Quality improvement updates - 4 April 2013

New policy guidance, tools and initiatives from across the UK. For more information about the quality improvement theme see Quality and Safety eBulletin: quality improvement. 

Some of the resources linked to are in PDF format - see how to access PDF files.

Entries are arranged under the following headings:

Audit, reviews, legislation

Audit Scotland: Responding to challenges and change. An overview of local government in Scotland 2013. Councils face tougher challenges in the year ahead, particularly in dealing with budget pressures. Plans to integrate health and social care are among other changes which present both challenges and opportunities for councils.

DH: Statutory guidance on joint strategic needs assessments (JSNAs) and joint health and wellbeing strategies (JHWSs). This statutory guidance explains the duties and powers of JSNAs and JHWSs. It aims to support health and wellbeing boards and their partners by laying out duties to be taken by CCGs, local authorities and health and wellbeing boards; explaining how JSNAs and JHWSs will fit together with commissioning plans; and how JSNAs and JHWSs will enable improvement to local health and wellbeing.

Healthcare Quality Improvement Partnerships (HQIP): Audits named for ‘Everyone Counts' consultant-level data publication. The ten clinical audits providing consultant-level data for publication as part of the NHS Commissioning Board's (CB) 'Everyone Counts' guidance have been confirmed. They include: adult cardiac surgery; bariatric surgery; head and neck surgery; intentional cardiology; orthopaedic surgery; thyroid and endocrine surgery; urological surgery and vascular surgery.

HQIP: NCAPOP: Sudden Arrhythmic Death Syndrome affects those in their thirties the most, new figures show. People aged 30 to 39 years are the age group most at risk of sudden death caused by irregular heart rhythms, also known as Sudden Arrhythmic Death Syndrome (SADS). The new report from the National Audit of Sudden Arrhythmic Death Syndrome shows that the average age at death where recorded was 32, with almost a quarter of deaths in the 30 to 39 age group.

Monitor: Detailed guidance for external assurance on quality reports 2012/13. This document sets out detailed guidance for NHS foundation trusts and their auditors to enable them to carry out the external assurance engagement on 2012/13 quality reports.

Monitor: Enforcement guidance. This guidance explains the action that Monitor can take to enforce compliance with the provider licence and other regulatory obligations on providers and others required to provide Monitor with information needed to perform its functions. It explains when Monitor may formally investigate potential breaches; the processes which will be followed; and the factors considered when deciding what requirements to impose should Monitor find a breach of the provider licence.

Monitor: Compliance framework. This updated framework outlines Monitor's approach to monitoring risks to foundation trusts' compliance with their financial and governance licence conditions and for triggering further investigation. It will apply for foundation trusts up until the risk assessment framework comes into effect later this year.

Monitor: The respective roles of Monitor, the Office of Fair Trading and the Competition Commission in relation to mergers involving NHS trusts and NHS foundation trusts. This briefing note explains who is responsible for reviewing the following types of merger transactions: mergers between two or more NHS foundation trusts; mergers between an NHS foundation trust and an NHS trust; and mergers between two or more NHS trusts.

Guidance, innovation, tools

DH: The health and care system explained. The new health and care system becomes fully operational from 1 April to deliver the ambitions set out in the Health and Social Care Act. The NHS Commissioning Board, Public Health England, the NHS Trust Development Authority and Health Education England will take on their full range of responsibilities. Locally, clinical commissioning groups – made up of doctors, nurses and other professionals – will buy services for patients, while local councils formally take on their new roles in promoting public health. Health and wellbeing boards will bring together local organisations to work in partnership and Healthwatch will provide a powerful voice for patients and local communities.

Equality and Human Rights Commission (EHRC): Buying better outcomes: mainstreaming equality considerations in procurement. This guidance explains how public authorities may approach the task of ensuring that they comply with the public sector equality duty obligations at different stages of the procurement cycle and outlines equality issues that need to be considered at each stage.

Health Foundation: Health Secretary Jeremy Hunt commends innovative Shine project. An innovative project that used Skype for follow-up outpatient appointments with diabetic patients has been commended by Secretary of State for Health Jeremy Hunt, in a speech on innovation. The Newham University Hospital NHS Trust was one of several projects highlighted by Jeremy Hunt, when he spoke of global good practice innovative projects.

