routinely submitting hospital episode statistics, but independent sector providers are not routinely required to collect the same information about their patients, even where patient care is funded by the NHS.

This means there is little comparative information about the quality of care service users receive from independent sector providers, or how they move through the complex mental health system.

So the Department of Health's current information review is timely. The DH is also developing a standard contract for the commissioning of mental health services, a sequel to the contract for commissioning of acute hospital services published in December 2007.

It must grasp this opportunity to ensure that an equivalent system for collecting information across the NHS and independent sectors is put in place.

System under pressure

To get a sense of the scale of the problem, approximately one in six people experience a mental health problem and 13 per cent of the NHS budget is spent on mental health services. At the same time, the mental health system is becoming more complex.

The rise in conditions such as depression, dementia and co-morbid drug dependency and the complexities involved in working across organisations, including the criminal justice system, have placed additional pressures on the system.

There has been growth in the independent mental health sector since the early 1990s. The 2007 census of mental health inpatients showed 14 per cent of all adult inpatients in England and Wales on that day were in independent sector establishments, up from 11 per cent in 2006.

Increasing by 16 per cent in 2006 and valued at£845m, mental health is the strongest growth area of independent sector hospital services. In that year, NHS spending accounted for 85 per cent of revenues.

The sector is a significant provider of low and medium-secure services, involving predominantly long stay, often forensic, care for patients with complex mental health needs. It also provides many child and adolescent mental health services.

The mental health minimum data set is a significant development in information to support improvements in the performance of mental health services. For the first time, NHS clinicians and managers have information on patients that they can use to plan and manage services, as well as to conduct clinical audits. Also for the first time, it is possible to identify, at least to some extent, how patients move through the complex system of NHS mental health services.

However, information about patients in the independent provider sector is much more limited, because many of the statutory data returns that apply to the NHS, especially in relation to patient-level data sets, are not currently required of independent healthcare providers.

So little information is available to monitor the numbers and details of either patients receiving mental healthcare in independent sector providers or the quality of that care. There is also little information about how inpatients move around within the NHS and independent healthcare.

This lack of suitable information can compromise the collaboration between service commissioners, NHS providers and the independent sector in ensuring consistency in the quality of care and preventing patients from being "lost" in the commissioning system.

Some data is available on the number of detained patients in independent sector providers (those admitted under the Mental Health Act 1983 and Mental Health Act 2007), with some personal details. but while this information provides a useful overview, it does not enable the detailed analyses that patient-level data can support.

Data is needed on patients in independent services for areas including admission and readmission rates, length of stay, place of admission and discharge, detention status, out-of-area treatments and mortality. Both the provider and the patient's primary care trust need it.

The unique patient identifiers in such data sets enable patients to be tracked as they move around the healthcare system, including both inpatient and community care.

Their limitations notwithstanding, they are used widely and to good effect in the NHS.

Independent sector providers could also use such information to demonstrate to commissioners the effectiveness of their services. And NHS mental health trusts could use it to see how they compare with independent providers.

We recognise that gaps exist in the data NHS providers are required to collect and there is evidence that commissioners do not always use the available data to best effect. A small study by the Healthcare Commission looked at how commissioners ensured NHS money was spent on mental health services to provide maximum benefit to the communities they serve.

It found services were not always based on detailed assessments of local need. Funding was based on historical block contracts and planning tended to concentrate on the types of services to be provided, rather than on appropriate amounts of services.

New commission

The report highlighted that data collection across mental health services was often inconsistent. And nor was there consistency in how to achieve better value for money.

From the regulatory perspective, information on independent mental health services will be critical when the new regulator of health and social care, the Care Quality Commission, comes into being. Charged with assessing the performance of PCTs in their role as commissioners of services, the new commission is to continue with the risk-based, information-led system of regulation, so it will need access to good-quality information about all providers of mental healthcare.

Changes in this situation are overdue and have a steady chorus of support from the sector. Routine submissions of patient-level data in a standardised format across all providers is imperative for monitoring NHS-commissioned care and patient flows, irrespective of whether it is publicly or privately provided.

The growth of private sector provision, the rising numbers of compulsory admissions, the new Mental Health Act and equality legislation (particularly in relation to race, given the over-representation of some minority ethnic groups in inpatient mental health services), add to the debate.

In a climate of plurality of provision, improved choice for service users, increased accountability for boards and a reduction in the burden of regulation, it is critical that the DH, the Information Centre and other national agencies drive these changes in information and that PCTs as commissioners of care enforce them robustly.

These developments must ensure that independent sector services providing care to NHS patients are required to submit the same data as NHS services as part of their contractual obligation to commissioners.