Mental health in Sussex and East Surrey: the case for ...€¦ · 2016/17 The total spend by CCGs...
Transcript of Mental health in Sussex and East Surrey: the case for ...€¦ · 2016/17 The total spend by CCGs...
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Sussex&EastSurreySustainability&TransformationPartnership
MentalhealthinSussexandEastSurrey:thecaseforchangeJuly2017(v0.5)
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ExecutiveSummary(1/2)ThiscaseforchangelaysoutwherethehealthandcaresysteminSussexandEastSurreycanbetterhelpthosewithmentalhealthconditionstoleadmorefulfilledlives.Itcoversaccess,provisionandoutcomechallengesfacedbyouradultandyouthpopulations.IthasbeenproducedinresponsetothenationalcallintheFiveYearForwardViewforMentalHealthandtheCareAct2014.Itaimstoimprovehealthandsocialoutcomesandreducevariationforpeoplewithmentalhealthconditionsby2020/21.
Indevelopingthiscaseforchange,weheldworkshopswithserviceusers,NHSandlocalauthorityprofessionals,voluntarysectorrepresentatives,healthandcarecommissionersandproviders,interviewedsystemleaders,surveyedserviceusersandGPs,andanalyseddataprovidedbycommissionersandprovidersofmentalhealthservicesandothers.
Oncommonmentalhealthdisorders,SussexandEastSurreycurrentlymeetsaccessandwaitingtimestandardsforpsychologicaltherapies,andrecoveryandimprovementratesexceedormatchnationalstandards.Inlinewithnationalrequirements,SussexandEastSurreywillhavetoexpandprovisionsothat25%ofpeoplewhorequirethesetherapiesareabletoaccessthem.ThereisastrongclinicalviewthatpeoplewhoaretoocomplexforIAPT,butnotsevereenoughforsecondarycareassessmentandtreatment,areunderserved.Buildingcapacityinprimarycarecouldmanagesomepatients,especiallythosewithbothphysicalandmentalhealthconditions,closertohomeandtherebyreducepresentationsandreferralstophysicalandmentalhealthsecondarycare.
Turningtosevereandenduringmentalillness(SMI),individualswithSMIdiebetween15and20yearsyoungerthanthosewithout.TheprevalenceofSMIis5%higherthannationally,affecting25,000individuals.Fourinfiveofthoseindividualsrequiringearlyinterventioninpsychosisdoreceiveitwithintwoweeks.InSussex,individualsreferredtoassessmentandtreatmentservicesaretwentytimesmorelikelytoreceivepsychologicaltherapiesiftheyarereferredforcommonmentalhealthconditionsthanpsychosis.A betterofferforserviceusersincommunitysettingswouldallowmoreeffectivesupportforthosewhorequiresecondarycare.Halfofserviceusersreceivesupportformeaningfulemploymentactivitywithlessthan20%receivingfamilyinterventions.
Fordementia,prevalenceis25%higherthannationally,willincreasefurtherasthepopulationages,whiletheproportionof thosewithadiagnosisis5%lower.Dementiaserviceusersalreadyrepresentaquarterofsecondarycarecontactsinmentalhealth.Manypresentinacutecare,achallengerecognisedinplansforimprovedlocalcare.Aquarterofthosefittoleaveacutecarewaitover50daysfordischarge.
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ExecutiveSummary(2/2)
Threequartersoffirstepisodesofmentalillhealthoccurinyoungpeoplebeforetheageof25.Thereisthegreatestmismatchbetweenprevalenceandserviceuseforthisgroup,whichsuggestsSussexandEastSurreyshouldprovidedifferentwaystoaccessservicesthatworkbetterforyoungpeople.Producingservicescollaborativelywithyoungpeopleappearstobethebestwaytoachievethis,withalocalpilotinHastingsachieving100%recommendationrates.
Turningtocrisisservices,oneinseventypeopleincontactwithsecondarymentalhealthservicesreporthavingacrisisplan,andoveraquarterofserviceusersreportthattheydonotknowwhattodoinacrisis.Thismayreflectdifferentroutesintocrisisservices,resultingfromcurrentcommissioningapproaches,anddrivesattendanceatemergencydepartments.
Asmentalillhealthleadstophysicalillhealth,andviceversa,weshouldaddressmentalandphysicalneedstogether.Asthenumberofco-morbidities,andhenceneeds,increasewithage,the17%increaseinourpopulationoverseventyinthenextfouryearswillrequireevercloserintegrationbetweenmentalhealth,physicalhealthandsocialservices.
ThehealthandcaresysteminSussexandEastSurreyfacesasignificantfinancialchallengewithaforecastdeficitof~£750mby2020/21.Localauthoritybudgetshavedeclinedby22%whiletheshareoffundsallocatedbyCCGstomentalhealthhasdeclinedfrom10%to9.9%since2013/14.Thisfundingconstraintwillrequirenewwaysofdeliveringservicestosupportpeopletomaintainthebesthealthandwellbeingpossible.ThereisamismatchbetweentheamountCCGsspendonmentalhealthandthevalueofservicesprovidedfortheirlocalpopulations.
Ourabilitytoimprovecarereliesonourstaffandthebetteruseofinformation.SussexandEastSurreyhashighvacancyratesforacutementalhealthwhichresultsinhighagencyspend.Althoughtherearefundstodevelopnewservices,supplyofstaffforexistingservicesremainsaconstraint.Thecurrentstateofinformationhampersourabilitytoplanandtrackdelivery.
Nowwehaveathoroughunderstandingofthechallengesweneedtoaddress,wewillbeworkingtogether,withourpartnersandouruserstodevelopsustainableopportunitiestoimprovehealthandsocialoutcomesforadultandyoungpeople’smentalhealthserviceusers.Thesewillcometogetherintoa strategicframeworkanddeliveryroadmapformentalhealthinSussexandEastSurrey.
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Contents
Depressionandanxiety
Dementiaandcognitiveimpairment
Youthservices
Psychosis
Resourcesandenablers
Nextsteps
Nationalandlocalcontext
Physicalandmentalhealthintegration
Crisis
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IntroductionInFebruary2016, theindependentMentalHealthTaskforcebroughttogetherhealthandcareleaders,peoplewhouseservicesandexpertsinthefieldtocreatea FiveYearForwardViewforMentalHealthfortheNHSinEngland.Thissetsoutnationalchallengesandprioritiesforimprovement.InJuly2017,theCQCproduceditsStateofCarereportthathighlightedstaffshortages,poorinformationsystemsandcrisiscommissioningasnationalmentalhealthcareimprovementareas.TheCareAct2014requireslocalauthoritiestopromotewellbeingandmaximiseindependence,particularlyforthosewithestablishedorcomplexhealthconditions,suchasseverementalillnessordementia
ThiscaseforchangebuildsontheForwardView,andlaysoutwherethehealthandcaresysteminSussexandEastSurreycanbetterhelpthosewithmentalhealthconditionstoleadmorefulfilledlives.Itisintendedtoprovidethefocusforthedevelopmentofopportunitiesinastrategicmentalhealthframework.
ThetraditionalwayofdeliveringservicesacrosstheSTPfootprintwillnotmeetdesiredoutcomesandexpectationsofserviceusersinthefuture.Notonlyisfundinginsufficientacrossthewholesystemtomeettheanticipatedincreaseindemandusingthecurrentmodel,butweknowthatbetteroutcomescanbeachievedbydesigningandproducingservicesjointlywithserviceusers.Thismeansweneedafundamentalrethinkofhowweinvolvepeersindesignanddelivery,howweworkacrosscurrentcareboundariesaswellasthenatureandrangeofservicesinthecommunity.
Indevelopingthiscaseforchange,we:
• Heldtwoworkshopswithserviceusers,NHSandlocalauthorityprofessionals,healthandcarecommissionersandproviders;• Interviewed~60systemleaders,GPsandrepresentativesofserviceusers;• Surveyedover400serviceusersandcarersusinganonlinesurvey• SurveyedGPs;• Soughtviewsfromcliniciansandthevoluntarysector;• Analyseddataprovidedbylocalauthorities,commissionersandprovidersofmentalhealthservicesandothers.
Thiscaseforchangearticulatesanumberofstrategicandoperationalchallengesregardingthecurrentprovisionofmentalhealthservices.Thescopeofthisworkcoversadultsofallagesandyouthservicesforthoseaged14-25.Additionalworkfordevelopmentofchildren’smentalhealthservicesisbeingcarriedoutintandem.
SOURCE:Thefiveyearforwardviewformentalhealth,NHSEngland2016
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TheFiveYearForwardViewforMentalHealthsetsoutnationalchallengesandprioritiesforimprovementNHSEnglandhaspublishedtheFiveYearForwardViewformentalhealththatsetsoutnationalimprovementareastobeachievedby2020/21.Thisincludesarequirementtoincreaseaccesstotreatment,commencetreatmentearlier,eliminateoutofareaplacements,provideall-agementalhealthhospitalliaisonteamsandreducesuicideratesandprematuremortality.