Housing Learning and Improvement Network and Elderly Accommodation Counsel: Mapping future housing and care demand made easier. The Housing Learning and Improvement Network and Elderly Accommodation Counsel have joined forces to develop a free predictive modelling tool that enables local authorities and their partners forecast the demand for specialist housing and care up until 2030.

Institute for Research and Innovation in Social Services (IRISS): Understanding and measuring outcomes: the role of qualitative data. This guide has been developed to support the collection and use of personal outcomes data. It explores the links between an outcomes approach and qualitative data, why qualitative data is important and what it can achieve. It also outlines a practical approach exploring collecting, recording, analysing and reporting qualitative data about personal outcomes, as well as highlighting different approaches to qualitative analysis through case studies of people using qualitative data about outcomes for the first time.

King’s Fund: The King's Fund. Developing supportive design for people with dementia. If an organisation has been invited to submit a stage 2 application for dementia environment funding they are required to complete and return the summary page from the assessment tool relevant to their project area. These tools contain seven overarching criteria, and a set of questions to prompt discussions between clinical/care staff, estates colleagues, patients and carers. They have been informed by research evidence and best practice and have been robustly and rigorously tested in a range of different care settings. Please note in order to access these tools, free registration is required.

NHS Diabetes: Best practice for commissioning diabetes services: an integrated care framework. This report was developed in response to the needs of new commissioners and health professionals involved in diabetes care. It aims to provide practical guidance and key principles for these groups to better commission and provide integrated care for people with diabetes; and to ensure that people with diabetes have access to a joined up service from the time of diagnosis, through more complex management, complications, inpatient care to end-of-life care.

NHS Employers: QOF guidance 2013/14 (PDF 1.2MB). NHS Employers, the NHS Commissioning Board and the General Practitioners Committee have jointly published the 2013/14 quality and outcomes framework (QOF) guidance.

NHS Improvement: Managing exacerbations in COPD toolkit (PDF 615KB). NHS Improvement – Lung worked with a number of sites to develop alternative approaches and models of care to improve the services available to patients. The resulting toolkit has been designed to share the learning and show how to make change happen.

NHS Improvement: Top tips to overcome the challenge of commissioning diagnostic services.
This short guide presents top tips for commissioners to meet the most common challenges in the delivery of diagnostic services.

NHS Networks: 2011/12 programme budgeting data now available. The 2011/12 programme budgeting data is now available in the form of an interactive benchmarking tool. The tool contains detailed information on PCT expenditure by healthcare condition.

Robert Wood Johnson: Tools for Continuous Quality Improvement. This American site provides access to tools for continuous quality improvement developed through Robert Wood Johnson Foundation investments. These include support software developed by Rutgers to track organisational performance improvement in real time; a checklist developed by the Institute for Healthcare Improvement (IHI), and the IHI Improvement Map, among other tools.

Practice examples and case studies

NHS Confederation: Service reconfiguration case studies. These case studies are part of a series designed to share good practice and lessons learned by local NHS organisations involved in major reviews of local health services. Northumbria Healthcare NHS Foundation Trust's new urgent and emergency care facility culminated from several years’ strategic planning, and a comprehensive programme of engagement with staff and the local community. The Better Healthcare in Bucks programme sought to reshape services in Buckinghamshire to deliver better, more cost-effective and sustainable care in the most appropriate setting. Please note some of these resources require free registration for access.

Reports, commentary, statistics

Armed Forces Health Partnerships: Report on the consultation on the healthcare needs of injured veterans and their families. This report is the outcome of a conference which brought together veterans with those responsible for commissioning and provision of their health and care services. The report will help shape the services which the Legion and Combat Stress provide and inform the Department of Health’s plans for injured personnel, both during and after transition from service to civilian life.

Association for Palliative Medicine and the National End of Life Care Programme: Integrated care pathway – survey of professionals. The Association for Palliative Medicine and the National End of Life Care Programme are encouraging registered nurses to take part in a survey, the aim of which is to identify when and how professionals working in England use integrated care pathways (ICP) in caring for people in the last days to hours of life. The deadline for this survey is Thursday 25 April 2013.

