Consultation outcome

Risk assessment framework update: summary of responses to Monitor’s consultation (March 2015)

Updated 26 March 2015

Applies to England

1. Introduction

In December 2014 we published a consultation on updates to the Risk assessment framework. The Risk assessment framework sets out how we assess risk to the continuity of services and the risk of poor governance. It enables us to identify potential concerns that can lead us either to request further information from a foundation trust or to open an investigation. We have used the Risk assessment framework to monitor NHS foundation trusts since 1 October 2013 and we said that after a year of operation, we would review how it has been working in practice and would make adjustments if needed.

The consultation was open for 8 weeks and closed on 18 February 2015. We received 53 responses from a range of stakeholders, with the majority of responses being from foundation trusts. We welcome the responses we received and we’ve highlighted below how we have considered them.

We consider that on the whole the Risk assessment framework has been fulfilling its objectives to date and we asked 16 questions in the consultation about a small number of proposed updates. Below is a high level summary of the responses we received to each proposed update.

The updated Risk assessment framework for 2015/16 is now available.

2. Introducing access measures for mental health providers

In early October 2014 the government announced 2 new access targets for mental health with a strong commitment to rolling them out across the sector in 2015/16:

• 2-week wait for receiving treatment from the Early Intervention in Psychosis (EIP) programme: providers will be required to treat 50% of patients with a National Institute for Health and Care Excellence-approved care package within 2 weeks
• referral-to-treatment target for Improving Access to Psychological Therapies (IAPT): this applies to waits from referral to the start of a course of treatment; providers will be required to see 75% of patients within 6 weeks and 95% of patients within 18 weeks

We consulted on introducing both of these access measures as new governance proxies for mental health trusts as we consider they are similar to the national access targets that we currently use for acute providers such as A&E and cancer wait times. A majority of the respondents who answered this question were providers of mental health services and most supported their inclusion in the Risk assessment framework as governance proxies. Therefore we will be introducing them.

A number of respondents also made comments about the definitions or reporting requirements for EIP and IAPT. These comments are more relevant to NHS England and the Health and Social Care Information Centre (HSCIC) who are responsible for developing and implementing these new national indictors. Therefore we have passed over a summary of these comments (unattributed), for their consideration.

2.1 Early Intervention in Psychosis Risk assessment framework implementation option

We consulted on 3 potential options for when we would start using EIP as a governance proxy and noted we would continue to liaise with NHS England about the progress of work to develop the indicator and the impact, if any, on the timetable. We highlighted that option 3 was our preferred option. This involved using the indicator as a formal Risk assessment framework trigger from April 2016, using it as a corroborating indicator during 2015/16 and requiring trusts to report against the measure from April 2015. Since the consultation has closed we have received further information from NHS England about their implementation timetable. We now understand that HSCIC intends to begin collecting EIP data from October 2015. This means it is not possible for us to ask trusts to report to us before this time and we have therefore altered our approach.

Instead of trusts reporting from Q1 2015/16, we will ask trusts to report to us from Q4 2015/16, and the indicator will be used as a formal Risk assessment framework trigger from April 2016 (Q1 2016/17). This aligns with the NHS England implementation timetable and should allow sufficient time for any reporting issues to be resolved before it is used as a formal trigger. It is also consistent with the views of a number of respondents who noted the importance of allowing time for the data collection issues to be resolved before using the indicator formally.

2.2 Improving Access to Psychological Therapies Risk assessment framework implementation option

We consulted on 2 potential options for when we would start using IAPT as a governance proxy and noted we would continue to liaise with NHS England about progress on how to develop the indicator and the impact, if any, on the implementation timetable. In the consultation we suggested that our preferred option was to ask trusts to report from Q1 2015/16 and that we would begin to use the measure as a formal trigger from Q3 2015/16. Since the consultation has closed we have received further information from NHS England about the implementation timetable and we now understand that providers are not required to be compliant with the trigger until April 2016. Therefore, we have altered our proposed approach to introducing IAPT into the Risk assessment framework.

We will now ask trusts to report to us from Q3 2015/16 and use the measure as a formal trigger from April 2016 (Q1 2016/17). As with EIP, this aligns with the NHS England implementation timetable and should allow sufficient time for any reporting issues to be resolved before it is used as a formal trigger. It is also consistent with the views of a number of respondents who noted the importance of allowing time for the data collection issues to be resolved before using the indicator formally.