Thebasisoftheserequirementsnationallyare:
• Oneinfouradultsnationally experiencesatleastonediagnosablementalhealthprobleminanygivenyear• 75%ofallmentalhealthproblemshavebeenestablishedbytheageof24• Peoplewithsevereandprolongedmentalillnessareatriskofdyingonaverage15to20yearsearlierthanotherpeople–
oneofthegreatesthealthinequalitiesinEngland.Twothirdsofthesedeathsarefromavoidablephysicalillnesses,includingheartdiseaseandcancer
• Peoplewithlongtermphysicalillnessessuffermorecomplicationsiftheyalsodevelopmentalhealthproblems,increasingthecostofcarebyanaverageof45percentintheabsenceofholisticsupport
• Oneinfiveolderpeoplelivinginthecommunityand40percentofolderpeoplelivingincarehomesareaffectedbydepression
• Suicideisrising,aftermanyyearsofdecline.SuicideratesinEnglandhaveincreasedsteadilyinrecentyears,peakingat4,882deathsin2014.Theriseismostmarkedamongstmiddleagedmen.Suicideisnowtheleadingcauseofdeathformenaged15–49
• Nineoutoftenadultswithmentalhealthproblemsaresupportedinprimarycare• Toooften,peopleinmentalhealthcrisisarestillaccessingmentalhealthcareviacontactwiththepolice• Mentalhealthaccountsfor23percentofNHSactivitybutNHSspendingonsecondarymentalhealthservicesisequivalent
tojusthalfofthis• Thecosttotheeconomyofmentalillhealthisestimatedat£105billionayear– roughlythecostoftheentireNHS
SOURCE:Thefiveyearforwardviewformentalhealth,NHSEngland2016
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MentalhealthservicesinourSTPcoverfourplacesforour1.8mresidentpopulation
SOURCE:JSNAs,providerandCCGdatareturns2017;QOF2015/16,ONS2015
• TheresidentpopulationofSussexandEastSurreyis1.8m• 15%ofthepopulationisover70• Nearlyhalfofthepopulationliveinruralcommunities• 170,571peopleareregisteredwithdepressionattheirGPpractice• 17,669peopleareregisteredwithaseriousmentalillness• BrightonandHovehasahigherrateofadmissionformentaland
behavioraldisordersduetoalcohol(134per100,000comparedto87per100,000inEngland)
• Giventheneedtoensurelocalisedcare,fourplacebasedplansarebeingcreatedtoservedistinctgeographiesinourSTP- CoastalCare- NorthCentralSussex andEastSurreyAlliance- SouthCentralSussex andEastSurreyAlliance- EastSussexBetterTogether
Demographics• TheCCGsspent£127monblockcontractadultmentalhealthin
2016/17• ThetotalspendbyCCGsonmentalhealthservicesin2016/17was
£232m,thiswas9.9%oftheCCGs’totalallocatedbudget• Localauthoritieshaveidentifiedaspendof£89monadultmental
health(2016/17)• Themainmentalhealthserviceprovidersinclude:
- SussexPartnershipNHSFoundationTrust(SPFT)- SurreyandBordersPartnershipNHSFoundationTrust(SaBP)- SussexCommunityNHSFoundationTrust(SCFT)
• Around50,000adultsarecurrentlyincontactwithsecondarymentalhealthservicesand37,000incontactwithIAPTservices
• 4%ofadultmentalhealthserviceusersaretreatedinhospitalbeds,themajorityofcareisundertakeninthecommunity
Mentalhealthproviderlandscape
H
+H
Communitysite
Inpatientunit
Placesofsafety
EastSurreybedsfortheresidentsofthewholeofSurrey
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CCGsinSussexandEastSurreyspend£232monmentalhealth,whilelocalauthoritiesidentify£97masadultmentalhealthspend
Source:CCGdatareturns2016/17,providerdatareturns,LocalAuthoritydatareturns;CarnallFarraranalysis
LocalAuthorityadult:mentalhealth£88.8m
PooledbudgetsWSCC£8.8m
Blockcontractoutofscope£22.7m
IAPT:£17.2mCCGblockcontractspendinscope
£127m
Specialistplacements(CCG)£11.5m
CCG:Otherdementia£9.7m
CCG:Othernon-dementia£16.7m
• Inadditiontoidentifiedfunds,
- AboutathirdofGPconsultationshaveamentalhealthcomponent
- Peoplewithmentalhealthconditionsarebigusersofacutephysicalhealthservices
- Localauthoritiesdodeployresourcesfrombudgetsnotidentifiedasmentalhealthbudgets
- Thevoluntarysectorraiseandspendtheirownfundsonmentalhealth
CCGothernon-definedspend£24.0m
B&HCCG£3.4mtoB&HCC
£232m
£97m
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Contents
Depressionandanxiety
Dementiaandcognitiveimpairment
Youthservices
Psychosis
Resourcesandenablers
Nextsteps
Nationalandlocalcontext
Physicalandmentalhealthintegration
Crisis
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SussexandEastSurreycanbuildongoodperformancetoexpandaccessandimproveprovisionforcommonmentalhealthdisorders
TheprevalenceofcommonmentalhealthdisordersinSussexandEastSurreyis16%lowerthannationally.Localpsychologicaltherapiesperformwell,exceedingaccesstargetrates(15%target),recoveryrates(50%target),reliableimprovementrates(63%target)andsixweekwaittimes(75%withinsixweeks).Thenationallymandatedtargettoincreaseaccesstopsychologicaltherapiesto25%ofprevalencewillrequiredelivering56%moretherapies,althoughlocalfundingforthishasnotbeensecuredinallareas.Improvingaccesswillalsorequireintegratingpsychologicaltherapieswithphysicalhealthcare.StructuresandpartnershipstobuildcapacityinprimarycareandsupportintegrationarebeingdevelopedacrossSussexandEastSurrey,withTimetoTalkbeinganationalpilotsite.Suchintegrationshouldimproverecovery,andreducereferralstoandpresentationsinphysicalandmentalhealthsecondarycare.
ThereisstrongclinicalconsensusthatthereisagapinserviceprovisionforpeoplewhoseneedsaretooseveretomeetthecriteriaforIAPTservices,butnotsevereenoughtoqualifyforsecondarycareassessmentandtreatmentservices.Furtherworkisrequiredtounderstandthecohortofindividualswhofallintothisgap.Evenforthosewhoareacceptedbysecondarycare,only15%ofpeoplereceiveapsychologicalintervention.
Alocalauditofclinicalstandardshighlightstheneedtoimprove24/7accesstoservices,performmorestafftrainingforinterventionsperNICEguidance,providecleardischargeplansandprovideholisticcarethatincludeshousingandfinancesupport.
Source:CarnallFarraranalysis
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ThereareareasofgoodpracticeacrosstheSTPtosupportindividualswithcommonmentalhealthconditionsthatwecanbuildon
SOURCES:Providerdatareturn2016/17;HealthinMind:http://www.sussexpartnership.nhs.uk/service-health-mind,SPFT2017
Workingcollaborativelywithadigitalprovider(IESO)tointegrateadigitaloption(typedCBTtherapy), creatingflexibilityfor additional face-tofaceprovisionforthosepatientswhoneedit (e.g.thoseneedinginterpreters)
• Createdasystematic,digital, alertsystem foridentifyingpatientswhohavenotrecoveredmidtherapy,allowingthecliniciantotargetthosepatientswhoarenotrecoveringwithadditionalresources
• Moreflexibleuseofsteppedcarepathway,toenableadditionalinterventionstobeusedtotargetresidualsymptomsofanxietyanddepressionandsupportpatientsintorecovery
Improved recovery (43%upwardsto52%)andaccess(12.%upwardsto15.%)inCrawley,anareaofhigh socialdeprivation.
What?
How?
Impact?
What?
How?
Impact?
What?
How?
Impact?
Provide coursesandothertypesoftherapiesthathelpwithstress,anxietyandlowmood. Whateverthereasonsareforfeelingdown,relationships,moneyorwork,weofferaservicethatmayhelpyoufeelpositiveagain
• TheserviceisFREEandavailabletoadultsovertheageof18livingintheEastSussexarea
• Theservicesinclude:Telephonesupportandguidedself-help,shortwellbeingcourses,CognitiveBehaviouralTherapy,Eyemovementdesensitisationandreprocessing(EMDR),positivewellbeingcourse,inter-personaltherapy,mindfulness,lowself-esteemworkshop,consultationsandangermanagementcourses
• 98%Agreethattheyfeltwelcomedandlistenedto
• 97%Agreethattheyfoundtheconsultationveryhelpfulandweregivengoodinformation
• 89%Agreethatfollowingthefirstinterventiontheyfeltincreasinglyoptimisticabouttheirfuture
HealthinMIND TimetoTalkGPPersistentSymptomsservice
Providesupportforpatientswithcomplexpersistentphysicalsymptomswherethereisnoobviousunderlyingmedicalexplanation.
• Thepersonbeingreferredwillhavepresentedwithpersistentphysicalsymptomsforatleastsixmonthswhereaclearphysicalcausehasnotbeensufficienttofullyexplainthesymptomsexperienced.
• Assessment&treatmentwillbebasedonabiopsychosocialformulationtounderstandthesedifficulties
• Treatmentplanswillinclude1to1sessions,groupworkorongoingGPinput
• Thisisatwoyearpilotthatyethassufficientdataforevaluation.
• Attheendofyear2,theprojectwillneedtobeabletodemonstrateinanEvaluationReportthatthereareimprovedoutcomesforpatientsaswellasreductionsinsecondarycare,diagnostictestsandmedication.
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16.7%
18.3%
13.7%
15.0%
15.8%
12.8%
16.1%
14.7%
HWLH
EHS
Crawley
HMS
CWS
EastSurrey*
H&R
B&H
12.0% 12.4% 12.7% 12.8% 12.9% 13.3% 13.8%
17.3% 13.4%
15.6%
HWLH
EHS
Crawley
HMS
CWS
EastSurrey
H&R
B&H
STP
England
Theprevalenceofcommonmentalhealthdisordersis16%lowerthannationally,however,accesstorelevanttherapyneedstoincreasesignificantlyby2020/21
EstimatedprevalenceofcommonmentalhealthdisordersPercentageofpopulationaged16-74,204/15
SOURCES:Providerdatareturns2017,PHEFingertips2014/15,2016/17;CarnallFarraranalysis
Currentnationaltarget15%
AccessratesforIAPTentryPercentage,2016/17
16%
Note:EastSurreyisSeptember2016
• In2016/17therewere27,500IAPTfirstassessmentsagainstatargetof25,000• Thementalhealthfiveyearforwardviewrequires25%ofpeoplewithcommonmentalhealthconditionstobeableto
accessIAPT,whichwouldincreasethenumberoffirstassessmentsby15,500(56%)to43,000ayear
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AllCCGsexceptBrightonandHovemeetthe6weektargetforreferralstotreatment
1.8
3.4
3.2
4.3
5.5
2.0
1.8
1.7
3.0
2.8
CWS
H&R
EHS
HWLH
B&H
HMS
Crawley
EastSurrey
STP
England
Averagewait- referraltotreatmentWeeks,2016/17
240%
Meeting6weektargetPercentageoffirsttreatmentswithin6weeks,2016/17
98%
89%
89%
83%
68%
98%
98%
96%
89%
89%
CWS
H&R
EHS
HWLH
B&H
HMS
Crawley
EastSurrey
STP
England
Nationaltarget75%
Source:PHEFingertips2016/17;IAPTData2017;CarnallFarraranalysis
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WeareperformingwellforIAPToutcomes,reliablerecoveryexceedsthenationaltargetwhilereliableimprovementisrunningaheadofthenationalaverage
SOURCE:IAPTstatisticalrelease2017,PHEFingertips2016/17;CarnallFarraranalysis
52%
50%
54%
54%
41%
54%
46%
50%
50%
49%
CWS
H&R
EHS
HWLH
B&H
HMS
Crawley
EastSurrey
STP
England
ReliablerecoveryPercentage,2016/17
70%
64%
67%
66%
62%
71%
69%
70%
67%
65%
CWS
H&R
EHS
HWLH
B&H
HMS
Crawley
EastSurrey
STP
England
ReliableimprovementPercentage,2016/17
Nationalaverage65%Nationaltarget50%
• Reliablerecovery:Theproportionofpeoplecompletingtreatmentwhohaveshownsignificantimprovementandrecovered• Reliableimprovement:Thisshowsallthepeoplewhosesymptomshaveimprovedoverthecourseoftreatment,includingthoseinwhomtheimprovementfellshortoffullrecovery.
