Mental health: A year and half after the groundbreaking 10 high-impact changes were published comes a new version specifically for mental health services, writes Jackie Ardley

When the Modernisation Agency published the 10 high-impact changes for service improvement and delivery in September 2004, mental health leaders were keen to test their relevance and adapt them to improve mental health services.

But while there was a guide for primary care trusts and for clinicians, there was nothing for mental health.

Through its regional development centres, the Care Services Improvement Partnership has found examples of service and process redesign in health and social care communities. They focused on areas where the effect of the high-impact changes could be measured.

The result is the launch this month of the 10 high-impact changes for mental health services, and two accompanying publications.

These present the 10 areas that have the greatest positive impact on service user and carer experience, service delivery, outcomes and staff.

1 Treat home-based care and support as the norm

Aim: To avoid hospital admission unless necessary.

Example: Easington crisis resolution and home treatment team, Tees, Esk and Wear Valleys trust.

Reduction in admissions from 175 in 2002 to 128 in 2003 and 92 in 2004; 100 per cent were satisfied or very satisfied with the care they received; bed days were reduced by 649 over one year, saving£142,780.

2 Improve flow of service users and carers across health and social care by improving access to screening and assessment

Aim: To make it easier for service users and carers to access screening and assessment services.

Example: Northumberland, Tyne and Wear trust introduced full booking for its Newcastle and North Tyneside perinatal service.

Average response time down from 21 days to 11 days; referrers' increased confidence in the postnatal depression protocol; a 50 per cent reduction in unnecessary referrals.

3 Manage variation in service user discharge processes

Aim: Timely and consistent discharge from all services.

Example: Sheffield Care trust adult mental health acute services introduced a discharge facilitator.

Reduced bed occupancy; of 182 users at risk of losing their home or needing a change in accommodation during 2004-05, 67 per cent did not experience any delays in discharge; delay periods were reduced by 50 per cent from an average 11 to five weeks

4 Manage variation in access

Aim: To ensure responsive and consistent access to services.

Example: East Cambridge and Fenland choose and book system, Cambridgeshire and Peterborough Mental Health Partnership trust.

Child and adolescent mental health services report a steady decline in did not attend rates; older people's services had a zero did not attend rate (96 referrals); positive feedback from users.

5 Avoid unnecessary contact for users and provide necessary contact in the right setting

Aim: To support effective planned and negotiated care and follow-up contact that is determined only by need or service user-led request.

Example: Mersey Care trust established a pharmacy technician to lead a seamless medicines management approach.

Service users are able to access all their medications via their GP and community pharmacy service; reduced prescription expenditure.

6 Increase the reliability of interventions by designing care around what is known to work and that service users and carers inform and influence

Aim: To underpin care with good practice and evidence, enabling service users and carers to be at the centre of decisions and establishing systems to support their meaningful involvement and participation.

Example: Service users play a central role in shaping and running the Haven, a joint project led by North Essex Mental Heath Partnership trust for the support and treatment of people with a personality disorder.

An 87 per cent reduction in Mental Health Act (section 136) orders a year; annual acute inpatient admissions down by 85 per cent; a 60 per cent reduction in use of accident and emergency services.

7 Apply a systematic approach to enable the recovery of people with long-term conditions

Aim: To provide an approach that supports and empowers people with long-term conditions to better manage their mental health.

Example: West London Mental Health trust's Cafe on the Hill.

Service users gain work experience and qualifications; on average there are 13 team workers (service users) in the cafe, eight of whom have completed the NVQ in food preparation.

8 Improve service-user flow by removing queues

Aim: To reduce the time service users wait at any point.

Example: Mersey Care trust adult mental health directorate gateway worker impact.

Decisions on all referrals received are made and communicated to service users in 24 hours; the routine referral waiting time is four weeks, emergency is the same day and urgent one week.

9 Optimise service-user and carer flow through an integrated care pathway

Aim: To increase efficiency and outcomes through a whole-service evidence-based and systematic approach to delivering a care package.

Example: Gloucester recovery in psychosis service, Gloucestershire Partnership trust and Cheltenham Community Projects.

Reduced bed occupancy; 93 per cent of first-episode users and their families now access behavioural family intervention; all carers receive carer assessment; all service users and carers are aware of the care programme; over three years to March 2006, duration of untreated psychosis has fallen from 13 to three months; fewer Mental Health Act assessments; at April 2006, there had been no incidents of suicide among their clients aged 14-35, despite a 70 times higher risk in this client group.

10 Redesign and extend roles in line with efficient service user and carer pathways to attract and retain an effective workforce

Aim: To ensure that services meet the needs of service users and carers and that skilled and motivated staff are recruited and retained.

Example: Memory nurse role at the Memory Assessment and Research Centre, Hampshire Partnership trust.

Reduction of waiting for new referrals to four weeks; new service users up by 50 per cent: an additional 200 people can be seen per year by memory nurses, on top of memory clinic attendance; an additional 1,000 follow-up appointments can be held each year; three memory nurses are supplementary prescribers; more activity for much lower cost.

These success stories depend on trusts' engagement and work with staff and service users.

More than 80 case studies have been produced and many of them highlight good practice. As much work is still in progress, we know the case studies are in early days. They will be updated twice a year to bring knowledge and experience to the field.