National Mental Health Act Quality Improvement Programme
Commissioned by NHS England and co-delivered with Virginia Mason Institute, we supported 51 mental health wards to deliver locally-led, centrally supported & co-produced quality improvement projects to improve equity for patients from diverse backgrounds.
The 2018 Independent Review of Mental Health Act highlighted the significant inequities in the experience of patients from ethnically and culturally diverse backgrounds, patients with learning disabilities and autistic patients within mental health inpatient services. For example, in 2022, people from ethnically diverse backgrounds were more than 4x more likely to be detained under the Mental Health Act, while 90% of autistic people detained in hospitals were there due to the Mental Health Act.
The 2021 Government White Paper, Reforming the Mental Health Act, recommended that NHS England deliver a national Quality Improvement (QI) programme for mental health inpatient services to address these inequities at a local level.
Pictured: the team from The Orchard, one of the participating wards in the programme.
The Approach
We used a three-pronged approach in delivering the Mental Health Act (MHA) QI Programme to support participating mental health wards to design and embed meaningful locally-led, centrally-supported change ideas that had been co-produced with individuals with lived experience.
Ward-level coaching:
We delivered over 1750 hours of QI coaching to project teams from 51 mental health inpatient wards from 33 different providers located across England.
We ran initial in-person full-day improvement workshops for each team to introduce them to the equity lens of the project, review their ward data and processes, identify areas of inequity in the experience of their patients, and brainstorm potential change ideas for their QI projects. Teams then received weekly QI coaching sessions to support them in developing and implementing their chosen change ideas.
We worked with all service types within scope (e.g. children and young people’s services, psychiatric intensive care units, secure services) and the individual project teams consisted of a mix of ward-based and clinical staff, and individuals with lived experience to ensure that the equity-focused change ideas implemented were co-produced and centred around patient voice.
Executive sponsorship:
Each ward had an identified executive sponsor within their organisation who they met with at various points throughout the programme to review the progress of their change ideas, connect with wider organisational support, and identify opportunities for sharing their change ideas more widely within their organisation. Executive sponsors also received separate coaching from our colleagues at VMI to support them with addressing patient inequities at an organisation level through both one-to-one sessions and group workshops with other members of their leadership team.
Learning events:
The programme team facilitated learning events to develop participants’ knowledge of equity-related topics, foster connection between participants, and to share learning and best practice. The events included 8 national workshops and webinars on a variety of equity-related topics and the creation of a monthly community of practice for the lived experience practitioners involved in the programme.
The Impact
Over the 27 months of the programme, we worked with more than 350 clinical and operational staff and 50 lived experience practitioners to co-produce change ideas that have impacted at least 800 patients to date, with many more benefitting from the changes over time as they become embedded on wards and shared across organisations.
Project teams implemented a diverse range of change ideas to address different inequities, such as:
- Co-designing accessible documentation to identify patients cultural, sensory and communication needs at admission
- Implementing an accessible care plan template and visual discharge plan to enable patients to take ownership of their progress and forward momentum on the ward
- Organising training for staff on identifying and managing pressure wounds in patients from ethnically diverse backgrounds.
The coaching itself also introduced project teams and their executive sponsors to a variety of QI and equity tools and methodologies (e.g. root cause analysis, equity pauses, equity huddle cards) to support them with embedding a systemic approach to equity-based QI work within their ward/ organisation.
Whilst the full impact of the change ideas has not yet been realised given the short timeframe for the design and implementation of the wards’ QI projects, the early results from initial local and programme-level data collection show significant benefits for patients on participating wards:
Patients and carers are empowered to share their needs and preferences with the staff supporting them.
- 75% patients in the programme evaluation patient ethnographic interviews reported that they felt listened to by staff when communicating their preferences.
Patients and carers have greater opportunities to work in partnership with staff to co-produce their care.
- On Shelley Ward (a secure adult ward), where a more accessible care plan template and monthly goals document were implemented 92% of patients felt more familiar with their care plans and 84% felt that the care delivered on the ward is more consistent and in line with their care plans as a result of the change.
- On Winsford Ward (a secure specialist learning disability and autism ward), 100% of patients reported feeling heard in their ward round meetings following the introduction of a new pre-ward round document to capture their voices and points for discussion.
Patients are receiving enhanced support for their individual needs (particularly sensory, cultural, communication, cultural and religious needs).
- On Cubley Court (a dementia ward), 100% of the patients able to engage with the more accessible Mental Health Act rights document developed by the project team found it more accessible.
- 75% patients in the programme evaluation patient ethnographic interviews reported that they felt that the support they received was considerate of their individual needs.
Staff feel more able and confident in identifying, understanding and supporting the needs of patients from ethnically diverse backgrounds on their ward.
- Over the course of the wider implementation phase, there was a 28.7 percentage point increase in staff agreement that the support and care on their ward is inclusive of the diverse cultures and needs of patients from ethnically diverse backgrounds.
Staff feel more able and confident in identifying, understanding and supporting the needs of patients with learning disabilities and autistic patients on their ward.
- There was a 35.2 percentage point increase in staff confidence in supporting the needs of patients with learning disabilities on their ward over the course of the coaching, and a 37.3 percentage point increase in their confidence to support the needs of autistic patients.
Staff feel more confident with taking a systemic approach to equity-based quality improvement.
- The end-of-programme survey showed a 20% increase in staff confidence in using QI tools and techniques from a mean of 6.5/10 to 7.8/10.
- The end-of-programme survey showed a 21% increase in staff confidence in taking part in and facilitating conversations about inequity, privilege, power dynamics, and protected characteristics.
Additionally, individuals with lived experience (both lived experience practitioners and current patients and carers) are more involved with co-producing improvements to support and care in mental health services - the end-of-programme survey showed a 32.8 percentage point increase in staff agreement that patients, carers and lived experience practitioners are regularly involved in designing improvements to support and care in their service.
The PSC Factor
The PSC’s expertise in supporting locally-led, centrally-supported quality improvement initiatives, our extensive experience of working with mental health services, and our established connections with mental health trusts around the country provided a strong foundation with which to approach the set up and delivery of this large-scale, national programme. We worked in partnership with Virginia Mason Institute (VMI) whose executive coaching capabilities meant that they were well-placed to deliver coaching to the executive sponsors of participating ward teams.
Recognising the importance and value of keeping the voices of those with lived experience of mental health services at the heart of the programme, we recruited lived experience associates to serve as members of both the programme delivery team and wider steering group. Our lived experience associates were key team members, providing robust challenge to the programme to grapple with issues such as ensuring the meaningful coproduction of change ideas by the ward teams, and raising awareness of whiteness within the programme. The lived experience associates on the programme delivery team also co-delivered improvement days and weekly coaching sessions.
This was a first for The PSC and part of our wider efforts to incorporate lived experience involvement in our project work to enhance its impact in meeting the needs of service users. We're continuing to work within this space - for example, co-delivering NHS England's Culture of Care programme.
If you want to find out more about our lived experience involvement work and how we can support your organisation, get in touch with us at hello@thepsc.co.uk, and follow us on LinkedIn for regular updates.