At HTN Now: Digital Social Care and Mental Health, we were joined by Vicky Boswell, Associate Director of Performance, and Tom Jones, Head of Business Intelligence, from North Staffordshire Combined Healthcare.
Vicky and Tom discussed accessing mental health data for quality care and ICS analysis, with a focus on how North Staffordshire Combined Health are using data to get an accurate understanding of the pattern of care activity following the restoration and recovery of services in 2022/23. Plus, to target where resources are most needed and to generate a wide range of automated submissions and reports.
Vicky shared how the session would focus on data management in three key areas: population health management, activity reporting to support COVID recovery, and demand and capacity planning across the integrated care board (ICB).
To begin, some background on North Staffordshire Combined Health was provided. “We’re a leading provider of mental health, social care, learning disability and substance misuse services, as well as some primary care services,” Vicky said. “Our services are for a wide range of people with different needs, and they operate in hospitals and communities, though the majority are community based. The focus here is really about how data can support those community services.”
Vicky highlighted that as a mental health trust, working in partnership is crucially important. “People’s mental health needs are associated with the whole of their lives,” she said. “We have well-established partnership arrangements and three partnership boards. We’re also really committed to developing partnership arrangements with the integrated care system (ICS).”
National data strategy
The national strategy Data Saves Lives aims to drive transformation in health and care by reshaping the way that data is used, and by harnessing the data-driven power and innovation seen during the pandemic to drive transformation.
“The last of the seven principles within the strategy is around creating a very good infrastructure for data,” Vicky said. “That’s what we’ve been focusing on as a trust. We have established a new data warehouse, we are mindful that it’s really important that our infrastructure can support our ambitions.”
The trust’s business intelligence strategy is to improve accuracy, availability and accessibility of organisational reporting; to move away from information and reporting to insight and high value analytics, including predictive analysis. Additionally, the strategy aims to develop a realistic and aligned understanding of demand and capacity planning; and to inform clinical decision-making by using a population health management approach to tackle health inequity.
“The importance of that infrastructure through the data warehouse platform is that we need a platform that is agile and flexible,” Vicky stated. “We want to increase the scope of automation and crucially reduce manual data management. We need to have a single version of the truth and consistent trust in the output. We need a data warehouse platform that is fit for the future that will support our ambition to develop and integrate more systems along with supporting opportunities to innovate across the ICS, for example integrating our systems with other providers. Our infrastructure should enable us to be in the best position to pursue those opportunities.”
National mental health strategy
Vicky shared some context about mental health services, particularly with regards to the impact of COVID-19. “There was a significant change in operations during lockdown,” she said. “In common with a lot of NHS providers, we experienced that suppressed demand. People were not going to GPs with concerns about mental health, so GPs were not referring them through to the trust.
“Following the easing of restrictions, we began to see an increase in referrals and in some services that has continued at pace. For instance, in common with the national picture, referrals to our services for trans children and young people have continued to increase significantly. We’re also aware that in terms of mental health need, there’s an ongoing impact of social isolation.”
Looking ahead, Vicky said, “We’re concerned about the impact the cost of living crisis will have on mental health as we’re going into winter. Some people, particularly those living in areas of high deprivation, may be vulnerable, concerned about heating their homes or feeding their children, and we’re working with local authorities partners to try and mitigate that risk and think about possible interventions.”
Community Mental Health Transformation is a “really big initiative,” Vicky said, “and links to the NHS Long-Term Plan. It aims to support individuals with severe mental illness who can fall into the cracks between services. It is recognised that those individuals have 3.7 times higher mortality rate than the rest of the population.”
Vicky emphasised that community transformation should put service users and carers at the centre of the work, and it needs to provide an integrated package. “We are working with partner organisations to really improve the experience of people with severe mental illness,” she said. “We’re working with primary care, looking at early identification and those initiatives that can support people at the early stages, to hopefully prevent mental health needs becoming more complex. We’re working with local authorities and other secondary care partners on other areas, for example to link mental health with the care of physical health. Crucially, we’re working with the third sector too – we’re in a position now to commission other organisations, which is great, as we can work together to make sure social needs are addressed such as supporting people to access welfare benefits or to have informal meetings for peer support.”
North Staffordshire Combined Health’s own transformation plans include putting in place new pathways for individuals, for example, intervention in psychosis or eating disorders, or individual placement and support to help people back into employment.
“Recognising and tackling health inequalities is really where data is able to support us effectively in this,” Vicky said. “Through data we can create reports and better our understanding of the outcomes for these new pathways.”