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ThereisaserviceprovisiongapforindividualswhodonotmeetthecriteriaforIAPTorassessmentandtreatmentservicesinsecondarycare
SOURCE:MentalHealthServicesinSussex:the‘Step3Plus’patientgroup2014
• NotallserviceusersreceivetherighttreatmentandcarebecausetheyfallbetweencommunityIAPTandsecondarycareassessmentandtreatmentservicesandwedonotknowhowmanypeoplearecurrentlyaffectedbythis
• Theneedsofthesepatientgroupsareoftenmetbyservicesstretchingtheircriteriaandresources.• Thisinputoftendoesn’tresultinthemosteffective,ormostcostefficientuseofresourcesavailable
• Peoplewhoneedpsychologicaltreatment(particularlypsychologicaltherapy)butwhoseneedsdonotmeetcriteriaforcurrentlycommissionedservices
• PeoplewhohavecomplexpsychologicalneedsthatarebeyondtheskillsandtrainingofIAPTstaffbutwhosedifficultiesarenotsevereordisablingenoughtorequirecoordinatedandhighlyspecialisttreatmentinsecondarycareservices
• Examplepatientsincludepeoplewithpsychosisthathavebeenstableforsometime,butwhomaybesufferingfromanxietyordepressionandcannotaccessto IAPTasitisnotsetuptomeettheneedsofthisgroup.
AbettermodelofcareThisgrouppresentwithneedswherepsychologicaltherapywouldusuallybethefirstchoiceoftreatmentapproachperNICEguidance.Staffdeliveringtheseinterventionsshouldarguablybesittinginaprimarycaresetting(butcloselysupportedbymedicalandpsychologistcolleaguesinsecondarycare)offeringabroaderrangeofinterventions,withstaffwithabroaderskillsbase,withdifferenttargets,fromourIAPTservices.This‘step3pluspsychologicaltherapyservice’couldshareacommontriagerouteintoprimarycarementalhealthserviceswithIAPTbutbedeliveredbyaseparatestaffgroup.Therapistswoulddrawonabroaderapproachtopsychologicalassessmentandtreatment,drawingonarangeofmodels,ratherthanonespecificmodel.
NOTE:1 PatientswithneedsthataretoocomplexforIAPTservicesbutnotsevereenoughtorequirethecoordinatedmulti-disciplinaryinputofsecondarycarementalhealthservices
Whofallsintothisgap?
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Buildingcapacityinprimarycarecouldmanagesomepatientsclosertohomeandtherebyreduceactivityinsecondarycare
SOURCE:Jointcommissioningpanelformentalhealthvolumetwo:practicalmentalhealthcommissioning
25
25
12
9
8
8
7
4
1
Commonmentalhealthproblem
Sub-thresholdcommonmentalhealthproblem
Personalitydisorder
Longtermconditionandmentalillhealth
Alcoholdependency
Sub-thresholdpsychosis
Medicallyunexplainedsymptoms
Drugdependency
Psychosis
Mentalhealthneedspresentingingeneralpractice(PercentpatientsonatypicalGPlist)
• Commonmentalhealthproblemsandsomepsychosissupportcanbeseeninprimarycarebutcapacityinprimarycareislimited
• Theseoftenpresentwithphysicalhealthneeds,hencemanagingtheminprimarycarewouldreducepresentationsandreferralstobothphysicalandmentalhealthsecondarycare.
• Closeralignmentofprimarycare,communitycareandsocialworkerfunctionswillbecriticaltocreatecapacitytosupportmentalhealthclosertohome
• Careprovidedclosertohomewillreduceunplannedpresentationsandreferralstophysicalandmentalhealthsecondarycare
• Trainingforgeneralpracticetoincreaseconfidencetoprovidesupportandsignpostappropriatelocalservicesisrequired
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Aclinicalstandardsaudithighlightedriskmanagement,stafftraining,careplanningandinformationsharingindepressionandanxietycareasgaps
SOURCE:ClinicalStandardsauditprovider(SPFTandSaBP)andCCGreturnsJune,2017;CarnallFarraranalysis
Sharinginformation
Providingassessmentandintervention
• Informationaboutcarepathway,treatment,mentalhealthactandcontactdetailsareavailableforpatients,carersandhealthcarepractitioners
• Patientsaresupportedtoaccess housingandfinancesupport• Jointworkingprotocols/carepathwaysinplacetosupportpatientsinaccessingotherhealthcareservices• Jointworkingprotocol/carepathwaywithprimaryhealthcareteamsisinplace
Providingholisticcare
• Healthoutcomesateachappointmentarerecordedandfindingsareusedtoadjustdeliveryofinterventions.• Peoplewithseveredepressionandachronicphysicalhealthproblemreceiveacombinationofantidepressantmedication
andindividualcognitivebehaviouraltherapy.• ThereisactivecollaborationbetweenChildandAdolescentMentalHealthServicesandWorkingAgeAdultServicesfor
transferringpatientsbetweenservices.Thisstartsatleast6monthsbeforethedateoftransfer.• Thereispolicyinplaceforthecareofpatientswithdualdiagnosis• Activitiesareprovided7daysaweekandoutofhours• Cleardischargeplanissenttotheserviceuserandallrelevantpartieswithin10daysofdischarge.
Managingrisk
• Arrangementisinplacetoallowserviceusersandcarerstoaccesshelp,frommentalhealthservices,24hoursaday,7daysaweek
• Riskassessmentsandmanagementplansareupdatedregularly• Teamsfollowprotocoltomanageinformalpatientswhodischargethemselvesagainstmedicaladvice• Proactivelyfollowsupwithreferrersandserviceuserswhohavenotattendedanappointment
Standardsconsideredveryimportantbycommissionersandreportedasnotbeingconsistentlymetbyproviders
Stafftraining • PractitionersreceiveregulartrainingandsupervisionthatensurestheyarecompetentindeliveringinterventionsinaccordancewithNICEguidance,legalframeworkandphysicalhealthassessment
Clinicalstandardsbelowwereself-ratedbythetwomainmentalhealthtrustsasareasthatarenotyetfullymet.ThesearealsothestandardsthatCCGsindependentlyconsidertobethemostimportanttodelivereffectivecare.
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Contents
Depressionandanxiety
Dementiaandcognitiveimpairment
Youthservices
Psychosis
Resourcesandenablers
Nextsteps
Nationalandlocalcontext
Physicalandmentalhealthintegration
Crisis
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SussexandEastSurreyhasahigherprevalenceofsevereandenduringmentalillnessthannationallyandtherearegapsinserviceprovision
Thereareapproximately25,000peopleinSussexandEastSurreylivingwithseverementalhealthneedsandtheseindividualsareforecasttodie15to20yearssoonerthanthosewithout.Thoseareaswithhigherlevelsofdeprivationalsohaveahigherprevalenceofpsychosis,suggestingscopeforsupportforwiderlifechallengesinthisserviceusergroup.
SMIprevalenceis5%higherthanthenationalaverage.Fourinfivepeoplereferredforearlyinterventioninpsychosisreceiveitwithintwoweeks.Prescribingdatasuggestsvariationfromgoodpracticeinprimarycare,whileinSussex,serviceusersreferredtosecondarycarearetwentytimesmorelikelytoreceivepsychologicaltherapiesiftheyarereferredforcommonmentalhealthdisordersthaniftheyarereferredforpsychosis.
ThosewhohavebeenidentifiedashavinganSMIfinditdifficulttoaccesstherangeofpsychological,social,employmentandphysicalhealthcaresupportthatisrecommendedbyNICE.Evidenceshowsthatemploymentsupportandfamilyinterventionscansupportrecovery,yetSussexandEastSurreysupportslessthan50%intoemploymentandalthoughSPFTperformedattopquartile,lessthanoneinfivereceivefamilyinterventions.Abetterofferforserviceusersincommunitysettingscouldallowmoreeffectivesupportforthoserequiringsecondarycare.
Alocalauditofclinicalstandardshighlightstheneedtoimproveserviceprovisionforriskmanagement,assessmentandintervention,holisticcareandinformationsharing.
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2020
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82.9
62.2
Non-mentalhealthserviceusers
Mentalhealthserviceusers
MaleswithseverementalillnessinSussexandEastSurreydie20.6yearssoonerthanthosewhodon’t,femalesdie15.7yearssooner
Source:Makingthecaseforintegratingmentalandphysicalhealthcare,SussexandEastSurreySTP,CommissionedbyNHSEngland,2017
86.170.4
Non-mentalhealthserviceusers
Mentalhealthserviceusers
Lifeexpectancyatbirthinyears:MalesYears,2012/13– 2014/15pooled
Lifeexpectancyatbirthinyears:FemalesYears,2012/13– 2014/15pooled
-20.6- 15.7
• Themortalityrateofthementalhealthserviceusersis2.6to26.4timeshigherthantherestofthepopulation• Populationwithseverementalhealthillness1 accumulates454,549lifeyearslost
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Higherdeprivationiscorrelatedwithhighersevereandenduringmentalillness(SMI)prevalenceinalmostallareas
Indexofmultipledeprivation(IMD)scoreScore,2015
SOURCES:DepartmentforCommunitiesandLocalGovernment2015;QOF2015/16,
PrevalenceofSMIPercentage,2015/16
• IMDscoresinSussexandEastSurreySTPrangefrom8.3to25.8
• ThehighertheIMDscore,thehighertherateofSMI(withtheexceptionofCrawley)
• HastingsandRother/ BrightonandHovehavethehighestIMDscoresandthehighestnumbersofpopulationdiagnosedwithSMI
• HorshamandMidSussexhasthelowestrateofdeprivationandlowestSMIprevalence
25.8
23.4
18.0
17.8
15.8
12.1
11.2
8.3
H&R
B&H
EHS
Crawley
CWS
HWLH
EastSurrey
HMS
1.32
1.19
1.07
0.73
0.91
0.86
0.78
0.70
H&R
B&H
EHS
Crawley
CWS
HWLH
EastSurrey
HMS
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2222
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SMIprevalenceis5%higherthanthenationalaveragewithunexplainedvariationintheuseofearlyintervention
0.89
0.94
1.32
1.19
1.07
0.91
0.86
0.78
0.73
0.70
England
STP
H&R
B&H
EHS
CWS
HWLH
EastSurrey
Crawley
HMS
SMIprevalencerate(QOF)PercentageofGPpopulation,2015/16
PatientsincontactwithsecondarymentalhealthservicesclusteredaspsychoticPatientsper1000weightedpopulation,2017
3.6
3.6
15.1
4.4
3.6
3.7
3.8
3.7
4.4
HMS
Crawley
EastSurrey
HWLH
CWS
EHS
B&H
H&R
STP
ReferralstoearlyinterventionsinpsychosisteamNumberofseenreferralsper1000weightedpopulation,2017
Note:referralstoearlyinterventionsteamsareonlycountedifitwasafirstreferral,orsecondifaninternalreferralwasmadeandthepatientwasseen
• TheSussexCCGshaveatargetof194newreferralsperyeartoearlyinterventioninpsychosisteams
• In2016/17158patientswerereferredintotheEIPteamandhadatleastoneappointment
15.1
0.10
0.10
0.10
0.18
0.11
0.04
0.06
0.05
0.08
HMS
Crawley
EastSurrey
HWLH
CWS
EHS
B&H
H&R
STP5%
Source:QOF2015/16,Providerdatareturns2017
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2323
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Prescribingdataforpsychosisandrelatedconditionsvariesby65%,suggestingvariationfromgoodpracticeinprimarycare
SOURCES:CCGdatareturns2016/17,CarnallFarraranalysis
28 2824 22 20 18 17 17
HWLH B&H H&R EastSurrey CWS EHS HMS Crawley
Scriptsper1000weightedmentalhealthpopulation,2016/17
65%
Scriptsare65%higherinHighWeald
LewesHavens/BrightonandHovethanHorshamandMidSussex/Crawley
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Individualsreferredtoassessmentandtreatmentservicesarealmosttwentytimesmorelikelytoreceivepsychologicaltherapiesforcommonmentalhealthneeds
SOURCE:SPFTcluster11stepdowntoprimarycarepaper2014;;HastingsandRotherassessmentandtreatmentservice2016annualservicereport;CarnallFarraranalysis
• Thereisconsiderableinequityastowhogetsaccesstotheexistingresourceinsecondarycare;equivalenttobeingalmosttwentytimesmorelikelytoreceivepsychologicaltherapiesifreferredforcommonmentalhealthdisorders(clusters1-8)thanforpsychosis(clusters11-17)
• Only14%ofpeopleinsecondarycareservicesactuallyreceiveapsychologicaltherapy
• Manycommonmentalhealthproblemscouldbetreatedoutsideofsecondarycaresettingsifcapacitywerecreatedclosertohome
• ApilotinNorthWestSussexrunbySPFThaslookedatimprovingcapacitytoofferpsychologicaltherapytopeoplewithpsychosis
Percentcaseloadforpsychology/psychologicaltherapiesforassessmentandtreatmentservices
23
83
19
6
58
12
ReferralstoATSs Caseload
Psychosis
Dementiaandcognitiveimpairment
Commonmentalhealthproblems
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2525
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WhileallCCGsmeetthewaitingtimetargetforearlyinterventioninpsychosis,firstepisodesaccountfor10%ofpsychosiscontacts
*Target:Morethan50%ofpeopleexperiencingfirstepisodepsychosiswillbetreatedwithaNICE-approvedcarepackagewithintwoweeksofreferral.
