Recording referral-based activity

Within the following services it’s expected that a clinical response priority is captured for each referral recorded to;

• Crisis Resolution and Home Treatment Teams
• 24/7 Crisis lines
• Single Point of Access services

All activity for crisis services accessible via NHS 111 ‘select mental health option’ should be reported against the 24/7 Crisis Response Line team type when submitting to the MHSDS.

In some areas the crisis line support may be provided as part of a broader function that’s referred to locally as a Single Point of Access service. Where this is the case only the activity coming through the NHS 111 ‘select mental health option’ should be recorded against the 24/7 crisis line team type with a clinical response priority recorded against the referral.

All other activity should be recorded against the Single Point of Access team type and a clinical response priority should still be recorded, to identify where more urgent or emergency responses are needed.

The Clinical Response Priority Type field is used to determine whether a referral is ‘routine’, ‘urgent’, ‘very urgent’ (added in v5.0 of the MHSDS) or ‘emergency’ (Table 3). This information is a crucial requirement for organising and monitoring response times in community-based crisis services. 

Recording of this field was investigated as part of exploratory analysis. Of the 1,454,892 community crisis referrals in the MHSDS which started between 1 April 2020 and 31 March 2021, 76,754 (5.4%) had no Clinical Response Priority Type recorded. This represents a significant improvement on 2017 (around 22% not recorded). Further improvement is needed to support implementation and assurance of national policy, particularly in encouraging consistent interpretation and recording of the definitions of these priorities across all services.

Table 3: Extract from the Technical Output Specification; table MHS101 Referral

Please always consult the published Technical Output Specification for any changes.

The definition for each Clinical Response Priority Type code (i.e. the definition of the terms emergency, very urgent, urgent/serious and routine) varies depending on the care pathway and providers should reference national guidance for the pathway in question. For example, the term ‘urgent’ is currently used to describe a one week waiting time requirement in the context of eating disorder services. 

This guidance seeks to define these terms in the context of community-based urgent and emergency mental health (crisis) services. This includes all teams providing the functions of urgent and emergency support, advice & triage and assessment (including a brief follow-up) for people of all ages. 

The definitions in Table 4 have been provided by NHS England. These are aligned with the UK mental health triage scale, which many urgent mental health services already use. They were developed after 11 pilot sites field-tested the potential introduction of standards for urgent mental health care.

In line with national policy, all providers are required to implement the use of the clinical response priorities across all relevant departments.

It should be noted that by definition, all ‘urgent’ and ‘very urgent’ referrals should be followed by a face-to-face response, and this should be reflected in referrals with a face-to-face contact in the MHSDS. It is also likely that many ‘emergency’ referrals will also need to be followed by a face-to-face contact from a mental health service.

Table 4: Clinical response priority definitions for mental health crisis services

To understand if people in scope for a mental health care pathway are accessing the recommended services, it is important to be able to identify the services with which they are in contact. At the highest level, it is necessary to understand which teams or services the person in scope has been referred to. 

It is understood that teams or services with similar roles can have different names within provider organisations and they should be mapped to the most relevant national codes. The list of service or team types within the MHSDS has been designed to be age-agnostic, in order to prevent the unnecessary expansion of the code list (Table 5). Instead, where age specific services are in place, this can be identified through the age of the patients.

It is important to note that there has been a fundamental change in the way Team Type is captured in the MHSDS from version 6.

Overview of key structure changes:

• MHS101 Service or Team Referral table still captures details of each separate referral, and identifies the primary MH service or team involved in the referral
• MHS102 Other Service or Team Type table captures details of any additional services or teams involved in the same referral submitted in MHS101
• the new MHS902 Service or Team Details table captures service and team details and acts as a look up table linked to MHS101 and/or MHS102
• multiple referrals would require multiple MHS101 submissions, for example referrals to different mental health services
• the MHS101 referral needs to stay open for the duration of the referral and would be closed once all the related MHS102 activity is complete, for example involvement from other mental health teams

As a result of the changes, if only one team or service is involved in the care of the patient, the MHS102 Other Service or Team Type table no longer needs to be submitted. The primary team in MHS101 Service or Team Referral table is identified via linkage to the new MHS902 table and the MHS102 table now only captures details of any other team or service that is involved in the same referral.

If you do not submit the MHS902ServiceTeamDetails table for community-based referrals then we cannot identify the Service or Team Type that the patient was referred to. Therefore, any measure that uses the Service or Team Type will be affected and not be an accurate reflection of the activity taking place for a particular provider.

Community-based mental health crisis services and liaison services are shown in blue text with grey highlight. Please always consult the published Technical Output Specification for any changes.

Table 5: Extract from the Technical Output Specification; table MHS902 Service or Team Details.

NHS-funded teams providing urgent and emergency mental health support, advice & triage and assessment should normally record one of following team types:

• A02 - Crisis Resolution Team/Home Treatment Service
• A18 - Single Point of Access Service
• A19 - 24/7 Crisis Response Line
• A20 - Health Based Place Of Safety Service
• A21 - Crisis Café/Safe Haven/Sanctuary Service
• A22 - Walk-in Crisis Assessment Unit Service
• A23 - Psychiatric Decision Unit Service
• A24 - Acute Day Service
• A25 - Crisis House Service

For crisis lines, in particular for Children and Young People (CYP), the practitioner responding may be part of a community mental health team but function as part of the A19 - 24/7 Crisis Response, in which case the A19 code should be used in any referrals or Drop in Contact activity.