Care and Social Services Inspectorate Wales (CSSIW) & Healthcare Inspectorate Wales: Deprivation of Liberty Safeguards: Annual Monitoring Report for Health and Social Care. This is the third annual report setting out the way that the Deprivation of Liberty Safeguards (the Safeguards) have been used across Wales. It combines the findings arising from the inspection work of Healthcare Inspectorate Wales (HIW) and Care and Social Services Inspectorate Wales (CSSIW), and draws on information gathered from local authorities and health boards (supervisory bodies).

Care Quality Commission (CQC): CQC finds Mental Capacity Act not well understood across all sectors and calls for more work by providers and commissioners to improve. The CQC’s report on its monitoring of the Deprivation of Liberty Safeguards reveals that there is still a widespread lack of understanding of the wider Mental Capacity Act. The Mental Capacity Act is a very important mechanism for protecting the rights of people who do not have the ability (mental capacity) to make certain decisions for themselves. CQC’s evidence shows that in some care homes and hospitals, people’s freedom to make decisions for themselves is restricted without proper consideration of their ability to consent or refuse.
Report: Monitoring the use of the Mental Capacity Act Deprivation of Liberty Safeguards in 2011/12  (PDF 1.3MB). 
Summary (PDF 546KB).

Child and Maternal Health Observatory (ChiMat): Child Health Profiles 2013. These 2013 profiles draw together information to present a picture of health in each local area in a user-friendly format. They provide a snapshot of child health and well-being for each local authority in England using key health indicators which enables comparison locally, regionally and nationally.
List of profiles for Yorkshire and the Humber region including Doncaster, Rotherham and North Lincolnshire.

Commonwealth Fund: Multinational comparisons of health systems data, 2012. International comparisons of health care systems offer valuable tools to health ministers, policymakers, and academics wishing to evaluate the performance of their country's system. This chartbook, uses data collected by the Organization for Economic Cooperation and Development (OECD) to compare health care systems and performance on a range of topics, including spending, hospitals, physicians, pharmaceuticals, prevention, mortality, quality and safety, and prices. Data is presented across several industrialized countries: Australia, Canada, Denmark, France, Germany, Japan, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.

Conference Board of Canada: Improving value at hospitals through process management.
Using five case studies, this Conference Board of Canada report demonstrates how process management techniques, such as Six Sigma and Lean, which have been used successfully in other sectors, can improve health care outcomes and reduce costs in Canada.

DH: Transforming care: a national response to Winterbourne View hospital. Final report into the events at Winterbourne View hospital and a programme of action to transform services.

DH: Consultation outcome. Review of the number of requests made to NHS organisations for national data returns. This document forms the Government response to the consultation on the Fundamental Review of Data Returns. It provides background to the Fundamental Review, and sets out what was heard from the consultation process and how this factors into the final recommendations for data returns.

DH: EU directive on patients' rights to healthcare in other European countries. This is a consultation on the government’s suggestions for implementing the EU Directive 2011/24/EU. This directive concerns patients’ rights to cross-border healthcare in other member states of the European Economic Area. The consultation closes on 24 May 2013.

DH: Children, Families and Maternity e-bulletin: March 2013. This e-bulletin features the system wide response to the Children and Young People’s Outcomes Forum report and offers the chance to sign up to a national pledge to improve children’s health and reduce child deaths.

DH: Health profiles for England at a glance. These profiles give an overview of health for each local authority in England to help improve local people’s health and reduce inequality. They are designed to help local government and health services understand health in their areas and discuss how to tackle issues. They highlight potential problems and opportunities by making comparisons with other areas and with the national average.

DH: Number of individuals getting NHS continuing healthcare: 2009 to 2010 onwards. This spreadsheet provides the numbers of individuals in receipt of NHS continuing healthcare on a quarterly basis from 2009/10 to date. The table has been updated to show the latest figures for quarter 1 of 2012 to 2013.

DH: NHS Trust Development Authority directions 2013. These directions enable the NHS Trust Development Authority to assume certain functions currently or previously managed by the Department of Health, SHAs and the Appointments Commission. Two previous sets of directions are being revoked and their contents incorporated into these ones.

DH: Living With and Beyond Cancer: Taking Action to Improve Outcomes. This publication aims to support commissioners, commissioning support units and providers to take the necessary actions to improve cancer survivorship outcomes. It sets out what has been learned about survivorship, including interventions to meet needs that have been tested and are ready to be spread across England.