Source:NHSEEIPwaitingtimes,2107;SPFT
EarlyinterventioninpsychosiswaitPercentage,2017
8978 70
84 90
6379 77 80
9 1922
16 335
2113 16
1 3 9 8 27 3
1 1 3 1
>0-2weeks >2-6weeks
>6-12weeks 12plus
NationalTarget50%*
8%
13%
6%
11%
11%
8%
10%
11%
10%
92%
87%
94%
89%
89%
92%
90%
89%
90%
CWS
H&R
EHS
HWLH
B&H
HMS
Crawley
EastSurrey
STP Cluster10- firstepisode
Otherpsychosisclusters
PsychosiscontactsbyclusterContacts2016/17
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2626
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Psychosisaccountsforlessthanafifthofpatients,butmorethanhalfofoccupiedbeddays
*Target:Morethan50%ofpeopleexperiencingfirstepisodepsychosiswillbetreatedwithaNICE-approvedcarepackagewithintwoweeksofreferral.
Source:SPFTandSaBPdatareturns2016/17
Patients,contacts,andOBDsforpatientswithapsychosissuperclusterPercentage,2017
19%
36%
56%
Patients Contacts OBD
• Theaveragelengthofstayin2016/17forpsychosiswas57days(55daysforSPFT;108daysSaBP)
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2727
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73.6%
76.4%
75.9%
72.7%
72.3%
75.5%
75.3%
75.9%
74.7%
76.0%
CWS
H&R
EHS
HWLH
B&H
HMS
Crawley
EastSurrey
STP
England
78.8%
78.0%
76.9%
77.7%
72.2%
78.5%
80.8%
80.1%
77.8%
81.3%
CWS
H&R
EHS
HWLH
B&H
HMS
Crawley
EastSurrey
STP
England
ThosewhohavebeenidentifiedashavinganSMImaynotreceivethecorrectphysicalhealthandpsychologicalsupport
SOURCES:PHEFingertips2013-2016,CarnallFarraranalysis
PhysicalhealthchecksPercentageofpeoplewithSMI,whohavereceivedtheircompletelistofphysicalchecks2013/14
ComprehensivecareplanPercentageofpeoplewithSMIwhohaveacomprehensivecareplan2015/16
Accesstopsychologicaltherapy (2013/14)Percentageofpsychosiscarespellsreceivingpsychologicaltherapy
6.2
13.0
5.2
11.9
7.6
6.8
7.1
1.7
7.4
7.0
CWS
H&R
EHS
HWLH
B&H
HMS
Crawley
EastSurrey
STP
England
Englandaverage Englandaverage Englandaverage
AlthoughSussexandEastSurreyoutperform,expertopinionisthatuptohalfwouldbenefit
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2828
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Inthelastnationalaudit,fewerserviceusersatbothSPFTandSaBPreportedhavingsupporttofindajobthanthenationalaverage...
SOURCE:NationalAuditofSchizophrenia,October2014
IdonothaveajobandIamnotgettinghelptofindone
Idonothaveajobbutamgettinghelpfindingone
TheproportionofservicesuserswhowerelookingforworkwhoreportedthattheywereorwerenotgettinghelptofindonePercentageofserviceusers,2014
SaBPSPFT
0
20
40
60
80
100
Totalnationalsample
Topquartile
• AtSaBP andSPFT42%receivedsupporttofindajob
• Nationally50%receivedsupporttofindajob
• Inthetopquartile63%receivedsupporttofindajob
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2929
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...AndalthoughSPFTperformedattopquartile,fewreceivedafamilyintervention
SOURCE:NationalAuditforSchizophrenia,October2014
Ihavehadoramhavingthistreatment
PatientwhohavereceivedafamilyinterventionPercentageofserviceusers,2014
SaBPSPFT
0
20
40
60
80
100
Totalnationalsample
Idonotwantthistreatment
Ihavenotreceivedthistreatment
Topquartile
• AtSPFT16%haveafamilyintervention
• AtSaBP11%haveafamilyintervention
• Nationally11%haveafamilyintervention
• Inthetopquartile16%haveafamilyintervention
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3030
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Theclinicalstandardsaudithighlightedriskmanagement,careplanningandinformationsharing inpsychosiscareasgaps
SOURCE:ClinicalStandardsauditproviderandCCGreturns,June,2017;CarnallFarraranalysis
Sharinginformation
Providingassessmentandintervention
• Informationaboutcarepathway,treatment,mentalhealthactandcontactdetailsareavailableforpatients,carersandhealthcarepractitioners
• Patientsaresupportedtoaccess housingandfinancesupport• Jointworkingprotocols/carepathwaysinplacetosupportpatientsinaccessingotherhealthcareservices• Jointworkingprotocol/carepathwaywithprimaryhealthcareteamsisinplace
Providingholisticcare
• CBTandfamilyinterventionshouldbedeliveredinaccordanceofNICEguidelines.• Adultswithschizophrenianotrespondingadequatelytotreatmentwithatleast2 antipsychoticdrugsareofferedclozapine• Comprehensivephysicalhealthassessmentsforadultswithpsychosisorschizophreniashouldfocusonphysicalhealth
problemscommoninpeoplewithpsychosisandschizophreniainaccordanceofNICEguidelines.• Interventionsshouldbeconsideredtohelppeoplestopsmoking.• ThereisactivecollaborationbetweenChildandAdolescentMentalHealthServicesandWorkingAgeAdultServicesfor
transferringpatientsbetweenservices.Thisstartsatleast6monthsbeforethedateoftransfer• Thereispolicyinplaceforthecareofpatientswithdualdiagnosis• Activitiesareprovided7daysaweekandoutofhours• Cleardischargeplanissenttotheserviceuserandallrelevantpartieswithin10daysofdischarge
Managingrisk
• Arrangementisinplacetoallowserviceusersandcarerstoaccesshelp,frommentalhealthservices,24hoursaday,7daysaweek
• Riskassessmentsandmanagementplansareupdatedregularly• Teamsfollowprotocoltomanageinformalpatientswhodischargethemselvesagainstmedicaladvice• Proactivelyfollowsupwithreferrersandserviceuserswhohavenotattendedanappointment
Standardsconsideredveryimportantbycommissionersandreportedasnotbeingconsistentlymetbyproviders
Clinicalstandardsbelowwereself-ratedbythetwomainmentalhealthtrustsasareasthatarenotyetfullymet.ThesearealsothestandardsthatCCGsindependentlyconsidertobethemostimportanttodelivereffectivecare.
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3131
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Contents
Depressionandanxiety
Dementiaandcognitiveimpairment
Youthservices
Psychosis
Resourcesandenablers
Nextsteps
Nationalandlocalcontext
Physicalandmentalhealthintegration
Crisis
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3232
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Wehavehighprevalenceofdementiawithsignificantsecondarycarecontactsandweneedtoprovidecoordinatedcommunitysupportfordischarge
Theprevalenceofdementiais25%higherinSussexandEastSurreythannationally,itwillincreasesharplyasthepopulationages,andratesofdiagnosiscurrentlylagthenationalrateby4%.Contactswithsecondarycarevarysharply.Dementiaandcognitiveimpairmentalreadyrepresents27%ofmentalhealthcontactsinsecondarycare,andthevolumewillincreaseasthepopulationages.
Clinicalviewsondementiaserviceshighlightalackofsuitableinfrastructure,aneedtoimproveaccesstophysicalhealthsupportandlackofspecialistsupport.Improvingstafftrainingcouldprovidejoinedupsupportacrosscaredisciplines.
