Mental Health Minimum Data Set Research Articles

Acute day units in non-residential settings for people in mental health crisis: the AD-CARE mixed-methods study

Background For people in mental health crisis, acute day units provide daily structured sessions and peer support in non-residential settings as an alternative to crisis resolution teams. Objectives To investigate the provision, effectiveness, intervention acceptability and re-admission rates of acute day units. Design Work package 1 – mapping and national questionnaire survey of acute day units. Work package 2.1 – cohort study comparing outcomes during a 6-month period between acute day unit and crisis resolution team participants. Work package 2.2 – qualitative interviews with staff and service users of acute day units. Work package 3 – a cohort study within the Mental Health Minimum Data Set exploring re-admissions to acute care over 6 months. A patient and public involvement group supported the study throughout. Setting and participants Work package 1 – all non-residential acute day units (NHS and voluntary sector) in England. Work packages 2.1 and 2.2 – four NHS trusts with staff, service users and carers in acute day units and crisis resolution teams. Work package 3 – all individuals using mental health NHS trusts in England. Results Work package 1 – we identified 27 acute day units in 17 out of 58 trusts. Acute day units are typically available on weekdays from 10 a.m. to 4 p.m., providing a wide range of interventions and a multidisciplinary team, including clinicians, and having an average attendance of 5 weeks. Work package 2.1 – we recruited 744 participants (acute day units, n = 431; crisis resolution teams, n = 312). In the primary analysis, 21% of acute day unit participants (vs. 23% of crisis resolution team participants) were re-admitted to acute mental health services over 6 months. There was no statistically significant difference in the fully adjusted model (acute day unit hazard ratio 0.78, 95% confidence interval 0.54 to 1.14; p = 0.20), with highly heterogeneous results between trusts. Acute day unit participants had higher satisfaction and well-being scores and lower depression scores than crisis resolution team participants. The health economics analysis found no difference in resource use or cost between the acute day unit and crisis resolution team groups in the fully adjusted analysis. Work package 2.2 – 36 people were interviewed (acute day unit staff, n = 12; service users, n = 21; carers, n = 3). There was an overwhelming consensus that acute day units are highly valued. Service users found the high amount of contact time and staff continuity, peer support and structure provided by acute day units particularly beneficial. Staff also valued providing continuity, building strong therapeutic relationships and providing a variety of flexible, personalised support. Work package 3 – of 231,998 individuals discharged from acute care (crisis resolution team, acute day unit or inpatient ward), 21.4% were re-admitted for acute treatment within 6 months, with women, single people, people of mixed or black ethnicity, those living in more deprived areas and those in the severe psychosis care cluster being more likely to be re-admitted. Little variation in re-admissions was explained at the trust level, or between trusts with and trusts without acute day units (adjusted odds ratio 0.96, 95% confidence interval 0.80 to 1.15). Limitations In work package 1, some of the information is likely to be incomplete as a result of trusts’ self-reporting. There may have been recruitment bias in work packages 2.1 and 2.2. Part of the health economics analysis relied on clinical Health of the Nations Outcome Scale ratings. The Mental Health Minimum Data Set did not contain a variable identifying acute day units, and some covariates had a considerable number of missing data. Conclusions Acute day units are not provided routinely in the NHS but are highly valued by staff and service users, giving better outcomes in terms of satisfaction, well-being and depression than, and no significant differences in risk of re-admission or increased costs from, crisis resolution teams. Future work should investigate wider health and care system structures and the place of acute day units within them; the development of a model of best practice for acute day units; and staff turnover and well-being (including the impacts of these on care). Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 18. See the NIHR Journals Library website for further project information.

Effects of ethnic density on the risk of compulsory psychiatric admission for individuals attending secondary care mental health services: evidence from a large-scale study in England.