DH: Number of individuals getting NHS continuing healthcare: 2009 to 2010 onwards. This spreadsheet provides the numbers of individuals in receipt of NHS continuing healthcare on a quarterly basis from 2009/10 to date. The table has been updated to show the latest figures for quarter 1 of 2012 to 2013.

Department of Health, Social Services and Public Safety (DHSSPS): Revised Service Framework for Cardiovascular Health and Wellbeing Consultation. The Framework was originally launched in 2009, and upon reaching the end of its 3 year life cycle, has been subjected to a fundamental review. The revised Framework includes 43 standards which relate to a number of specific conditions, as well as communication, patient and public involvement, health improvement and protection, medicines management, palliative and end of life care and research.

Health and Social Care Information Centre (HSCIC): Adult Critical Care Data in England - April 2011 to March 2012. This is the fourth publication of adult critical care data, which forms part of Hospital Episode Statistics (HES) and is collected as part of the Critical Care Minimum Data Set (CCMDS). It covers critical care periods ending between 1 April 2011 and 31 March 2012, and draws on records submitted by providers as an attachment to the inpatient record.

HSCIC: NHS Outcomes Framework Indicators - March 2013 release. The NHS Outcomes Framework indicators form part of the NHS Outcomes Framework, which: provides national level accountability for the outcomes the NHS delivers and drives transparency, quality improvement and outcome measurement throughout the NHS.

HSCIC: Regional variation in hospital admission rates for long term condition. Hospital admission rates for patients with long term conditions differ markedly across the country, new analysis from the Health and Social Care Information Centre (HSCIC) has shown.

Health Foundation: The puzzle of changing relationships. This report aims to contribute to the understanding of how changing relationships impacts on the quality of care. It does this by reviewing the conceptual and theoretical literature on relationships between service users and providers and then exploring the extent to which a chosen set of interventions correlate with the conceptual evidence, and their likely impacts on the quality of care.

Health in Wales: Consultation on draft regulations that will give effect to the new statutory food hygiene rating scheme for Wales. The Welsh Government is asking for public opinion on draft regulations that will give effect to the new statutory food hygiene rating scheme for Wales established by the Food Hygiene Rating (Wales) Act 2013. The Act received Royal Assent on 4 March 2013.

Health in Wales: Building a new system for paying for care in Wales. The Deputy Minister for Social Services has issued a written statement outlining her intent to build on the reforms already introduced in Wales for paying for care.

Healthcare Improvement Scotland: Palliative and end of life care. For all palliative and end of life care services in Scotland, these indicators specify a minimum set of measures that demonstrate person-centred, safe and effective care is being delivered. Patients, carers, third sector and healthcare professionals helped to develop the indicators for palliative and end of life care.

House of Commons Communities and Local Government Committee: The role of local authorities in health issues: eighth report of session 2012–13. This report urges councils to fully grasp the opportunities provided to them in the new health care structure by adopting a holistic approach to public health. It also raises concerns over the complex accountability mechanisms of the reformed system, particularly regarding who will be in charge in the event of a health emergency. It recommends that the government set out clearly and unambiguously the lines of responsibility. It also notes that the incentive in the funding formula is in need of review.

Housing LIN: Housing with Care Matters, March 2013 (PDF 2.2MB). This newsletter has comment and information relevant to everyone working at the interface of housing, care and support.

King’s Fund: Ten priorities for commissioners. paper was originally published in March 2011. It has been updated to reflect the changes in the NHS from 1 April 2013. There are several common themes across the ten priorities and it is clear that commissioners need to help drive the following: more systematic and proactive management of chronic disease; the empowerment of patients; a population-based approach to commissioning; and more integrated models of care.

MHP Health Mandate: Quality at a glance: Using aggregate measures to assess the quality of NHS hospitals. MHP Health Mandate has published the first ever overall assessment of NHS hospital quality in England, based on what matters most to people. The Quality Index has been published as part of Quality at a glance: Using aggregate measures to assess the quality of NHS hospitals and is MHP Health Mandate’s contribution to the ongoing debate about how best to measure quality in the NHS.

Monitor: Guidance for commissioners on ensuring the continuity of health care services: designating commissioner requested services and location specific services. Commissioner requested services are services which local commissioners believe should continue to be provided locally if any individual provider is at risk of failing financially. This framework sets out an end-to-end process that guides commissioners from initiating the work of designating services as commissioner requested services through to deciding which services should be defined as location specific services in the event that a provider fails financially. In addition to this guidance, an interactive toolkit has also been developed to guide commissioners through the framework and to provide a mechanism to record the evidence used and the thinking underlying a decision to designate or not.