Adisproportionatenumberofthosefittoleavetheircurrentsettingofcarehavedementia,withoveraquarterofpatientswithdementiaoracognitiveimpairmentfittoleavewaitingforover50daystoleavetheirsettingsofcare.ThePlace-basedplansinSussexandEastSurreyidentifiedthosewithdementiaasasapriorityforcarecoordination andotherinterventions
Alocalclinicalstandardsauditsuggests24/7serviceaccess,planningforpalliativecare,jointworkingprotocolsforstaffanddischargeplanningcouldbeimproved
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3333
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Dementiaprevalenceis25%higherthannationallyandthepopulation over70isgoingtogrowby17%by2020/21DementiaprevalenceratePercentageofGPweightedpopulation,2015/16
0.5%
0.8%
0.8%
1.0%
1.1%
1.2%
1.3%
1.2%
1.0%
0.8%
0.3%
0.4%
0.5%
0.5%
0.7%
0.6%
0.6%
0.7%
0.5%
0.4%
B&H
Crawley
H&R
EHS
CWS
HMS
EastSurrey
HWLH
STP
England
Recorded Undiagnosed
SOURCES:Providerdatareturns2017,QOF2015/16,CarnallFarraranalysis
Increaseinpopulationover70yearsoldby2021Percentage,2017
12%
14%
18%
18%
16%
19%
17%
19%
17%
16%
B&H
Crawley
H&R
EHS
CWS
HMS
EastSurrey
HWLH
STP
England
• Byapplyingthesameprevalencerate,includingtheundiagnosedrate(1.5%),thenumberofpopulationaged70+withdementiawillgrowby10.3%withinSussexandEastSurrey
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Thedementiadiagnosisrateis4%lowerthannationallyandthenumberofpatientswithdementiaincontactwithsecondaryservicesvariesacrosstheSTP
PatientsincontactwithsecondarymentalhealthservicesclusteredasorganicPatientsper1000weightedpopulation
DementiadiagnosisratePercentofpeoplebeingdiagnosedoverestimatedprevalencelocally
SOURCES:Providerdatareturns2017,NHSDigitalJune2017,CarnallFarraranalysis
• OnlyHorshamandMidSussexisdiagnosingdementiaataratehigherthannationally
• Lowercontactsinsecondarycaremaybeanindicationofmoredevelopedprimarycareandcommunity-baseddementiadiagnosisandpost-diagnosticservices
2.4
7.8
2.6
4.2
10.8
11.9
15.5
5.5
7.2
B&H
Crawley
H&R
EHS
CWS
HMS
EastSurrey
HWLH
STP
64.3%
64.9%
65.0%
67.3%
63.0%
68.5%
68.0%
64.6%
65.2%
68.0%
B&H
Crawley
H&R
EHS
CWS
HMS
EastSurrey
HWLH
STP
England4%
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3535
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SOURCES:Providerdatareturns2017,Alzheimer’sSociety,QOF2015-16,NHSDigitaldiagnosisrate2016-17
MentalhealthpopulationinSussexandEastSurreyPercentofpeopleincontactwithsecondaryservicesbyCCG
35%
13% 21% 21%
12%
36% 28% 32%
27%
CWS H&R EHS HWLH B&H HMS Crawley EastSurrey
STP
• Thereare18,180individualsinourSTPwhohavebeendiagnosedwithdementia,afurther9,668areestimatedtobeundiagnosed
• Ifcurrenttrendscontinueandnoactionistaken,thenumberofpeoplewithdementiaintheUKisforecasttoincreasetoby40% overthenext12yearsand156%overthenext38years
Dementiaandcognitiveimpairmentalreadyrepresents27%ofmentalhealthcontactsinsecondarycare,andthevolumewillincreaseasthepopulationages
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3636
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Uncoordinatedcareforthosewithdementiaresultsinpooroutcomesandinappropriatecaresettinguse
SOURCE:ViewsprovidedbyconsultantpsychiatristsatSPFT(2017)
Thereisalotofphysicalandmentalhealthcomorbidityinelderlypatients,especiallythosewithdementiaandnoeasyaccessto
physicalhealthcareforourpatients.
Forourinpatientswithdementia,theyareinvariablyphysicallyfrail,andthewardsatRSCH
fortheelderlylooksimilartothewardsforpatientswithdementiainthatthepatientshave
bothphysicalandmentalillness.
ThemedicationsthatweprescribeforBPSD(behaviouralandpsychologicalsymptomsofdementia)oftencausephysicalhealthissues,andthemostseniorphysicalhealthadviceonthewardscomesfromtheJuniorDrs.We
needformalliaisonwiththeGeriatricianstoadequatelymanagethesepatients.
Ifpeoplewithdementiaaresounwellthattheyareadmittedtothegeneralhospitalthentheylose
theirdementiawardbedandtheirmentalillnessisnotadequatelymanagedonageneralward.Weneedsomejointlymanagedbedsandforour
nursingandmedicalstafftohaveadequateandregulartraininginphysicalhealth.
Difficulttoaccessphysicalhealthcare
Lackofspecialistsupport
Lackofsuitableinfrastructure
Lackofjointupcarewithadequatestafftraining
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3737
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Adisproportionatenumberofthosefittoleavetheircurrentsettingofcarehavedementia
NOTES: 1 Formallydiagnosedashavingdementia– responserate=97%2 Formallydiagnosedashavingacognitiveimpairment– responserate=96%
SOURCES:SESbedstateaudit2016;CarnallFarrarAnalysis
Patients’fittoleave’ formallydiagnosedwithdementiaPercentage,2016
0%
8%
18%
14%
15%
16%
23%
21%
28%
0%
7%
17%
20%
21%
21%
23%
23%
55%
QVH
ESHT- community
SCT
BSUH
SaSH
ESHT- acute
WSHT
SPFT
FirstCommunity
TotalpatientcohortwithdementiaPatients‘fittoleave’withdementia
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3838
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NOTES:1 HospitalsincludingFirstCommunity,SPFT,WSHT,ESHT,BSUH,SaSHandSCT.
With27%ofpatientswithdementiaoracognitiveimpairmentwaitingforover50daystoleavetheirsettingsofcare
SOURCE:SESbedstateaudit2016,CarnallFarraranalysis
Timespentas‘fittoleave’fordementiaorcognitiveimpairmentpatientsProportionof‘fittoleave’patients,percentage,2016
8%
15%
27% 23%
26%
1% 1-7days
8-14days
15- 28days
28- 49days
50- 365days
365 +
• 99individualsor26%ofpatientwhohaveaformaldiagnosticofdementiaoracognitiveimpairmentremaininacuteandcommunitybedsacrossforbetween50and365daysoncetheyaremedicallyfittoleave
• 3individualshavewaitedoverayeartobedischargedafterbeingdeclaredmedicallyfit
• Ifwecanimprovethesupportofferforpeopleintheircommunitieswewillbeabletoreducelengthyandunnecessarystaysinsecondarycare
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3939
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Place-basedplanningworkinSussexandEastSurreyidentifiedthosewithdementiaasasapriorityforcarecoordination
SOURCE:NorthCSESA,SouthCSESAandCostalsegmentationanalyses 2017,CarnallFarraranalysis
• Thereareover4,000elderlyandover600adultsdiagnosedwithdementiainNorthCSESA.
• Elderlywithdementiause5%ofhealthandcareresources(40.0m),despitebeing 1%ofthepopulation.
• Adultswithdementiause1%ofhealthandcareresources(4.8m)andaccountfor0.1%ofthepopulation.
• Elderlywithmoderatefrailtyaccountforthelargestspendperheadofthesetwocohorts.
NorthCSESAadultsandelderlywithdementia
• Over6,750elderlyand700adultshavebeendiagnosedwithdementiainCoastalCare1.
• Elderlywithdementiause7%ofhealthandcareresources(64.5m),despitebeing1%ofthepopulation.
• Adultswithdementiause0.4%ofhealthandcareresources(£3.4m)andaccountfor0.1%ofthepopulation.
• Elderlywithmoderatefrailtyaccountforthelargestspendperheadofthesetwocohorts.
CoastalCareadultsandelderlywithdementia
• Thereareover4,800elderlyand780adultsdiagnosedwithdementiainSouthCSESA
• Elderlywithdementiause4%ofhealthandcareresources(46.9m),despitebeing 1%ofthepopulation.
• Adultswithdementiause0.4%ofhealthandcareresources(4.8m)andaccountfor0.1%ofthepopulation.
• Elderlywithmoderatefrailtyaccountforthelargestspendperheadofthesetwocohorts.
SouthCSESAadultsandelderlywithdementia
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4040
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Theclinicalstandardsauditidentifiedriskmanagement,careplanningandinformationsharingindementiacareasgaps
SOURCE:ClinicalStandardsauditproviderandCCGreturns,June,2017;CarnallFarraranalysis
Sharinginformation
Providingassessmentandintervention
• Informationaboutcarepathway,treatmentandcontactdetailsareavailableforpatients,carersandhealthcarepractitioners
• Carersareinformedaboutdischargeplan
• Serviceuserandcarerareinformedregardingtreatmentplanandinvolvedindecisionmakingontheirpreferredcare
• Patientsaresupportedtoaccess housingandfinancesupport• Jointworkingprotocols/carepathwaysinplacetosupportpatientsinaccessingotherhealthcareservices• Jointworkingprotocol/carepathwaywithprimaryhealthcareteamsisinplace
Providingholisticcare
Involvingpatientandcarer
• Laterstagesofdementiaareassessedtoidentifyandplanpalliativecareneeds• Activitiesareprovided7daysaweekandoutofhours• Cleardischargeplanissenttotheserviceuserandallrelevantpartieswithin10daysofdischarge.
Managingrisk
• Arrangementisinplacetoallowserviceusersandcarerstoaccesshelp,frommentalhealthservices,24hoursaday,7daysaweek
• Riskassessmentsandmanagementplansareupdatedregularly• Teamsfollowprotocoltomanageinformalpatientswhodischargethemselvesagainstmedicaladvice• Proactivelyfollowsupwithreferrersandserviceuserswhohavenotattendedanappointment
Standardsconsideredveryimportantbycommissionersandreportedaspartiallymetornotmetbyproviders
Clinicalstandardsbelowwereself-ratedbythetwomainmentalhealthtrustsasareasthatarenotyetfullymet.ThesearealsothestandardsthatCCGsindependentlyconsidertobethemostimportanttodelivereffectivecare.
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4141
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Contents
Depressionandanxiety
Dementiaandcognitiveimpairment
Youthservices
Psychosis
Resourcesandenablers
Nextsteps
Nationalandlocalcontext
Physicalandmentalhealthintegration
Crisis
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4242
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Youngpeopleaged14-25formahomogenousgroupthatneeddistinctiveandco-producedapproachestomentalhealthcare
SOURCE:CarnallFarraranalysis
Threequartersoffirstepisodesofmentalillhealthoccurinyoungpeoplebeforetheageof25andtheprevalenceofmentalhealthneedsforyoungpeopleishigherthanotheragegroups.Thisiscompoundedbygreateremployment,educationandtrainingproblemsforyoungpeoplethananyotheragegroup.InSussexandEastSurreyweface17%greaterself-harmforyoungpeoplethanthenationalaverageandthisvariessignificantlyacrosstheSTP.
Themismatchbetweenprevalenceofmentalillnessanduseofservicesisgreaterfor16-24yearoldsthananyotheragegroup,whichsuggestsSussexandEastSurreyshouldprovidedifferentwaystoaccessservicesthatworkforyoungpeople.
Producingservicescollaborativelywithyoungpeopleappearstobethebestwaytoachievethis.WehaveanexistingpilotforyouthservicesinHastings(i-Rock)thatprovideslowerthresholdsfor200individualstoaccessservices,actingasaonestopshopincludingemploymentandhousingsupport.Ithasbeenco-producedwithyoungpeoplewitha100%recommendationrate,indicatingthatthisapproachtoservicedesignisrequiredacrossSussexandEastSurrey.
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4343
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SOURCE:LSEyouthmentalhealth:neweconomicevidenceproject2014;Crawleypathfindermentalhealthproject
Highneeds
Benefitsofyouthservicemodel
Servicegap
• Thetreatmentgapismuchwiderforadolescentsandyoungadultsthanitisforotheragegroups:onlyaboutahalfoftheyoungpeopleaged16-25withmentalhealthproblemswerereceivingmentalhealthservices.
• Ineffectivenessoftraditionalservicestomeettheneedsofyoungpeoplewithemergingmentalhealthneeds.YoungpeopleareleastlikelytoattendtheirGPtogethelpformentalhealthrelatedproblems– thismeansthatthesystemisweakestwhereitneedstobestrongest(McGorry,2010).
• Youngpeopleoftenexperiencementalhealthdifficulties(1in10childrenandyoungpeopleintheUKsufferfromadiagnosablementalhealthdisorder;75%offirstepisodesofmentalillnessoccurbetweentheagesof15&25).