Black, Asian and minority ethnicity groups may experience better health outcomes when living in areas of high own-group ethnic density - the so-called 'ethnic density' hypothesis. We tested this hypothesis for the treatment outcome of compulsory admission. Data from the 2010-2011 Mental Health Minimum Dataset (N = 1 053 617) was linked to the 2011 Census and 2010 Index of Multiple Deprivation. Own-group ethnic density was calculated by dividing the number of residents per ethnic group for each lower layer super output area (LSOA) in the Census by the LSOA total population. Multilevel modelling estimated the effect of own-group ethnic density on the risk of compulsory admission by ethnic group (White British, White other, Black, Asian and mixed), accounting for patient characteristics (age and gender), area-level deprivation and population density. Asian and White British patients experienced a reduced risk of compulsory admission when living in the areas of high own-group ethnic density [odds ratios (OR) 0.97, 95% credible interval (CI) 0.95-0.99 and 0.94, 95% CI 0.93-0.95, respectively], whereas White minority patients were at increased risk when living in neighbourhoods of higher own-group ethnic concentration (OR 1.18, 95% CI 1.11-1.26). Higher levels of own-group ethnic density were associated with an increased risk of compulsory admission for mixed-ethnicity patients, but only when deprivation and population density were excluded from the model. Neighbourhood-level concentration of own-group ethnicity for Black patients did not influence the risk of compulsory admission. We found only minimal support for the ethnic density hypothesis for the treatment outcome of compulsory admission to under the Mental Health Act.

The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study

Background Serious mental illness, including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with serious mental illness are treated in primary care by general practitioners, who are financially incentivised to meet quality targets for patients with chronic conditions, including serious mental illness, under the Quality and Outcomes Framework. The Quality and Outcomes Framework, however, omits important aspects of quality. Objectives We examined whether or not better quality of primary care for people with serious mental illness improved a range of outcomes. Design and setting We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, accident and emergency attendances, Office for National Statistics mortality data and community mental health records in the Mental Health Minimum Data Set. We used survival analysis to estimate whether or not selected quality indicators affect the time until patients experience an outcome. Participants Four cohorts of people with serious mental illness, depending on the outcomes examined and inclusion criteria. Interventions Quality of care was measured with (1) Quality and Outcomes Framework indicators (care plans and annual physical reviews) and (2) non-Quality and Outcomes Framework indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by general practitioners). Main outcome measures Several outcomes were examined: emergency admissions for serious mental illness and ambulatory care sensitive conditions; all unplanned admissions; accident and emergency attendances; mortality; re-entry into specialist mental health services; and costs attributed to primary, secondary and community mental health care. Results Care plans were associated with lower risk of accident and emergency attendance (hazard ratio 0.74, 95% confidence interval 0.69 to 0.80), serious mental illness admission (hazard ratio 0.67, 95% confidence interval 0.59 to 0.75), ambulatory care sensitive condition admission (hazard ratio 0.73, 95% confidence interval 0.64 to 0.83), and lower overall health-care (£53), primary care (£9), hospital (£26) and mental health-care costs (£12). Annual reviews were associated with reduced risk of accident and emergency attendance (hazard ratio 0.80, 95% confidence interval 0.76 to 0.85), serious mental illness admission (hazard ratio 0.75, 95% confidence interval 0.67 to 0.84), ambulatory care sensitive condition admission (hazard ratio 0.76, 95% confidence interval 0.67 to 0.87), and lower overall health-care (£34), primary care (£9) and mental health-care costs (£30). Higher general practitioner continuity was associated with lower risk of accident and emergency presentation (hazard ratio 0.89, 95% confidence interval 0.83 to 0.97) and ambulatory care sensitive condition admission (hazard ratio 0.77, 95% confidence interval 0.65 to 0.92), but not with serious mental illness admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or accident and emergency presentation. None of the quality measures was statistically significantly associated with risk of re-entry into specialist mental health care. Limitations There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences. Conclusions Better performance on Quality and Outcomes Framework measures and continuity of care are associated with better outcomes and lower resource utilisation, and could generate moderate cost savings. Future work Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 25. See the NIHR Journals Library website for further project information.