National Voices: New structures in health and care: policy briefing for the voluntary sector. This briefing gives an overview of the main changes to health and care structures that impact on the voluntary sector and the people it supports, in line with Regional Voices' aims as a strategic partner to the Department of Health to keep the voluntary sector updated about the changes that affect it, and to influence upcoming changes to ensure that the voluntary sector voice is heard.

NHS Commissioning Board: CCG authorisation review summary (PDF 910KB). The NHS Commissioning Board has published 'Clinical commissioning group authorisation: Review of waves 1, 2 and 3'. This document summarises the outcomes of the first formal review of the CCGs with conditions in waves 1 to 3. Following the first three waves of authorisation there were 130 CCGs with conditions. As a result of their continued hard work and commitment, 63 have now demonstrated that they have made enough progress to remove all their conditions. Those CCGs in wave 4, which were only authorised earlier this month, have some additional time to demonstrate their progress. The next review will be held in June 2013 for those CCGs which were authorised in wave 4, or for those in waves 1 to 3 which are still holding conditions, and then quarterly thereafter.

NHS England: Updated NHS standard contract. These alerts have been published in order to inform commissioners of changes to the NHS standard contract. The changes apply to care homes and community and mental health services. For commissioners of care homes, action is required to ensure that new and varied commissioning contracts include the never events applicable to care homes. For commissioners of community and mental health services action is required to ensure that new and varied commissioning contracts include the appropriate operational standards, national quality requirements and reporting requirements.

NHS Improvement: Directory of diagnostic services for commissioning organisations (PDF 393KB). This guide brings together in one place information about all of the diagnostic modalities to inform decisions about commissioning diagnostic services. The resources have been developed by national clinical directors for endoscopy, imaging, pathology and physiological diagnostics in conjunction with NHS Improvement and the innovative services that they have worked with.

NHS Prescription Services: NHS and local authority reforms factsheets. NHS Prescription Services (a service provided by the NHS Business Services Authority) calculates and pays the remuneration and reimbursement due to pharmacies and appliance contractors across England for dispensing NHS FP10 prescriptions in primary care as part of NHS pharmaceutical services provision. The organisational changes and new arrangements for commissioning health services which has come into effect on April 2013 will mean clinical commissioning groups and local authorities will wish to use pharmaceutical services and will therefore need access to FP10s and prescribing/financial information. NHS Prescription Services has produced factsheets to help existing users understand the changes.

NHS Right Care: The NHS atlas of variation in healthcare for people with liver disease. This atlas uses data sets in the form of maps to reveal the extent of variations in services and outcomes. It reveals widespread variation in the prevalence of risk factors for liver disease, including hepatitis infection, obesity and alcohol abuse in emergency admissions and routine treatments and operations in the expenditure on liver disease services across the NHS.

NHS Specialised Services: Reaction to High Court ruling. This press release responds to a judgement in the High Court on cardiac services for children.
RCN: RCN comment on cardiac services. The RCN responds to news that the High Court has ordered a decision about the closure of a child cardiac surgery unit in Leeds to be quashed.

Nuffield Trust: Changing of the guard: lessons for the new NHS from departing health leaders.
Just prior to the new NHS structures going live in April 2013, the Nuffield Trust has interviewed some of the most experienced NHS leaders to gather their lessons for the new generation of leaders. It includes frank reflections from 12 former or soon-to-depart hospital, primary care trust (PCT) and strategic health authority (SHA) chief executives, along with health regulators, offer insights into the challenges they faced during the last decade or more in the NHS.

Nuffield Trust: The lost decade. What does the latest budget mean for the NHS? The Budget 2013 confirms that funding for health in England will be frozen in real terms for a further year – up to 2015-16 – and the requirement to under-spend allocations is here to stay. The Government has also extended the one per cent cap on pay awards for a further year and is talking about limiting pay progression.