• Youngpeoplewithmentalhealthproblemsweremuchmorelikelynottobeinemployment,educationortrainingcomparedtosimilaryoungpeoplewithoutdisorders
• Thecurrenteconomicclimateandthehighrateofyouthunemploymentiscausingariseinmentalhealthproblemsforyoungpeople.
• TheInternationalYouthMentalHealthDeclaration(2013)requiresustobeprioritisingtheneedsofthisgroupandimprovingservicemodelstobetterfitwiththeirneeds.
• Youngpeople&theirfamiliestellustheywantthem.
• Youthservicemodelscanlocatethemselvesincentrallocationsandmakeiteasierforyoungpeopletoaccessthem.
• Youthservicemodelsdeliverbetteryouthengagementintreatmentandbetteroutcomesthroughimprovedaccessandretention.
• YouthservicemodelsenableustoovercomeproblematicissuesassociatedwiththetransitionbetweenCAMHSandadultservices(SinghTRACKstudy,2010).
• Bycreatingyouthserviceswewillbeabletoofferanearlierinterventionmodelandpreventgreaterproblemsfrombuildingupdownstream.ThisshouldintimeprovetobemorecosteffectiveasevidencedbytheEarlyInterventioninPsychosismodel(Knapp,2014).
• Greatercohesionandcollaborationbetweenthedifferentservices(healthandnon-health)alreadyworkingwithyoungpeoplewillhelpusmakethemostofthelimitedresourcesavailable
Therearenationalgapsinyouthservicesthatneededtobeaddressedlocally
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4444
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Prevalenceofmentalhealthproblemsisalreadysignificantamongst16-24yearolds
• 75%ofmentalhealthdisordersareestablishedbytheageof24,althoughmanyarenotdiagnoseduntilyearslater• Manyyouthsdonotattendtheirfirstappointment,andfewerreturnforasecondappointment
SOURCE:APMS2014
PrevalenceofmentalhealthproblemsPercentage,2014
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4545
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MH Prevalence /Service Use Gap
greatest for young people
0
5
10
15
20
25
30
16-24 25-34 35-44 45-54 55-64 65-74 75-85
Pe
rce
nt
Age
Prevalence
Service Use
Youngpeopleaged16-24usementalhealthserviceslessthantheirprevalenceindicatestheyshould
SOURCE:Investinginyouthmentalhealthisabestbuy, PDMcGorry- 2007;CarnallFarraranalysis
• The16-24agegrouphasthehighestprevalenceofmentalhealthissuesamongalltheauditedagegroups
• Thegapbetweenserviceuseandprevalencearegreatestforyoungpeoplecomparedtootheragegroups
• Mentalhealtharethebiggestdiseaseburdenintheage15-25comparedtootheragegroups
DiseaseburdenMentalhealthconditionprevalenceandserviceuse
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4646
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Youthhospitaladmissionsforselfharmare17%greaterthanthenationalaverageandthereis70%variationacrosstheSTP
Hospitaladmissionsasaresultofself-harmPer100,000population(10-24years),2016
SOURCE:PHEFingertips2016
398.8
465
347.6
362.3
429.8
439.4
471.9
524.8
551.4
590
National
STP
EHS
HMS
B&H
HWLH
Crawley
EastSurrey
CWS
H&R
+70%
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4747
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Wehaveinnovativeideassuchasthei-RockpilotinHastings thatcanbebuiltontosupportwiderapplication
SOURCE:Businesscaseforyouthmentalhealthservicepilot2016;NHSHastingsandRotherCCG;SussexPartnershipNHSFoundation Trust;EastSussexCountyCouncil
HastingsandRotheri-Rockyouthmentalhealthservicepilot(startedJune2016)
• Aonestopshoptosupportyoungpeopleaged14-25formentalheathissues,wellbeing,education,employmentandhousingsupport
• Over200individualshavebeensupported,neverwaitingformorethan30minutes
• 43%ofyoungpeopleaccessingtheservicearenotineducation,employmentortraining(4timeshigherthanthegeneralpopulation)andtheserviceconsistentlyreachespeopleinthe10%mostdeprivedareas
• Themostcommonageofusersis17,oftenrequiringsupportforanxiety/stress,relationship/employmentissuesorlowmood
• Over70%ofusersweregivensupportedaccesstoservicesand10%transitionedintoaservice
• 100%ofsurveyeduserswouldrecommendi-Rocktoafriendand40%reportedthattheywouldnothaveaccessedotherservices
• Thetraditionalchildandadolescentmentalhealthservice(CAMHS)toadultmentalhealthservicetransitioncanprovetobeproblematicandunsatisfactoryforthemajorityofyoungpeople
• Highthresholdsinstatutoryserviceprovisionandlackofcohesionbetweenstatutoryandnon-statutoryprovisionresultsinseveral“touchpoints”foryoungpeoplebeforeinterventionorsupportisgiven
• Engagementandretentioninservicesaresub-optimalwithhigherDNAratesanddisengagementinadultservicescomparedtothemore“youthfriendly”earlyinterventioninpsychosis(EIP)Services
• Adolescentsandyoungadultspresentwithneedsthatrequiresupportfrommorethanmentalhealthservicesalone(i.e.debtadvice,employmentsupport,anxietymanagement)buttheseareasarenotjoinedup
• Ultimatelythisleadstoincreasedcosts(directandindirect)andpooreroutcomesbothclinicallyandfunctionally
• Theyouthsupportsystemisbasedonservicesthatorganisationsprovideandneedstobebasedonoverallneedsofyoungpeopleandtheirfamilies
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4848
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Contents
Depressionandanxiety
Dementiaandcognitiveimpairment
Youthservices
Psychosis
Resourcesandenablers
Nextsteps
Nationalandlocalcontext
Physicalandmentalhealthintegration
Crisis
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4949
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Crisisserviceawarenessandprovisionappearshighlyvariablewithverylowratesofcrisisplanningsupport
SOURCE:CarnallFarraranalysis
AcrossSussexandEastSurrey,1.3%ofpeopleincontactwithstatutoryserviceshavecrisisplans,comparedwithanationalaverageof13.3%.ContactswithcrisisteamswhocansupportplanningarrangementsvariesconsiderablybyCCGarea,whileover25%ofserviceusersinSussexandEastSurreydon’tknowhowtoreceivehelpinacrisis.AlthoughmultiplepointsofaccessforcrisissupportarecommissionedbydifferentCCGs,someserviceusersstruggletoknowwheretoturnforhelp.Thismaycauseemergencycaresettingstobeusedbydefault.
WhenindividualswithmentalhealthneedspresentatemergencydepartmentstheoutcomevariesconsiderablybyTrust.Thisisstrikingforadmissionsandassociatedbeddaycoststhatrangebetween£34kand£1.3mperannumdependingontheTrust.
Almost20%ofreferralstosecondarycarearegeneratedinemergencydepartments,indicatingthatanumberofemergencyattendancescouldbehandledelsewhereifcrisisplanningandresponseweretobeimproved.Thiswouldincludesupportforpeoplewithearlystagesofdementiatopreparecrisisplans.
Forpsychiatricdisorders,attendancesatA&Eforaregenerallyhigherthanthenationalaveragewithover6,000ambulancejourneysmadetoA&Ein2016/17suggestinganeedtoprovideclearsignpostingtoalternativeandmoreeffectivesettingsofcare.
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5050
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FewermentalhealthserviceusershaveacrisisplanthannationallyandcontactswithcrisisteamsarehighlyvariableacrossCCGs
13.3
1.3
0.4
0.2
0.6
10.9
0.2
0.9
0.2
0.1
England
STP
B&H
CWS
Crawley
EastSurrey
EHS
H&R
HWLH
HMS
MentalHealthServiceuserswithcrisisplansAsapercentageofpeopleincontactwithservices(endofquartersnapshot),2015/16
SOURCE:PHEFingertips2015/16
ContactswithacrisisteamPer1,000population,2015/16
44.8
7.2
31.1
18.2
26.2
36.4
64.0
37.7
HMS
HWLH
H&R
EHS
EastSurrey
Crawley
CWS
B&H
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5151
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Yes,IwouldgototheAccidentandEmergencyDepartment
Althoughsimilartothenationalaverage,morecanbedonetosupportserviceuserswhoneedhelpincrisis
Doyouknowhowtogethelpinacrisis?Percentageofserviceusers,2014
Yes,IhaveanumberformentalhealthservicesIcanringinanemergency
No,IdonotknowhowIcangethelpinanemergency
0
20
40
60
80
100
SPFT SaBPTotalnational
sample
SOURCE:ReportofthesecondroundoftheNationalAuditofSchizophrenia2014
Topquartile
• AtSaBPandSPFT72.6%and72.7%knowhowtoseekhelpincrisis,respectively
• Nationally72.8%knowhowtoseekhelpincrisis
• Inthetopquartile81.8%knowhowtoseekhelpincrisis
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5252
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AlthoughmultiplepointsofaccessforcrisissupportarecommissionedbydifferentCCGs,someserviceusersstruggletoknowwheretoturnforhelp
SOURCE:PHEFingertips2015/16;CCGservicemapping;CarnallFarraranalysis
• Thirdsectormentalhealthhelpline• Rapidresponseopenaccessphonelineservice
• AssessmentandTreatmentService• CrisisResolutionandHomeTreatment (CRHT;throughSPFT)
• SPFTreferralcoordinator(8amto6.30pmthroughGP)
• Crisishouses• GP-ledurgentcarecentres• Rapidassessmentandinterventionteam
• Mentalhealthcrisisline• SafeHavens(5-11pm)• HomeTreatmentteams(throughtheCommunityMentalHealthRecoveryServices/PsychiatricLiaisonatA&E)
• Thirdsectormentalhealthhelpline• Rapidresponseopenaccessphonelineservice
• A&E(throughMHLiaisonservices)• S136pathway(throughStreettriage)• Hastingssanctuary• Nightsittingservice
“Itcanattimesbedifficulttopersuadethecrisisteamtotakeonapatientthatneedshelp”
“Thereisnorealalternativetobeingsectionedbypoliceifyougettocrisispoint”
“Weneedproperemergencyhelptobeavailablewhenacrisisoccurs.Thehelplinewasinadequateandleftme
feelingcompletelyisolatedandvulnerable,especiallyatnightand
weekends.”