Latent class analysis of the health of the nation outcome scales: A comparison of Swiss and English profiles and exploration of their predictive utility

The Health of the nation outcome scales (HoNOS) [1] were designed to measure the health and social functioning of adults with severe mental health problems. They form part of the English mental health minimum data set and are recommended by the department of health and are part of the attempt to develop “payment by results” (PbR) for mental health [2]. They are also widely used in Australia, New Zealand and Canada [3, 4], and have also been used in Europe [5]. Although they are widely used there are still questions about their psychometric validity and their ability to predict anything useful.

Investigating the relationship between costs and outcomes for English mental health providers: a bi-variate multi-level regression analysis.

Provider payment systems for mental health care that incentivize cost control and quality improvement have been a policy focus in a number of countries. In England, a new prospective provider payment system is being introduced to mental health that should encourage providers to control costs and improve outcomes. The aim of this research is to investigate the relationship between costs and outcomes to ascertain whether there is a trade-off between controlling costs and improving outcomes. The main data source is the Mental Health Minimum Data Set (MHMDS) for the years 2011/12 and 2012/13. Costs are calculated using NHS reference cost data while outcomes are measured using the Health of the Nation Outcome Scales (HoNOS). We estimate a bivariate multi-level model with costs and outcomes simultaneously. We calculate the correlation and plot the pairwise relationship between residual costs and outcomes at the provider level. After controlling for a range of demographic, need, social, and treatment variables, residual variation in costs and outcomes remains at the provider level. The correlation between residual costs and outcomes is negative, but very small, suggesting that cost-containment efforts by providers should not undermine outcome-improving efforts under the new payment system.

Variation in compulsory psychiatric inpatient admission in England: a cross-classified, multilevel analysis

The increasing rate of compulsory admission to psychiatric inpatient beds in England is worrying. Studying variation between places and services could be key to identifying targets for interventions to reverse this trend. We modelled spatial variation in compulsory admissions in England using national patient-level data and quantified the extent to which patient, local-area, and service-setting characteristics accounted for this variation. This study is a cross-sectional, multilevel analysis of the 2010-11 Mental Health Minimum Data Set (MHMDS). Data from eight provider trusts were excluded, including three independent provider trusts that lacked spatial identification codes. We excluded patients detained under sections of the Mental Health Act concerned only with conveyance to, or assessment in, a registered Place of Safety, or for short-term (≤72 h) assessment only, as these do not in themselves necessarily mean that the person will be admitted to an inpatient mental health bed. MHMDS contained reasonably complete data for a limited number of patient characteristics, namely age, sex, and ethnicity; however, several patient-level variables could not be included in our analysis because of high levels of missing data. Multilevel models were applied with MLwiN to estimate variation in compulsory admission, starting with null (unconditional) models that partitioned total variance in compulsory admission between each level in the model. The primary outcome was compulsory admission to a psychiatric inpatient bed, compared with people admitted voluntarily or receiving only community-based care. Data were available for 1 238 188 patients, covering 64 National Health Service provider trusts (93%) and 31 865 census lower super output areas (LSOAs; 98%). 7·5% and 5·6% of the variance in compulsory admission occurred at LSOA level and provider trust levels, respectively, after adjusting for patient characteristics. Black patients were almost three times more likely to be admitted compulsorily than were white patients (odds ratio [OR] 2·94, 95% CI 2·90-2·98). Compulsory admission was greater in more deprived areas (OR 1·22, 1·18-1·27) and in areas with more non-white residents (OR 1·51, 1·43-1·59), after adjusting for confounders. Rates of compulsory admission to inpatient psychiatric beds vary significantly between local areas and services, independent of patient, area, and service characteristics. Compulsory admission rates seem to reflect local factors, especially socioeconomic and ethnic population composition. Understanding how these factors condition access to, and use of, mental health care is likely to be important for developing interventions to reduce compulsion. National Institute for Health Research Health Services and Delivery Research Programme.

