GIRFT MH ED Breach Analysis Tool

Overview

GIRFT Mental Health Emergency Department Breach Analysis Tool - Overview & 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. The programme has developed a Breach Analysis Tool to better understand the key drivers of delays across the journey for mental health patients experiencing stays in excess of 12-hours in Emergency Departments. 

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

Scope of data collection

This online survey will initially be conducted as a one-off, time-limited collection exercise with participating sites in the GIRFT MH UEC programme ahead of wider national rollout. There will be two data collection periods:

June 2026
January 2027

Each provider is asked to submit data for 10 consecutive patients who experienced a 12+ hour ED breach (where their primary reason for attendance was mental health related). Further information on how to complete this survey can be found on the following page.

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.

Why your views matter

This survey provides the opportunity to build a rich national dataset on delays for mental health patients in Emergency Departments - something that does not currently exist at this level of detail.

Your participation will:

• Identify the true drivers of delay across the patient pathway
  Moving beyond assumptions to pinpoint where delays actually occur (e.g. assessment, MHA processes, bed availability, discharge)

• Shape national improvement priorities and policy
  Findings will directly inform GIRFT recommendations, national guidance, and future expectations for Mental Health Urgent & Emergency Care systems

• Support the development of better data standards
  Helping define what should be routinely captured in EPR systems and national datasets going forward

• Enable benchmarking and shared learning across systems
  Allowing services to compare patterns, identify variation, and learn from high-performing models

• Strengthen local cases for change
  Providing robust evidence that organisations can use to support business cases, pathway redesign, and investment decisions

• Improve outcomes and experience for patients in crisis
  Ultimately reducing time spent in ED, improving flow, and supporting faster access to appropriate care environments.

👉 Every submission contributes directly to a clearer national picture and more targeted, evidence-based improvement.