“Morefunding,andincreasedaccessforcrisisteamsoutside
officehourswillstoppeoplegoingtoA&E”
• DifferentCCGscommissiondifferentcrisisservices• MentalhealthliaisonservicescommissionedbyCCGsarenotyetoffered24/7• StrategiccommissioningofcrisissupportacrossSussexandEastSurreymaycreateamore
coordinatedandroundtheclockserviceoffer,basedonsharedbestpractice• CCGsarealreadycollaboratingtoimprovecrisissupportthroughajointservice
developmentandimprovementplanwithSPFTforCRHTs
Examplesofcrisisservicesofferedduringworkinghours
Examplesofcrisisservicesofferedoutsideworkinghours
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5353
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AttendanceatacuteemergencydepartmentswithaprimarymentalhealthneedresultsinmixedoutcomesforserviceusersandcostsbyTrust
1080
1570
55 2989 72 17
194
973
918
246
303 854
984
599
84403
555
812
12096 252
160121
29 399
SaSH WSHFT ESHT BSUH
Unknown
Other
Referred
GPfollowup
Discharged
Admitted-assessmentunit
Admitted-psychiatricunit
Admitted
Outcomeafteremergencydepartmentattendance(2016/17)Patientnumbers
Totalbeddaysandcosts(2016/17)Beddays
2000 1836
542 96
SaSH WSHFT EHST BSUH
1.3m 1.5m 189k
• Costdataonlyincludesreferencecostdata,theactualcostislikelytobehigherduetotheintensivenursingrequired
1902 3925 2856Total Costs(£)
Note:Admittedreferstothesametrust;referredincludestootherhealthcareproviderorGP;bedsdaysandcostsareonlyforadmittedpatientsSource:Providerdatareturns2016/17,CarnallFarraranalysis
• Asignificantproportionadmissionsarefor0or1daylengthofstays(SaSH73%,WSHT84%,ESHT75%,BSUH69%)suggestingtheyarerapidlyreferredonordischarged.
34k2034
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5454
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PrimaryCare54%
ED
18% Self-Referral8%
SecondaryCare6%
Otherhealthcareteams2%
LocalAuthority1%
Other11%
Note:PrimarycaredoesnotincludeIAPTSource:Providerdatareturns2016/17,CarnallFarraranalysis;1Makingthecaseforintegratingmentalandphysicalhealthcare,NHSE2017
ReferralsintosecondarycareoriginatefromseveralpointsofdeliveryPercentage,2016/17
*95%ofselfreferralsweretoIAPTservicesatSussexCommunity4%ofreferralsfromanemergencydepartmentteamaretoanA&Eliaisonteam
1902
3925
20342856
SaSH WSHFT ESHT BSUH
TotalattendancesatemergencydepartmentsandcostsAttendances,2016/17
282 384 311
Attendancesatemergencydepartmentsforpatientswhoseprimarydiagnosisdescriptionisamentalhealthneedi.e.overdose,depression,anxietypersonalitydisorder
Costs(£000s) 177
2.0% 2.8% 2.6%Percentage
oftotalattendances
1.9%
18%ofmentalhealthpatientsarereferredtosecondarycareservicesafterattendanceatemergencydepartments
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AttendancesatA&Evariesconsiderablyforpsychiatricdisordersandover6,000ambulancejourneysformentalhealtharemadeperyear
Source:PHEFingertips2012/13,Providerdatareturns,2016/17
AttendancesatA&EforapsychiatricdisorderPer100,000population(10-24years),2012/13
19
22
196
203
359
422
449
569
244
EastSurrey
Crawley
HMS
HWLH
CWS
B&H
EHS
H&R
England 6110
186
MentalHealth Section136
AmbulancejourneysmadeforSection136ormentalhealthneedsPatients,2016/17
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Contents
Depressionandanxiety
Dementiaandcognitiveimpairment
Youthservices
Psychosis
Resourcesandenablers
Nextsteps
Nationalandlocalcontext
Physicalandmentalhealthintegration
Crisis
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Integratingphysicalandmentalhealthisneededtoimproveoutcomesandprovideaconsistentservicetoourpopulation
Source:CarnallFarraranalysis
Mentalandphysicalhealthshouldbeaddressedtogetheraspoormentalhealthleadstopoorphysicalhealthandviceversa.169,000peopleinSussexandEastSurreyhavebothamentalhealthconditionandaphysicalcondition.Thisisequalto45%ofpeoplewithamentalhealthconditionhavingaphysicalcondition.
Notaddressingtheemotionalandmentalhealthchallengesofpeoplewithoneormorelongtermphysicalconditionsresultsinsignificantnegativehealthoutcomes.Italsoleadstosignificantadditionalcostsforservices.
Asthepopulationages,thechallengewillincrease.Thechancesofhavingdementiaincreasestwelvefoldintheover70s.Physicallongtermconditionsincreasewithageanddiabetesandcardiovasculardiseaseincreasetheriskofdementia.SussexandEastSurreywillhave34,000morepeopleovertheageof70by2020/21,reinforcingtheneedtotreatpeople,ratherthandiseases.
Wecanimprovehowmentalandphysicalhealthcometogether.Atpresent,thebedsweprovideformentalhealthneedsareoftenlocatedinsmallunitsawayfromservicesforphysicalconditions.
79%ofmentalhealthserviceusersandcarershaveexperiencedstigmaandthisoftencomesfromNHSprofessionals.Ifmentalandphysicalhealthcareandsupportisofferedbydefaultbystafftrainedinholisticcare,thiswillbeimproved.Over50%ofserviceusersand75%ofGPsstronglybelievethatcoordinationbetweenservicesisfragmentedandshouldbeovercometoimprovementalhealthcareincludingphysicalaspects.
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•Mentalhealthimpactoflivingwithachroniccondition• Psychiatricsideeffectsofmedication,e.g.,steroids• Directeffectsofhormonalimbalancesonmentalhealth• Increasedriskofdementiaamongpeoplewithdiabetes/cardiovasculardisease
• Physicalhealthsideeffectsofpsychotropicmedication,e.g.raisedriskofobesity• Directeffectsofchronicstressonthecardiovascular,nervousandimmunesystems• Directeffectsofeatingdisordersoself-harm,e.g.electrolyteimbalances• Higherrateofunhealthybehaviours,e.g.smokingorexcessivealcoholuse• Reducedabilityormotivationtomanagephysicalhealthconditions• Lesseffectivehelp–seeking• Barrierstoaccessingphysicalhealthcare,e.g.asaconsequenceofstigmaor‘diagnosticovershadowing’
Goodmentalhealthoutcomesrequireholisticmanagementandsupportforphysicalandmentalhealthconditions
SOURCE:TheKing’sFund– mentalhealthandnewmodelsofcareMay2017
SocialdeterminantsE.g.,poverty,socialisolation,discrimination,abuse,neglect,trauma,drugdependencies
Physicalhealth
Mentalhealth
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169,000people(45%)withamentalhealthconditionalsohaveaphysicalhealthconditioninSussexandEastSurrey
SOURCES:Peerintegrateddataset2016,CarnallFarraranalysis;Bringingtogetherphysicalandmentalhealth ,Kind’sFund2016NOTE:Databasedonnationalestimate
Mentalhealthconditions:16%ofpopulationofSussexandEastSurrey(371,000)
Longtermconditions:26%ofpopulationofSussexandEastSurrey(556,000)
27%ofpeoplewithlongtermphysicalconditionhaveamentalhealthproblem(169,000)
45%ofpeoplewithmentalhealthproblemhavealongtermphysicalcondition(169,000)
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Aspeopleage,theriskofdevelopingmultiplelongtermconditionsincreases
SOURCES:Peerintegrateddataset2016,CarnallFarraranalysis;Bringingtogetherphysicalandmentalhealth ,Kind’sFund2016
NumberofchroniccomorbiditiesbyagestratumPatientspercentage,2016
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TheSTPhasavariedbedbaseandsomesmallerunitswhicharenotco-locatedwithphysicalhealthservices
SOURCE:Providerdatareturns2016/17;CarnallFarraranalysis
STPbedbasebytypeNumberofbedsbyhospitallocation,2016/17
12
10
10
12
15
20
10
16
23
34
36
47
40
15
12
18
18
19
12
10
15
15
28
9
RutlandGarderns
Burrowes
CrawleyHospital*
HorshamHospital**
StAnnes
ShephardHouse
Lindridge
Connolly House
Oaklands
UckfieldHospital**
HKU
AmberstoneHospital
ConquestHospital*
Meadowfield
DoP(Eastbourne)*
LangleyGreen
MillView
PICU
InpatientOrganic
AcuteInpatient
InpatientFunctional
Acuteinpatient- SPFTrun
RehabilitationInpatient
*AcuteSite**CommunitySite(non-mentalhealth)
• Thereare17inpatientsitesinrunbySussexPartnershipinSussex
• Sevenofthesehavelessthan20bedsandarearenotlocatedwithphysicalhealthcareservices
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79%ofmentalhealthserviceusersandcarershaveexperiencedstigma,oftenfromNHSprofessionals...
21%
21%
21%
37%
Note:1ParticipantscanselectasmanyresponsesastheyhaveexperiencedSOURCE:ServiceuserandcarersurveyJune2017
Haveyouexperiencedstigmaand/ordiscriminationasaresultofamentalhealthproblem?Percentageofrespondents,2017
44%
36%
35%
33%
17%
5%
2%
2%
2%
Familymembers
NHSprofessionals
Friends
Workcolleagues
Neighbours
Public
Employer
Police
School
21%
79%
Never Yes
Ifyes,fromwho?Percentageofrespondentsselecting’yes’,2017
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69%
55%
44%
43%
39%
19%
9%
Treatmentisdelayedornotgivenearlyenough
Servicesdonotcommunicatewitheachotherwhendeliveringcaretothesameperson
Staffarenotalwaysavailablewhenweneedthem
PeopledonotthinkMentalHealthisimportant
PeopledonotknowenoughaboutMentalHealth
Informationisnotreadilyavailable
Servicearetoofarfromme/thefamily
“Weworkinsilosanddon’tknowwhatelseis
beingoffered”“Socialcareisvery
fragmentedandneedstoworkwithprimary
care”
“Fragmentedservicesisoneofourbiggest
roadblocks”
“Weneedtocommissionmoreservicesjointlyacrossdifferent
providers”
“Weuselotsofseparatesystemsthatdon’ttalk
toeachother”
Treatmentisdelayedornotgivenearlyenough
Servicesdonotcommunicatewitheachother
Staffarenotalwaysavailablewhenweneedthem
PeopledonotthinkMentalHealthisimportant
PeopledonotknowenoughaboutMentalHealth
Informationisnotreadilyavailable
Servicearetoofarfromme/thefamily
ServiceusersandcarerswantcommunicationbetweenservicesandstaffavailabilitytoimprovePercentageofrespondents,2017
76%
64%
62%
52%
14%
Fragmentedservices
Undercapacity
Lackoffunding
Delayedtreatments
Availabilityofinformation
Fragmentedservices
Undercapacity
Lackoffunding
Delayedtreatments
Availabilityofinformation
GPsviewfragmentedservicesasoneofthebiggestroadblockstodeliveringmentalhealthservicesPercentageofrespondents,2017
SOURCES:SussexandEastSurreyserviceuser/carerandGPsurveysJune2017;stakeholderinterview2017
...Whileabouthalfofserviceusers,carersandthreequartersofGPsbelievethatfragmentedservicespreventscoordinatedsupportbeingoffered
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Contents
Depressionandanxiety
Dementiaandcognitiveimpairment
Youthservices
Psychosis
Resourcesandenablers
Nextsteps
Nationalandlocalcontext
Physicalandmentalhealthintegration
Crisis
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SussexandEastSurreyfacesanongoingfinancial,workforceanddatarecordingchallenge
SOURCE:CarnallFarraranalysis
SussexandEastSurreyfacesasignificantfinancialproblemwithaforecasthealthandsocialcarechallengeestimatedat~£750mby2020/21.Localauthoritybudgetshavedeclinedbyanaverageof22% whiletheshareoffundsallocatedbyCCGstomentalhealthhasdecreasedfrom10%to9.9%since2013/14.Thisfundingconstraintwillrequirenewwaysofdeliveringservicestosupportpeopletomaintainthebesthealthandwellbeingpossible.