Comparing the performance of English mental health providers in achieving patient outcomes

Evidence on provider payment systems that incorporate patient outcomes is limited for mental health care. In England, funding for mental health care services is changing to a prospective payment system with a future objective of linking some part of provider payment to outcomes. This research examines performance of mental health providers offering hospital and community services, in order to investigate if some are delivering better outcomes. Outcomes are measured using the Health of the Nation Outcome Scales (HoNOS) – a clinician-rated routine outcome measure (CROM) mandated for national use. We use data from the Mental Health Minimum Data Set (MHMDS) – a dataset on specialist mental health care with national coverage – for the years 2011/12 and 2012/13 with a final estimation sample of 305,960 observations with follow-up HoNOS scores. A hierarchical ordered probit model is used and outcomes are risk adjusted with independent variables reflecting demographic, need, severity and social indicators. A hierarchical linear model is also estimated with the follow-up total HoNOS score as the dependent variable and the baseline total HoNOS score included as a risk-adjuster. Provider performance is captured by a random effect that is quantified using Empirical Bayes methods. We find that worse outcomes are associated with severity and better outcomes with older age and social support. After adjusting outcomes for various risk factors, variations in performance are still evident across providers. This suggests that if the intention to link some element of provider payment to outcomes becomes a reality, some providers may gain financially whilst others may lose. The paper contributes to the limited literature on risk adjustment of outcomes and performance assessment of providers in mental health in the context of prospective activity-based payment systems.

Variation in compulsory psychiatric inpatient admission in England: a cross-sectional, multilevel analysis

BackgroundRates of compulsory admission have increased in England in recent decades, and this trend is accelerating. Studying variation in rates between people and places can help identify modifiable causes.ObjectivesTo quantify and model variances in the rate of compulsory admission in England at different spatial levels and to assess the extent to which this was explained by characteristics of people and places.DesignCross-sectional analysis using multilevel statistical modelling.SettingEngland, including 98% of Census lower layer super output areas (LSOAs), 95% of primary care trusts (PCTs), 93% of general practices and all 69 NHS providers of specialist mental health services.Participants1,287,730 patients.Main outcome measureThe study outcome was compulsory admission, defined as time spent in an inpatient mental illness bed subject to the Mental Health Act (2007) in 2010/11. We excluded patients detained under sections applying to emergency assessment only (including those in places of safety), guardianship or supervision of community treatment. The control group comprised all other users of specialist mental health services during the same period.Data sourcesThe Mental Health Minimum Data Set (MHMDS). Data on explanatory variables, characterising each of the spatial levels in the data set, were obtained from a wide range of sources, and were linked using MHMDS identifiers.ResultsA total of 3.5% of patients had at least one compulsory admission in 2010/11. Of (unexplained) variance in the null model, 84.5% occurred between individuals. Statistically significant variance occurred between LSOAs [6.7%, 95% confidence interval (CI) 6.2% to 7.2%] and provider trusts (6.9%, 95% CI 4.3% to 9.5%). Variances at these higher levels remained statistically significant even after adjusting for a large number of explanatory variables, which together explained only 10.2% of variance in the study outcome. The number of provider trusts whose observed rate of compulsory admission differed from the model average to a statistically significant extent fell from 45 in the null model to 20 in the fully adjusted model. We found statistically significant associations between compulsory admission and age, gender, ethnicity, local area deprivation and ethnic density. There was a small but statistically significant association between (higher) bed occupancy and compulsory admission, but this was subsequently confounded by other covariates. Adjusting for PCT investment in mental health services did not improve model fit in the fully adjusted models.ConclusionsThis was the largest study of compulsory admissions in England. While 85% of the variance in this outcome occurred between individuals, statistically significant variance (around 7% each) occurred between places (LSOAs) and provider trusts. This higher-level variance in compulsory admission remained largely unchanged even after adjusting for a large number of explanatory variables. We were constrained by data available to us, and therefore our results must be interpreted with caution. We were also unable to consider many hypotheses suggested by the service users, carers and professionals who we consulted. There is an imperative to develop and evaluate interventions to reduce compulsory admission rates. This requires further research to extend our understanding of the reasons why these rates remain so high.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Safety of patients under the care of crisis resolution home treatment services in England: a retrospective analysis of suicide trends from 2003 to 2011