The relevant national code should be used based on the local team’s function, regardless of what the local team name or model is, or which age groups they support. Definitions of these team types, as set out in the MHSDS v6.0 user guidance, are provided in Appendix: Community-based crisis and acute care team type definitions and in future will be incorporated into the NHS Data Dictionary.

Note that the separate team type codes A03 - Crisis Resolution Team and A04 - Home Treatment Service are being retired in MHSDS v5.0. Where relevant, we encourage providers to switch to the combined A02 code at the earliest opportunity in preparation for that change. These codes are being retired as many providers combine these functions in a single team. That means national activity cannot be consistently separated out and so the individual codes are not adding sufficient value in the national dataset.

There are instances in which it is not possible to record a referral during a contact with open access triage services such as 24/7 crisis lines and crisis text services, due to insufficient information being shared by the service user, challenges linked to the pathway into services or the type of contact with the service user. To support data collection of this activity, a Drop in Contact table has been added to the mental health services dataset, with guidance provided in ection 5. of this document.

When people attend A&E with mental health needs, they should be referred to mental health liaison services or CYP equivalent services (usually either paediatric liaison or CYP community mental health teams providing in-reach).

NHS England have confirmed that the monitoring of activity in liaison mental health services will be undertaken using submissions to the MHSDS, and reports are now included in the national Urgent and Emergency Mental Health Dashboard (you will require a NHSFutures account to login).  

Teams that provide on-site specialist liaison mental health in general hospitals and who respond to referrals from either A&E or inpatient wards, should record team type A11 - Psychiatric Liaison Service. The referral source should be recorded for all referrals.

Adult crisis teams providing in-reach to general hospitals should not record themselves as psychiatric liaison. These teams should record team type A02 (as set out above), and ensure that the activity location type is recorded, for example where this is in A&E (refer to activity location section for more detail).

CYP liaison teams

Teams that provide dedicated specialist CYP mental health liaison based on-site in general hospitals, and which respond to either A&E or ward-based referrals, should use team type C05 - Paediatric Liaison Service. The referral source should be recorded for all referrals.

Crisis resolution and home treatment services

In v4.1 of the MHSDS, there are separate team types on crisis resolution (A03) and home treatment (A04), as well as the combined code (A02). In v5.0 of the MHSDS (implemented from the October 2021 reporting period onwards), only the combined code will be included. All teams delivering the following functions should use the combined code (A02) and ensure that activity location is recorded:

• CYP teams that provide crisis response in community settings and/or in-reach to Emergency Departments (A&E) / general hospitals
• CYP teams that provide an integrated crisis and liaison function combined with intensive home treatment

To understand what services are being delivered, it is important to know an assessment is taking place, in addition to knowing the service or team a person is referred to. Service providers should ensure accurate and full recording of the activity location type for any assessments undertaken as part of these pathways (Table 6). For example, this data will show when community-based crisis teams are providing crisis response to A&E departments.

Table 6 Extract from the Technical Output Specification; table MHS201 Care Contact.

Please always consult the published Technical Output Specification for any changes.

As part of recording referrals and registering patients, capturing data on protected characteristics and vulnerable groups is essential to enabling the identification, reporting and understanding of populations experiencing inequalities and supporting improvement in urgent mental health services. This is a priority to record for as many patients as possible, not only for urgent mental health team types, but for all service types. 

NHS England have developed guidance to support providers to improve  Data quality of protected characteristics and other vulnerable groups

Of particular priority is improved data on ethnicity, disability, sexual orientation and accommodation status, as data quality is low and these factors have a clear link to the support people need and assessment of equality across mental health services. For mental health services supporting children and young people, Looked After Child Indicator and Child Protection Plan Indication Code are required fields, which are also high priority for data improvement.

New data items were introduced in MHSDS v6.0 to better capture whether an inpatient is in scope of Transforming Care. For patient pathways that include specialist inpatient services for people with a learning disability and/or autism, it is required to complete the fields PATIENT DIAGNOSIS STATUS (LEARNING DISABILITY) and PATIENT DIAGNOSIS STATUS (AUTISM) in the MHS005 Patient Indicators table.

Providers will also need to implement changes to the accommodation status and gender data items that are being introduced in MHSDS v5.0, with more detail provided in the MHSDS user guidance.  

To enhance system understanding of MHSDS data quality, NHS England have produced a publicly available data quality dashboard. This includes a section focused on data for protected characteristics and vulnerable groups.

NHS England have confirmed that the response time for urgent and emergency services should be measured in hours.

Table 7: Extract from the Technical Output Specification; tables MHS101 Referral and MHS201 Care Contact. Please always consult the published Technical Output Specification for any changes.

Initial exploratory analysis investigated the times provided for the referral and care contact to check the accuracy of response times reporting. In order to determine if a person has received a contact within a certain number of hours, it is essential that the recording of both the referral time and the contact time must be precise to the number of minutes (Table 7). If it is not precise to that level, then some cases may be reported as receiving a contact within a certain number of hours when this was not the case.

The analysis identified a large amount of potential default reporting and rounding for both referral start times and contact times. For example, many cases are recorded as being on the hour or half past the hour (Figure 1).

To provide accurate reporting of the true response times for these pathways, the recording of Referral Request Received Time and Care Contact Time must be as accurate and near as possible to the minute the activity took place.

Systems must not be configured to record a default time when the true time is not known. Anyone involved in the manual entry of times in administrative systems must not enter default times when the true value is not known. It may be beneficial for the importance of accurate recording of times to be highlighted to front line staff and others involved in data entry.

It is accepted that there will be factors that limit the accuracy of time recording in any administrative system. It is also acknowledged that a certain level of accuracy is required to enable sufficiently robust analysis.