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Quality improvement in mental health


Some recent high-profile reports have shown that NHS mental health care services are under pressure. Last month, the BMA reported that the number of adults sent ‘out of area’ for mental health care has increased over the past couple of years, a practice the Commission on Acute Adult Psychiatric Care highlighted as one of a number of issues contributing to variation in the quality of care in mental health.

A couple of weeks ago, NHS Providers reported that chairs and chief executives of mental health trusts were concerned about the growth in the number of children and young people attending A&E departments for psychiatric issues and being referred to child and adolescent mental health services. Today, the Care Quality Commission has published a review of its inspections of specialist mental health services which raises concerns about access and waiting times and safety, amongst other things. The King’s Fund has also previously described the pressures being experienced in different parts of the mental health sector.

For staff working in mental health care at the moment, who go to work to make things better for the people in their care, I can imagine that such messages can feel overwhelming and demoralising.

So I’m pleased to say that our latest report focuses on examples of positive change in mental health, and on taking a systematic approach to improving care. To be clear, I don’t claim that quality improvement will resolve all of the issues mentioned above; funding is still needed to pay for better services. Nor is quality improvement a ‘quick fix’; creating the type of cultural shift needed to change an organisation’s whole approach to quality does take time. But it is important to share the stories about people in mental health services striving to make positive changes for service users, carers and staff – to show that many organisations are making continuous efforts to improve the safety, experience and effectiveness of care.

Quality improvement is a way to empower those closest to the complex problems – staff, service users and carers – to develop solutions. Quality improvement can also help organisations make the most of some of the strongest assets in mental health – a history of multidisciplinary working, service user involvement and co-production.

There is no doubt that finding the time to dedicate to quality improvement can be challenging, but as we saw in our case study organisations, leaders can really help to embed cultures of improvement. Leaders’ long-term commitment is essential; outcomes are often undermined by not applying quality improvement methods robustly and by treating the work like separate, time-limited projects as opposed to a continuous process.

Speaking of outcomes, it is worth mentioning here some of the reported benefits of quality improvement in mental health. At Tees, Esk and Wear Valleys NHS Foundation Trust, quality improvement led to reduced lengths of stay and bed occupancy in inpatient care and reduced waiting times for community-based services. East London NHS Foundation Trust has reduced violent incidents across wards, which has in turn helped reduce staff injury and absence from work. The Institute of Mental Health (in Singapore) has improved the way in which staff help to manage inpatients’ co-morbid diabetes. These organisations have achieved these outcomes through a cultural shift and making quality improvement the routine way of working. Similarly, my colleagues in Leadership and Organisational Development previously worked with Oxleas NHS Foundation Trust to redesign one strategic approach to quality improvement that encompassed all parts of the service.

The King’s Fund has argued that the NHS needs a coherent national strategy for quality improvement and also that transformation requires a stronger focus on bringing about ‘change from within’ – ie, engaging doctors, nurses and other staff in improvement work. The mental health organisations we have mentioned have taken steps in the right direction. Perhaps, in time, even more could be achieved by health and care organisations developing a collective, system-wide approach to quality improvement – by acting ‘like a sector’ (Dixon-Woods and Martin 2016).