Community care provided by crisis resolution home treatment teams is used increasingly as an alternative to admission to psychiatric wards. No systematic analysis has been done of the safety of these teams in terms of rates of suicide. We aimed to compare the rate and number of suicides among patients under the care of crisis resolution home treatment teams with those of psychiatric inpatients. We also assessed the clinical features of individuals who died by suicide in both home and hospital settings. We did a retrospective longitudinal analysis between 2003 and 2011 of all adults (aged 18 years or older) treated by the National Health Service in England who died by suicide while under the care of crisis resolution home treatment services or as a psychiatric inpatient. We obtained data from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness and from the Mental Health Minimum Dataset. 1256 deaths by suicide (12% of all patient suicides) were recorded among patients cared for under crisis resolution home treatment teams, an average of 140 deaths per year. Different denominators meant that direct comparison between groups was difficult, but the average rate of suicide under crisis resolution home treatment services (14·6 per 10 000 episodes under crisis care) seemed higher than the average rate of suicide among psychiatric inpatients (8·8 per 10 000 admissions). The number of suicides in patients under the care of crisis resolution home treatment teams increased from an average of 80 per year (in 2003 and 2004) to 163 per year (in 2010 and 2011) and were twice as frequent as inpatient suicides in the last few years of the study. However, because of the growing number of patients under the care of crisis resolution home treatment teams, the average rate of suicide fell by 18% between the first and last 2 years of the study. 548 (44%) patients who died by suicide under the care of crisis resolution home treatment teams lived alone and 594 (49%) had had a recent adverse life event. In a third of patients (n=428) under the care of crisis resolution home treatment teams, suicide happened within 3 months of discharge from psychiatric inpatient care. Although the number of suicides under the care of crisis resolution home treatment teams has risen since 2003, the rate has fallen. However, suicide rates remain high compared with the inpatient setting, and safety of individuals cared for by crisis resolution home treatment teams should be a priority for mental health services. For some vulnerable people who live alone or have adverse life circumstances, crisis resolution home treatment might not be the most appropriate care setting. Use of crisis resolution home treatment teams to facilitate early discharge could present a risk to some patients, which should be investigated further. Healthcare Quality Improvement Partnership.

Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross-sectional and before-and-after observational study

Research investigating which aspects of mental health service provision are most effective in prevention of suicide is scarce. We aimed to examine the uptake of key mental health service recommendations over time and to investigate the association between their implementation and suicide rates. We did a descriptive, cross-sectional, and before-and-after analysis of national suicide data in England and Wales. We collected data for individuals who died by suicide between 1997 and 2006 who were in contact with mental health services in the 12 months before death. Data were obtained as part of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. When denominator data were missing, we used information from the Mental Health Minimum Data Set. We compared suicide rates for services implementing most of the recommendations with those implementing fewer recommendations and examined rates before and after implementation. We stratified results for level of socioeconomic deprivation and size of service provider. The average number of recommendations implemented increased from 0·3 per service in 1998 to 7·2 in 2006. Implementation of recommendations was associated with lower suicide rates in both cross-sectional and before-and-after analyses. The provision of 24 h crisis care was associated with the biggest fall in suicide rates: from 11·44 per 10 000 patient contacts per year (95% CI 11·12-11·77) before to 9·32 (8·99-9·67) after (p<0·0001). Local policies on patients with dual diagnosis (10·55; 10·23-10·89 before vs 9·61; 9·18-10·05 after, p=0·0007) and multidisciplinary review after suicide (11·59; 11·31-11·88 before vs 10·48; 10·13-10·84 after, p<0·0001) were also associated with falling rates. Services that did not implement recommendations had little reduction in suicide. The biggest falls in suicide seemed to be in services with the most deprived catchment areas (incidence rate ratio 0·90; 95% CI 0·88-0·92) and the most patients (0·86; 0·84-0·88). Our findings suggest that aspects of provision of mental health services can affect suicide rates in clinical populations. Investigation of the relation between new initiatives and suicide could help to inform future suicide prevention efforts and improve safety for patients receiving mental health care. National Patient Safety Agency, UK.

