Corporate
Standard Operating Procedure: Mental Health & Learning Disabilities
Data Set (MHLDDS) – Outcomes for Patients on CPA
Document Control Summary
Status:
Replacement.
Replacing - R/GRE/sop/07
Version:
V2.0
Author/Owner:
Rob Abell, Senior Performance Development Manager
Approved by:
Policy and Procedures Committee
Date:
Ratified:
Policy and Procedures Committee
Date: 15/06/2015
Related Trust
Strategy or Aims:
Provide high quality services, built on best known practice and
evaluated through service user and carer feedback and clear process
and outcome measures.
Date:
May 2015
15/06/2015
Deliver all regulatory performance, Quality standards and compliance
indicators
Implementation
Date:
June 2015
Review Date:
June 2018
Key Words:
Mental health, learning disabilities, MHLDDS, data set, outcomes,
CPA
Associated Policy
or Standard
Operating
Procedures
Compliance with the Access and Outcome Indicators in Monitor’s Risk
Assessment Framework Policy
Standard Operating Procedure: Mental Health & Learning Disabilities Data Set (MHLDDS) – Outcomes
for Patients on CPA/v2.0
June 2015
Standard Operating Procedure:
Mental Health & Learning Disabilities Data Set (MHLDDS) – Outcomes for
Patients on CPA
Contents
1. Introduction........................................................................................................................................ 3
2. Rationale ........................................................................................................................................... 3
3. Measurement .................................................................................................................................... 4
4. Scope ................................................................................................................................................ 5
5. Summary of Responsibilities ............................................................................................................. 5
6. Non-compliance ................................................................................................................................ 6
7. Trust Expectations............................................................................................................................. 6
8. Further Guidance............................................................................................................................... 7
Version History Log
Version
2.0
Date Implemented
May 2015
Details of significant changes
Reference Documents Referred to
Document
Monitor’s Risk Assessment Framework
Health & Social care Information Centre – Mental Health and
Learning Disabilities Data Set (MHLDDS) v1.1 User Guidance
Document Date
March 2015
September 2014
It Is the Responsibility of all Users of this SOP to Ensure that the Correct
Version is Being Used.
All staff should regularly check the intranet site for information relating to the implementation of new or
revised versions of this SOP.
This SOP will normally be reviewed every 3 years unless changes to the legislation require otherwise.
Page 2 of 8
Standard Operating Procedure: Mental Health & Learning Disabilities Data Set (MHLDDS) – Outcomes
for Patients on CPA/v2.0
June 2015
1. Introduction
This document details the process by which SSSFT staff must record information for the:
Type of Indicator
Mandatory Indicator
Commissioner Indicator
Trust Indicator
Required by
x Monitor and CQC
Title
Mental Health & Learning Disabilities Data Set
(MHLDDS) – Outcomes
2. Rationale
The Mental Health Minimum Data Set (MHMDS) was renamed Mental Health and Learning Disabilities
Data Set (MHLDDS) following an expansion in scope (from September 2014) to include learning
disabilities and autism spectrum disorder patients. The MHLDDS is unique in its coverage, because it
covers not only services provided in hospitals, but also in outpatient clinics and in the community,
where the majority of people in contact with these services are treated.
It brings together key information from the mental health, learning disabilities or autism spectrum
disorder care pathway that has been captured on clinical systems as part of patient care. During
processing, this information is compiled into a single patient record. Submission of MHLDDS data is
mandatory for NHS funded care, including independent sector providers.
MHMDS supports a variety of secondary use functions such as:








commissioning
clinical audit
research
service planning
inspection and regulation
monitoring government policies and legislation
local and national performance management and benchmarking
national reporting and analysis
The MHLDDS is the data source used for the implementation of Mental Health Currencies and
Payment (formerly PbR). As such, the Mental Health Care Clusters, ISB 1509, and Mental Health
Clustering Tool, ISB 1078, Information Standards are implemented through the MHLDDS. MHLDDS is
also planned to be the future source of the Learning Disabilities payment system once requirements
are determined.
MHLDDS statistics are for anyone wanting a comprehensive national picture of the use of specialist
mental health, learning disabilities or autism spectrum disorder services in England, including:




policy makers
commissioners
mental health service users
members of the public
Page 3 of 8
Standard Operating Procedure: Mental Health & Learning Disabilities Data Set (MHLDDS) – Outcomes
for Patients on CPA/v2.0
June 2015
3. Measurement
This indicator applies to the following fields for all records for patients on CPA in each reporting period.
The indicator is measured by:
Denominator for all 3 indicators
The total number of adults (aged 18-69) who have received secondary mental health services and who
were on CPA at the end of the reporting period.
Indicator 1 – Employment Status
Numerator
The number of adults in the denominator whose employment status is known at the time of their most
recent assessment, formal review or other multidisciplinary care planning meeting, in a financial year.
Include only those whose assessments or reviews were carried out during the reference period. The
reference period is the last 12 months working back from the end of the reported quarter.
Indicator 2 – In Settled Accommodation
Numerator
The number of adults in the denominator whose accommodation status (i.e. settled or non-settled
accommodation) is known at the time of their most recent assessment, formal review or other
multidisciplinary care planning meeting. Include only those whose assessments or reviews were carried
out during the reference period. The reference period is the last 12 months working back from the end
of the reported quarter.
Indicator 3 – Having a ‘Health of the Nation Outcome Scale’ (HoNOS) assessment in the last 12
months
Numerator
The number of adults in the denominator who have had at least one HoNOS assessment in the past 12
months.
The overall indicator is calculated by:
The total number of completed valid records from the three numerators, divided the total amount of
records per patient in the denominator (three record sets (indicators) per patient so the denominator x
3)
Target
The current target is 50%.1
1
Monitor is assessing the completeness of data to make assessments of employment and accommodation on status. The target reflects
the minimum required level of data completeness, not performance itself.
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Standard Operating Procedure: Mental Health & Learning Disabilities Data Set (MHLDDS) – Outcomes
for Patients on CPAv2.0
June 2015
4. Scope
The indicator includes:
 all adults (aged 18 – 69) on CPA who receive specialist adult mental health care services in a
secondary care setting and are, or are thought to be, suffering from a mental illness.
The indicator excludes from both the numerator and the denominator of the indicator:
 Adults aged 18-69 who are in receipt of Trust services and who are not on CPA.
 Patients receiving treatment in a specialist Mental Health care service provider but are not
suffering from a mental illness, as detailed above.
Services in scope of the MHLDDS are:
Scope
Adult
Older Persons
Dual Diagnosis
IAPT
High Secure
Medium Secure
Low Secure
Learning Disability
Autism Spectrum Disorder
CAMHS
Early Intervention
Liaison Psychiatry
Independent Sector
Non-NHS Funded
MHLDDS (v1.1)
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes (Optional)
5. Summary of Responsibilities
Designation
Clinical Staff
Ward & Team Leaders
Responsibilities
 Carry out CPA process
 Capture employment, accommodation and HoNOS information for
all adults aged 18 – 69 on CPA
 Review employment, accommodation and HoNOS information at
CPA reviews
 Record information as required.
 Ensure the clinical information system is updated within 24 hours of
an assessment or a review taking place.
 Ensuring that all patients on CPA are reviewed within 6 months
(and in line with care cluster guidance) and that the patients’
housing, employment and HoNOS information is reviewed and reentered into the clinical IT system
 Validate reports and any figures showing as breaches/non
compliant, correct the record if necessary, including updating
patient records on the clinical system and provide feedback
Page 5 of 8
Standard Operating Procedure: Mental Health & Learning Disabilities Data Set (MHLDDS) – Outcomes
for Patients on CPAv2.0
June 2015
All staff

Every person who has contact with either:
a) a service user (either face to face or telephone contact)
or b) any individual (either face to face or telephone contact)
The service users care must be recorded within the progress notes
within the clinical system.
Page 6 of 8
Standard Operating Procedure: Mental Health & Learning Disabilities Data Set (MHLDDS) – Outcomes
for Patients on CPAv2.0
June 2015
Information Team
 Provide reports as required from the Data Warehouse
 Specification and publication of reports as specified in line with the
definition in this document.
 Where performance falls below the KPI threshold the Information
Team will provide the Executive Lead with the details of the
shortfall.
 Compliance or otherwise will be included in the Finance and
Performance Sub Committee and Trust Board papers submitted on
a monthly basis.
Service Leads
 Oversee the completion of actions to (which may involve
developing action plans) to address under-performance
 Provide narrative to the Executive Lead as required
 Provide evidence of service improvements established to address
performance
Executive Lead
 Request, where necessary, a narrative reason behind the shortfall
from the responsible teams
 Identify actions for the Directorate management teams to address
the shortfall
Performance
 On an ongoing basis, will review and monitor the performance
Development Team
trends of this indicator, informing the formal performance review
process and providing remedial action with teams where
appropriate.
Contract and Information
 Ad hoc requests for information and data pertaining to this indicator
Group
will all be assessed and dealt with by the Contract and Information
Group
6. Non-compliance
This indicator features in Monitor’s ‘Risk Assessment Framework’, and as such is a national priority
target which FTs are expected to achieve. Failure to meet this target is a breach of our Monitor
Licence. This indicator is reported to Monitor on a quarterly basis and as such affects the overall
governance risk rating of the Trust.
7. Trust Expectations

To meet the statutory requirements.

To use the Trust’s clinical system to record this activity in accordance with the data quality
requirements
 Distribution of information and data regarding this indicator will only be shared with external
agencies through nominated contacts.

The Contract and Information Group (chaired by the Director of Finance) will validate all
requests for information and data regarding this indicator prior to their distribution.

Teams are encouraged to agree local targets in excess of the contractual and statutory targets.
The Information Team will provide information in support of local targets.

The following directorates are in scope of the statutory targets:
o All patients on CPA - Mental Health, Learning Disabilities, Specialist Family
Services, Forensic Prison-In-Reach.
Page 7 of 8
Standard Operating Procedure: Mental Health & Learning Disabilities Data Set (MHLDDS) – Outcomes
for Patients on CPAv2.0
June 2015
Appendix
Guidance documents on the clinical
processes for RiO
The SQL code used to produce the
information from the SSSFT data
warehouse and reports
See guidance on the RiO “Quick Reference Guides and
Manuals” website http://nww.intranet.sssft.nhs.uk/RIOProject.aspx or contact your RiO Super User for
guidance
Contact the Trust Information Team who will provide
you with the latest version of the SQL code used to
produce reports
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