GIRFT Clinical Operational Standards for Mental Health in Urgent & Emergency Care - Self-Assessment Tool

Overview

Self-Assessment Tool – Overview and Information Governance

NHS England’s Getting It Right First Time (GIRFT) programme for Adult Acute Mental Health is a national initiative to support improvement in mental health crisis care across England.

GIRFT has developed a Self-Assessment Tool to assess current performance and support ongoing improvement in relation to the Clinical Operational Standards for Mental Health in Urgent and Emergency Care (April 2025).

The Clinical Operational Standards define best practice for the delivery of urgent and emergency mental health care for adults (aged 18 and over). They are designed to support the provision of timely, safe, and effective care for people presenting in mental health crisis across the urgent and emergency care pathway.

The Clinical Operational Standards and Self-Assessment Tool should be used as a practical framework by providers and systems to:

• Review current clinical and operational practice across the urgent and emergency care pathway
• Identify unwarranted variation and gaps in delivery
• Support consistent decision-making and escalation across services
• Prioritise and embed improvements as part of routine practice

The tool is designed to collect both qualitative and quantitative data to generate benchmarked, actionable insights. While much of this data is held locally by providers, it is not routinely submitted to national datasets. This tool aims to address this gap and improve national oversight of pressures on urgent and emergency mental health services, variation in performance, and patient experience, including prolonged waits.

This online survey will initially be conducted as a one-off data collection exercise with participating sites in the GIRFT MH UEC programme ahead of wider national rollout. The programme intends to request a further submission approximately six months following initial completion to support benchmarking of improvement over time.

GIRFT Programme – Information Governance Notice

Why are we collecting this data?

The results from the questionnaire will support NHS England’s duty under the Health and Care Act 2022 to protect and promote the interests of people who use health services by supporting the provision of care that is economic, efficient, and effective.

GIRFT is a national programme overseen by NHS England that aims to improve quality and patient outcomes through peer-to-peer discussions with clinicians and managers in trusts, alongside engagement with wider system partners. It combines comprehensive data analysis with clinical expertise to review current practice and identify opportunities for improvement.

How will the results be used?

Survey responses will be used to:

• Analyse and identify benchmarked, actionable insights
• Improve oversight of system pressures, variation in performance, and patient experience
• Inform development of key metrics for routine national collection and submission
• Support GIRFT peer review and implementation discussions across organisations and systems
• Inform recommendations in the GIRFT MH UEC national report and related clinical publications

The type and level of data being collected

The questionnaire will not collect patient identifiable or patient-level data.

The questions cover both quantitative and qualitative themes. Most responses are either yes/no or numerical, which GIRFT may use for benchmarking analysis.

The questionnaire may request the name and contact details of the individual submitting responses. This information will be used only to enable follow-up for clarification where required and will not be shared more widely.

Who will access the data and how will it be shared?

The results from the questionnaire will be stored within secure IT systems managed by NHS England.

Access to the data will be restricted to authorised GIRFT staff with appropriate permissions to use the data for NHS England purposes.

The data environment is regularly backed up, and information will be retained only for as long as required to support the delivery and implementation of the GIRFT programme.

Data may be shared internally within NHS England, including with regional and national teams, to support wider efficiency and productivity programmes and the delivery of statutory responsibilities.

Data may also be shared with other NHS organisations where necessary to support pathway coordination, service improvement, and improved outcomes and productivity.

Data quality and validation

NHS England will not routinely validate individual responses. Providers are responsible for ensuring that all submitted data is accurate, complete, and has undergone appropriate internal assurance processes prior to submission.

Key principle

This Self-Assessment Tool is intended as a developmental resource to support improvement. It is not a performance management or inspection tool.

Honest and evidence-based self-assessment is essential to ensure meaningful insights and to support improvement across providers and systems.