A commentary on: Demonstrating the Effectiveness of Housing Support Services for People with Mental Health Problems: A Review by Nicholas Pleace and Alison Wallace, Centre for Housing Policy, University of York

PurposeThis paper is an extended review and expert commentary on a recently published study by the Centre for Housing Policy (CHP) which discusses the complexities of research in “housing related support” in the UK context, and proposes further work. This review aims to explore the strengths and limitations of the study; and the potential wider relevance outside the UK research context.Design/methodology/approachThe review methodology is traditionally that of expert opinion. The reviewer draws upon previous evaluation studies of mental health and housing, commissioned by the UK Dept of Health, the (Dept of) Communities and Local Government, the National Institute for Mental Health in England, and the Care Services Improvement Partnership, including additional material on the Mental Health Minimum Dataset.FindingsThe CHP report reviewed raises important questions over the complexities of evidencing innovative services. Despite some omissions, it should be helpful to health local commissioners in assessing the value of services; and the further research the report proposes is to be welcomed. The report also provides a useful introduction to “housing related support” for an international research audience, less familiar with the UK social policy and funding context.Originality/valueThe review introduces and recommends the CHP study – which is itself a valuable contribution to future research on housing‐related support – to a wider audience. The review also includes additional material never before published on the potential research value in the context of the Mental Health Minimum Dataset.

Annual cost of managing bipolar disorder to the UK healthcare system

Bipolar disorder is a common illness characterized by recurrent episodes of pathological disturbances of mood. The aim of this study was to estimate the annual cost associated with bipolar disorder to the UK healthcare system (National Health Service). A retrospective observational study was conducted. Primary care resource use was estimated using the IMS Disease Analyzer, a nationally representative sample of general practitioner (GP) practices. Two sources of data from the NHS Information Centre were used to assess resource use in secondary care and in outpatient and community mental health. The number of bed days and day attendances for patients hospitalized was obtained from the Hospital Episode Statistics (HES). This was supplemented with Mental Health Minimum Dataset (MHMDS) to quantify outpatient and community mental health face-to-face contacts. Resource use was examined between 01 April 2007 and 31 March 2008. The annual NHS cost of bipolar disorder was estimated to be £ 342 million at 2009/2010 prices. Hospitalizations accounted for 60%, outpatient and community mental health 26.7%, and medication in primary care 7.4% of the overall direct costs of care. This study may be confounded by the absence of a control group. This study was limited to an assessment of direct healthcare costs only, not the wider societal cost of bipolar disorder. The direct medical cost of managing bipolar disorder in the UK healthcare system is considerable. Therapeutic strategies that optimize community-based management, prevention of recurrence and hospitalization could reduce the economic burden of this illness.

Metrics and measures in tackling the social determinants of health ‐ the example of mental health and housing