2.3 Monitoring NHS trusts that provide high secure and medium secure services

In 2013, the Secretary of State for Health agreed that providers of high secure mental health services could apply for foundation trust status. There are 3 providers^{[footnote 1]} in England that deliver high secure services and the first of these providers^{[footnote 2]} was authorised as a foundation trust in February 2015. We highlighted 4 potential indicator options for inclusion in the Risk assessment framework and noted that any indicators would need to be: provider specific; have a clear threshold; be well defined and timely. The 4 options we consulted on were:

• maintain high secure services bed occupancy at or below 93%
• percentage of patients not having a full health check every 12 months
• health check assessment not carried out within 24 hours of admission to high secure services
• proportion of patients admitted to high secure services within 14 days of eligibility

Feedback about the suitability of these indicators was mixed. Concerns were raised about how provider specific they were and whether the thresholds were fixed and suitable. In response to these concerns and following further discussions with NHS England to discuss the most appropriate method of monitoring high and medium secure providers we have amended our approach.

We do not consider that any of the indicators highlighted above meet the required criteria for inclusion into the Risk assessment framework. However, a couple of respondents noted that high secure service providers are required to abide by a set of safety and security directions issued by the Secretary of State, and this is distinct from other providers of mental health providers, so monitoring compliance with these directions may be a suitable governance proxy. Therefore, we will ask high secure service providers to exception report to us any non-compliance with the security and safety directions at the same time as they inform NHS England of non-compliance as part of their mandatory reporting. They will also be required to exception report serious incidents and outcomes of security and safety audits. Further, since all providers of high secure services also provide other mental health services they will be monitored against the existing mental health governance proxies as well as the new EIP and IAPT access measures highlighted above. We therefore believe our intended approach is proportionate and that there are adequate measures in place to monitor potential governance concerns of providers of high secure services within the Risk assessment framework.

We also asked if we should apply potential indicators for high secure services to medium secure services if they are applicable. However, for the same reasons we have not introduced them for high secure services, we are not planning to introduce the proposed indicators for medium secure services. Medium secure services do not have to maintain compliance with the Secretary of State’s directions, therefore we will not be introducing any additional, specific exception reporting requirements for medium secure services.

A range of additional indicators were highlighted as suggestions for high secure services and medium secure services by stakeholders. These included mortality rate, delayed transfers of care and patients who are discharged but self harm within 7 days. However, as with the indicators highlighted above, we consider these do not sufficiently meet the criteria of being timely, well-defined, clear threshold and provider specific, and are not necessarily the most appropriate proxies of governance concerns. Therefore they would not be suitable for inclusion in the Risk assessment framework.

We also asked whether the National Oversight Group should be included as a third-party reporter. Concerns were raised that as this was a group made up of different organisations it might not be appropriate to name it as a third-party reporter. Furthermore, individual organisations are already required to share exception reports with us. In addition, Monitor is working with NHS England to agree separate information-sharing arrangements for high secure services and intends to reflect these in a revision of the Monitor and NHS England Memorandum of Understanding. Therefore we no longer consider it necessary to specifically name the National Oversight Group as a third-party reporter.

3. Clarifications to quality governance indicators

We set out our intention to rename quality governance indicators as organisational health indicators. There was no explicit concern raised with changing the name. One respondent suggested that organisational health indicator was not necessarily an accurate reflection of the measures but no viable alternatives were highlighted. We therefore consider the term ‘organisational health indicators’ to be the best available and we will use this term in the updated Risk assessment framework.

4. Additions to the financial risk rating

We proposed to introduce an additional financial trigger where if a trust is rated either a ‘1’ on liquidity or capital service capacity (the 2 separate components that make up the overall Continuity of Service Risk Rating) we could consider investigating. This would help us potentially act earlier with trusts that are likely to have future financial problems. A majority of respondents saw no downside to the introduction of this additional trigger. Those who objected were mainly concerned about the extra burden of investigations. However, as with all other triggers in the Risk assessment framework, this additional trigger would highlight a concern that we may wish to investigate and would not automatically lead to an investigation or regulatory action. Given the balance of support was in favour of our proposal, we intend to introduce this additional trigger.

We highlighted in the consultation that we would clarify in the Risk assessment framework that we could stress test a foundation trust’s forward plans against different scenarios and assumptions and that where the quality of the trust’s plan is poor we may investigate. A number of respondents made comments regarding the stress testing of plans. Most agreed with the principle but noted the importance of being transparent about the assumptions used, the need to provide guidance to trusts about how the process would work and the need for early dialogue between trusts and Monitor. We agree with these comments and intend to publish guidance to coincide with when we next publish guidance on forward plans

5. Other clarifications

A small number of respondents highlighted other clarifications that would be useful, such as clarifying reporting requirements. Where appropriate, and if applicable to the role of the Risk assessment framework, we have made updates to provide additional clarity.

1. West London Mental Health NHS Trust (Broadmoor Hospital), Nottinghamshire Healthcare NHS Foundation Trust (Rampton Hospital) and Mersey Care NHS Trust (Ashworth Hospital). ↩

2. Nottinghamshire Healthcare NHS Foundation Trust ↩