Population health management and health equity assessments
“We are producing Health Equity Assessments for each primary care network area,” Vicky shared. “These look within each group of GP practices at what specifically is occurring with health inequalities in that area. Health inequalities are systemic and there are unjust differences in health across populations and between different groups.”
North Staffordshire Combined Health are keen to explore the wider determinants of health such as income, education, skills, housing and the environment that people live in, taking into account power and discrimination with regards to ethnicity, age, gender and so on. Other determinants include health behaviours such as smoking or diet, and psychosocial factors such as access to a social support network and people’s perceived level of control and self-worth.
Vicky showed an example of a PCN Health Equity Assessment pack (available to view at 17:39 on the video below). “We use a wide range of data sources including GP data and Census data. We build a picture of need according to the primary care networks, so we look at what is happening in terms of deprivation within certain areas. We can also look at our service usage and then we can assess whether that is comparable to the population or whether we’ve got higher incidents of severe mental illness or substance misuse in certain areas.
“Building on that further, we were asked by our substance misuse services to do a piece of work to help them to identify where two new substance misuse satellite services could be located. This population health management work really helped us to identify what. We found that there was a high correlation with high deprivation, and that 70 percent of activity was generated in the three areas experiencing the highest level of deprivation. On the back of that, the placement of the new satellite sites could be made close to those areas.”
In terms of activity planning, Vicky said, “We have an activity planning tool, which is automated and accessible to service managers and team managers. It shows activity over a period of time and averages. It enables our teams to track activity against the plan or the forecast, and it also highlights very clearly where activity may be decreasing or increasing. It enables more of a deep dive to understand what’s behind that and where creative action can be taken. The outputs of this are fed to the board report and our directorate performance packs and inform performance discussions each month with the executive team.”
This also “enables a robust narrative from clinical services and operations, to help explain the variances,” Vicky explained. “This also helps us with our conversations with commissioners, against contracted activity levels.”
Another change in delivery of care that was monitored was the impact of COVID-19 on in-person activity. Previously, community services had seen a high level of face-to-face contact, sometimes up to 90 percent. The pandemic changed this and triggered a shift to digital contact.
Vicky showed how this activity was tracked (to view the graph, go to 21:17 on the video). Face-to-face contact was measured along with telephone calls and telemedicine video conferencing, and the trust could see when face-to-face contact began to rise again.
“We’re not making a judgement about what is right or what is wrong for individual teams,” Vicky pointed out. “We know that services with a lot of younger patients actually tend to prefer digital contact, for example. Tracking the data just enables a discussion.”
Statistical process control
“We use statistical process control (SPC) routinely,” Vicky said. “It’s the way in which we report to our board on our key performance indicators. We also support quality improvement initiatives using SPC charts.”
A chart was shown as an example, available to view at 22:17.
“This is a typical way of looking at an activity,” Vicky commented, “perhaps looking at a two point comparison between two dates. You might make some assumptions if there’s variation or be concerned about how the performance is looking from the same point last year.
“But actually it’s much more effective to look at data trends over time. An SPC chart includes an algorithm to tell you if activity is below expectation or standard variation, or above expectation or standard variation. We find this really helpful, moving away from RAG-based reporting which we previously had – with that, if something is red, there is focus on the red. This chart gives a much more sophisticated and rigorous view of data which really helps to explain where we see variation and whether we should be concerned about it.”
Demand and capacity planning
Vicky handed over to Tom at this point. “In mental health, we recognise the complexity of activity in the way that patients use services or touch services,” he said. “It’s much complex than in physical health services. In a physical health hospital, you’ve got the services set up around conditions, more or less. You tend to have a linear movement through that service.
“In mental health, patients often move between services in a much more unpredictable way. We’ve got services set up for different types of conditions but we have general services as well. A patient might arrive, be assessed and sent to the general psychology team; that treatment might go on for weeks or months. But there may be an acute presentation that requires an inpatient stay, and as a result of that it might be decided that actually this is a third presentation of psychosis and they need to be moved to the early psychosis prevention team. After some work with that team, the patient may go back to the general psychology team.”
To try to understand that complexity, Tom said, the trust is working with the ICB to explore dynamic systems analysis. An example is shown at 25:50.
“It’s a very simple model to look at,” Tom said. “We’re trying to model the system as a series of stocks and flows that we can plug our data into, and see how patients move across services. The aim is to try and simplify that complexity.
“We’re working with the ICB on this locally; if it’s successful, we can look to see if we can apply the same knowledge at an ICS level. Then we can start seeing the movement between organisations, and we can potentially answer questions such as whether there is a string of DNA in a mental health setting that precipitates an A&E attendance. By looking into things like that, we can explore the movement between organisations and systems.”
Many thanks to Vicky and Tom for joining us at HTN Now.