This paper is an account of the discussions and recommendations by the exper t advisory panel on potential metrics and ‘sentinel indicators’ for improved outcomes in housing and mental health, as par t of an inter‐agency seminar called to advise on the development of metrics and measures for community mental health, for Fair Society, Healthy Lives: The Marmot Review (Marmot, 2010). The seminar covered all aspects of mental health in both its broadest and narrower senses.Much of the background material for these discussions, therefore, cuts across familiar knowledge silos between the fields of health and housing. Where it is necessary to elucidate the text, references are included to relevant research and policy frameworks that may be unfamiliar to the general reader. This paper is not, however, intended as a general literature review nor is it an evaluation of the available research. A paper on this subject will feature in a future issue of the Journal.1The conclusions from the panel discussion are presented in four main areas, reflecting the need to specify metrics across the wide‐ranging interface between housing and mental health, while still keeping the task manageable. Five current or potential health service metrics were proposed as having par ticular value as signal indicators. Two of these (relating to primary care prevention and public health) have no precision as yet, par tly as new services and approaches are still evolving. Among existing health datasets, the Mental Health Minimum Dataset (MHMDS) (NHS Information Centre, 2009a), SITuation REPor ts (SITREPS) (Department of Health, 2003), and the Summary Care Record data were singled out, though each is thought to need more work to improve the current data categories as well as data collection.One rather more fundamental point made was that the identifying, assessing and encouraging of effective inter‐sector par tnership work will be the key to tackling health inequalities. The use of other, non‐health services data therefore holds great potential for a better recognition both of needs and of outcomes in successful par tnership work, especially where this can be interpreted at local level. These wider comments are elaborated in the context of housing, but may be applicable to all effor ts to evidence and work with the social determinants and the social outcomes of mental health. For the future, a combination of well‐crafted nationally sanctioned metrics and the ‘soft intelligence’ of locally identified meaning may be most effective.Subsequent developments confirm the potential in cross‐sector development work, and indicate the potential for fur ther collaboration via the local performance framework. As policy frameworks continue to evolve rapidly, the ar ticle ends with a Codex, updating the relevant policy frameworks context since the seminar (in Spring 2009) and especially in the context of a new coalition government with aspirations to ar ticulate and promote public health in the context of the local performance framework and the ‘new localism’ agenda. This final section and comments therein are therefore entirely the responsibility of the author.

Adult mental health care in England

The policy background and current overall provision of mental health services for working age and older adults in England are described. Following the introduction of a new National Service Framework in 1999, an annual service mapping exercise was introduced. Data presented draw heavily on the mapping for 2003. This is supplemented by hospital admission statistics data from the new patient-based mental health minimum data set, introduced from April 2003, and a number of other corroborative sources. Data about services for older people are more restricted in scope and detail. Close attention is given to the extent to which data from these routine sources can be considered accurate.

Use of routinely collected data on psychiatric in-patient care

Since the start of the National Health Service, data have been collected on admissions to psychiatric in-patient units, first as the Mental Health Enquiry, then as part of Hospital Episode Statistics. Some details have changed but many have stayed remarkably consistent. Published literature on the wide range of research and policy work undertaken using this data source is reviewed. Early work was central to the government's deinstitutionalisation policy in the early 1960s. Subsequent studies cover a wide range of epidemiological and health services research issues. A new statistical base, the Mental Health Minimum Data Set, covering individuals receiving all types of health care is currently being set up. This will supplement (but not replace) admission statistics.

Computerised information systems in English mental health care providers in 1998.

This study formed part of the background work for the development work of a new Mental Health Minimum Data Set in England. It surveyed the range and nature of information systems currently used by English mental health care provider Trusts. It also surveyed relevant aspects of their organisational arrangements. Information was collected by a telephone survey of Trust information and clinical service managers. Most Trusts have a complex array of different information systems--the median number is four. Even where fully integrated systems are in place, these do not necessarily cover all data areas over the whole of the Trust's operations. Sixty-three percent of Trusts use more than one patient numbering system. Sixty-percent have implemented or formally piloted routine collection of outcome scoring, 51% using the Health of the Nation Outcome Scale (HoNOS). A simple model suggested that the proposed data set could realistically be implemented nationally over a 4-year timescale. Given the current information system context and planned developments it would be realistic to implement the proposed Mental Health Minimum Data Set over a 4-year timescale.

Psychotic disorders and parenting - the relevance of patients' children for general adult psychiatric services

Patients with psychotic disorders are often assumed to be sub-fertile, and when patients do have children, any child care concerns are usually passed on to social services. The children of patients with psychotic disorders may not, therefore, be of major concern to the responsible medical officer, and community mental health services have not been developed with families in mind. Routine statistics on psychiatric patient episodes do not include information on patients' children – a question covering this issue was included in the pilot draft of the Mental Health Minimum Data Set (approved for England by the Department of Health in September 1999), but was dropped because clinical professionals were reluctant to record this information, as they did not consider it relevant in this context (personal communication, G. Glover, 2000).