Nuffield Trust: Rating providers for quality: a policy worth pursuing? The Nuffield Trust was commissioned by the Secretary of State for Health to review whether ratings of provider performance should be used in health and social care. This report outlines the findings. This report is the final output of the review process. It was presented to the Secretary of State for Health on 22 March 2013. The report concludes that the costs and benefits in implementing a ratings system may be favourable for providers of social care and for general practices (given the potential for choice and the nature of care provided in those settings). The benefits are less certain for hospitals, given the way that ratings were designed and used in the past. The report lists a number of conditions that would have to be fulfilled for any potential benefits of hospital ratings to be fully realised.

Ofsted: What about the children? Joint working between adult and children's services when parents or carers have mental ill health and/or drug and alcohol problems. This thematic inspection by Ofsted and the Care Quality Commission explored how effectively adult and children’s services worked together to ensure that children affected by their parents’ or carers’ difficulties were supported and safe. The report draws on evidence from cases in nine local authorities and partner agencies and from the views of parents, carers, children, practitioners and managers. It calls on the government to make it a mandatory requirement for mental health services to collect data on children whose parents or carers have mental health difficulties and report on such data nationally.

Primary Care Commissioning (PCC): Partners in delivery: working in partnership with industry to support the implementation of the outcomes strategy for COPD and asthma (PDF 603KB). This guide sets out the various models of partnership working with the pharmaceutical and wider healthcare industry, including case studies from the Department of Health respiratory programme. It aims to demonstrate how partnership projects can form an important part of the commissioning landscape, and improve patient outcomes to those working in services across long-term conditions.

Royal College of Physicians (RCP): Alcohol and cancer: a report from the Alcohol Health Alliance UK. This report draws on the latest research to explain the relationship between alcohol and cancer and why this is a problem that the UK needs to tackle now. It calls for the implementation of key strategies to lower the amount the UK population drinks as a whole and to support those who drink excessively to cut down.

Royal College of Physicians (RCP): Smoking and mental health. This report argues that smoking in people with mental health conditions is neglected by the NHS. It reveals that much of the substantially lower life expectancy of people with mental disorders relates to smoking, which is often overlooked during the management and treatment of their mental health condition. It makes recommendations for all mental health services to become smoke-free areas and for increased smoking cessation support for people with mental disorders.

Royal Society for Public Health (RSPH): Health improvement in local government: challenges and opportunities. This report is the third in a series of briefings reviewing changes in commissioning public health in England, with a particular focus on public health improvement. Based on in-depth interviews with a range of professionals working in public health and associated fields, it provides an update on health improvement commissioning as public health moves into local authorities, while also identifying key opportunities and challenges that arise as a result of the transition.

Scottish Government: Delegation of Local Authority Functions: Mental Health (Care and Treatment) Scotland) Act 2003 and Adults with Incapacity (Scotland) Act 2000. This consultation seeks views with regards to the delegation of functions in 2 specific areas, these being Mental Health Officer ("MHO") functions under the Mental Health (Care and Treatment) (Scotland) Act 2003, and Local Authority ("LA") functions under the Adults with Incapacity (Scotland) Act 2000 required in relation to the health and social care integration proposals.

Scottish Government: The Scottish Government Response To ‘A Scotland for Children: A Consultation on a Children and Young People Bill'. This document sets out the Scottish Government’s Response to the 2012 consultation on the Children and Young People Bill.

Thomas Pocklington Trust: As life goes on: a closer look at how support services respond to the changing needs of people with sight loss. This follow-up study on the changing needs of people with long term sight loss finds continuing problems in the system including a lack of follow-up and emotional support; and difficulties in accessing social services meaning that people with long term sight loss are still not getting the help they need. Recommendations include: integrating services to make referrals between services smoother and provision of information more consistent and thorough; and raising awareness amongst GPs to increase awareness of the interaction of sight loss with other health conditions, and the links between sight loss and mental health.

World Health Organisation (WHO) – Europe. Joint meeting of experts on targets and indicators for health and well-being in Health 2020. This report details a joint meeting of experts who were called to advise on the measurement framework and indicators for the targets already set for Health 2020 (including well-being), and to determine the support needed by countries in the use of such a framework and for further development.

Welsh Government: Cross border protocol. Details the arrangements between the NHS in Wales and the NHS in England to help support patients who live on the Wales/England border.

Welsh Government: Breaking the Barriers. This is the second and final report of progress against the Welsh Government’s 'Breaking the Barriers' action plan. The report focuses on activity during 2012-13. These actions have allowed Wales to make further improvements in mental health and associated services under 'Together for Mental Health'.