SpendperweightedheadvariesamongtheCCGsby60%andamonglocalauthoritiesby252%andamismatchexistsbetweenwhatCCGspayforversusthevalueofservicesreceivedbytheirpopulation.Weareincurringgreatcosttosendpeopleoutofareawiththemajorityofcasesduetolocalprovidersnotofferingservices(£9mofactivity).ThevarietyofcommissionedservicesoutsideofmainblockcontractswithSPFT,SaBPandIAPTpresentsanopportunitytoexplorestrategicorjointcommissioning.
InSussexalone,wefacethesecondhighestvacancyrateforacutementalhealthservicesthathasledtoasustainedincreaseinagencyspendfrom£2.6min2012/13to£9.8min2015/16.Carersformanimportantpartofourworkforcebutover60%donotfeeladequatelysupported.
Althoughweknowthatservicesneedtobemoreholistic,wedonotrecordinformationonlifeoutcomeswellwithforhousing(74%unknown)oremployment(84%unknown).
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SussexandEastSurreyfacesasignificantfinancialproblem
Source:SESSTPFinanceSubgroup
• ThefinanceenvelopehealthandcareinSussexandEastSurreyis£3.7bnfor2017/18
• SPFTrecordeda£1.1mdeficitin2016/17,SaBPa£0.5msurplus(althoughunderlyingmovementsdiffer)
• TheNovemberSTPprojectedtheNHSgapwouldgrowto£653mthesocialcaregapto£212mby2020/21ifnothingisdone.However,giventhedeterioratingfinancialposition,thisislikelytobehigher
• Thefundingconstraintwillrequirenewwaysofdeliveringservicestosupportpeopletomaintainthebesthealthandwellbeingpossible
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ThetotalmentalhealthspendforCCGsin2016/17was£222m with£12monjointbudgetsand£89mofidentifiedlocalauthorityadultmentalhealthspend
Source:Provider/localauthoritydatareturns2016/17
130
13
12
9
14
8912
45
BlockcontractCCGs
IAPT
SpealistPlacements- CCG
Other-dementia
Other- non-dementia
LAspend
LAjointbugets
Other- outofscope
MentalhealthspendacrosstheSTP£m
• ThetotalspendonmentalhealthbyCCGsis£222m
• TheCCGsspend£177monadultsmentalhealth
• Thelocalauthoritieshaveidentifiedaspendof£89monadultmentalhealth
• WestSussexcountycouncilhaveapoolbudgetandcontributed£8.8m(13.5%)tothis
• BrightonandHoveCCGmakeanannualcontributiontowardsSection117andspecialistplacements of£3.4m
• Itmaybenecessarytoshiftthecurrentbalanceoffundingbetweenserviceareasandspecificelementsofcarepathwaystosupportgreaterinvestmentinpreventativeservicesandimproveoutcomes
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Source:CCGdatareturns,CCGannualaccounts(2013/14to2016/17),CCGBreakdownofProgrammeCosts2015/16Plans(£'000),NHSEngland- CCGAllocations2016-17to2020-21,CalculationofWeightedPopulation(MentalHealth),CarnallFarrarAnalysis
CCGspendonmentalhealthserviceshasdecreasedslightlyasashareoftotalallocationfrom10%in2013/14to9.9%in2016/17
10.0%
9.6%
8.6%
8.0%
12.6%
12.2%
7.1%
9.1%
9.9%
10.1%
9.8%
7.9%
8.7%
12.6%
12.2%
7.3%
9.6%
10.0%
CWS
H&R
EHS
HWLH
B&H
HMS
Crawley
EastSurrey
STP
2013/14 2016/17
ChangeinproportionofallocationspentonmentalhealthPercentage,2013/14– 2016/17 • Mentalhealthspendin2013/14acrossSussex
andEastSurreywas£206m;in2016/17itwas£232m
• CCGspendonmentalhealthhasincreasedby£26.2m.Thisisacompoundannualgrowthrate(CAGR)of4.1%
• Inrealtermsthisinanincreaseinmentalhealthspend
• However,theCCGallocationsacrosstheSTPgrewby4.5%inbetween2013/14and2016/17
• ThereforeCCGmentalhealthspendinghasdecreasedfrom10.0%ofthetotalallocationsto9.9%.
• Eastbourne,HailshamandSeafordistheonlyCCGthathasincreasedthepercentageoftheirallocationspentonmentalhealth
Note:CoastalWestSussex,HastingandRother,Eastbourne,HailshamandSeafordandHighWealdLewisHavenshaveaprimaryCareNHSEco-commissioningarrangementwhichhasincreasedtheirtotalallocation,thishasbeenremovedfromthetotalCCGallocation.CCGpeergroupingsbasedoncomplexityofpopulationmentalhealthneeds.
21%
10%
-2%
15%
2%
-57%
-24%
-20%
-3%
ComparisonofspendperheadtoCCGpeersPercentage,2015/16
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IncomeandcostperCCG£/standardisedunitactivity,2016/17
445
703
397
600642
415
558
440
749
466 450
622
496
725
0
100
200
300
400
500
600
700
800
CWS H&R EHS HWLH B&H HMS Crawley
Income Cost
Note:Dataincludesnon-psychotic,psychotic,organicandunclusteredincomeandcostSource:Providerdatareturns2016/17,CarnallFarraranalysis
ThereisamismatchbetweenwhatCCGspayin,andthevalueofservicesreceivedbytheirpopulation
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Localauthorityadultsocialcareservicesexpenditurehasreducedbyanaverageof3%againstbudgetsthathavefallenbyanaverageof22%
-8%
-3%
-2%
-5%
-3%
Brighton&Hove
EastSussex
Surrey
WestSussex
Weightedaverage
-28%
-25%
-20%
-19%
-22%
Realchangeinadultsocialcareexpenditure2013/14– 2017/18
Realchangeintotalserviceexpenditure2013/14– 2017/18
Source:Departmentforcommunitiesandlocalgovernment;HMTreasury;CarnallFarraranalysis
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120
75
10385
74 77 73 63
10
8
11
138 9 8
8
7
5
9
8 5 48
29
4915
16
19 18 2315
EastSurrey
CWS HWLH B&H H&R Crawley HMS EHS
MHTrustBlockContract
IAPT
SpecalistPlacements
OtherProviders
165 128
BrightonandHoveCCG’sincludes£3.4mannualcontributiontothecitycouncil,theirIAPTserviceincludesemploymentsupportandwellbeingservices
137 123 109 109 108 94
Source:CCGdatareturns2016/17,providerdatareturns,LocalAuthoritydatareturns;CarnallFarraranalysis
ThereishighvariationinspendperheadonmentalhealthforbothCCGs(60%)andlocalauthorities(252%)
MentalhealthCCGweightedspendperhead(2016/17)£,allspend
66
4132
19
WestSussex
Brighton&Hove
EastSussex Surrey
66 3241 19
Mentalhealthweightedlocalauthorityspendperhead(2016/17)£,adultspend
+60%
+252%
Thisisspendidentifiedasadultmentalhealthspend;therewillbespendonmentalhealthfromotherbudgets.Itdoesnotincludejointbudgets(WSCC)orBrightonandHoveCCGannualcontributiontowardsSection117andspecialistplacements,WSCCincludes£1mtobettercarecontributiontomentalhealth
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Inpatientcapacityisconstrainedbybedoccupancyrangingbetween91%and103%acrossSussex
Source:CarnalFarrarbedaudit,March2017,providerdatareturns,CarnallFarraranalysis
94% 91%
103% 103%
92%
Rehabilitation Dementiaandcognitive
impairment
Functional Acute PICU
OccupancyratebybedtypeforNHSprovidersinSussex(2016/17)Percent
Bedtype No.of beds
Rehabilitation 77 (SPFT)12(SaBP)
Dementiaandcognitiveimpairment
67
Functional-olderpeople
82
Acute-working ages 196
PICU 22
EastSurreyuses14bedsatLangleyGreenlocatedinSussex(Crawley)
Thereare45bedsacrossSPFTwhicharenotfitforpurpose:• RutlandGardens’inHovea10bedrehabilitationunit• StRaphaelWardinHastingsandRotherisinadequatelysizedandconfigured,itis isa15bedacuteworkingageward• Beechwood,a20beddementiaandcognitiveimpairmentwardatUckfield hospitalbedswillbereprovisioned attheSt
Anne’sCentreinHastingssubjecttoinvestmentapproval
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1
33
118
58
10 4
1
4
3 8
ASD Complex/Refractory Neuropsychiatry PD
OutsideofSPFTblockcontract
SPFTdoesnotprovidethisservice
Otherreason
SussexCCGsspent£9monspecialistplacementsin2016/17andsecondarycarecapacityandcapabilitywouldberequiredlocallytoavoidthese
Source:Provider/CCGdatareturn
Reasonsforoutofareaspecialistplacements(SPFT)Numberofplacements,2016/17
Costofoutofareaspecialistplacements£m,2016/17
SPFToutofblock
SPFTdoesnotprovidethis
servie
Otherreason EastSurrey
£9.0m£1.7m £1.0m
Note:otherreasonincludes,specialistservicerequired,ASC/CHCfundingrefused.DataincludedallplacementsthatSPFTmanage thatarenotNHSfunded;EastSurreyhasspecialistplacementsincludedintheirblockcontract
£0.8m
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AgencyspendatSPFTandSaBPasaproportionofthewagebillhasincreasedsince2012/13
Source:MentalhealthtrustannualreportsforSPFTandSaBP,SPFTproviderreturns
Agencyspendasapercentageoftotalwagebill(Percent)
1.6%
4.4% 4.4% 5.2%
6.5% 8.2% 8.9%
12.5% 12.1%
9.7%
2012/13 2013/14 2014/15 2015/16 2016/17
SPFT
SaBP
Spendonagency(£m)8.9 9.7 13.7 10.52.6 7.9 8.1 13.6 12.910.7
• Asthefiveyearforwardviewformentalhealthisimplemented,serviceareasthatarenovelorexcitingforstafftoworkinwillincrease
• Thiscreatesariskthatstaffshortagesintraditionalserviceareaswillincreaseasstaffmoveintonewservices
• SussexandEastSurreyneedstoensurethatworkforceplanningmitigatesagainstthisoutcome
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Themajorityofthebankandagencyworkforceishospitalnursingstaff,whereapproximatelyonethirdofpostsarevacant
8.4%
15.1%
32.7%
16.8%
5.7%
13.3%
5.2%
2.4%
33.8%
20.3%
1.3%
0.4%
Consultants
Othermedicalstaff
Nursing:Hospital
Nursing:Community
Psychology&Psychotherapy
AHPsSaBP
SPFT
VacancyratePercentage,2016/17
Source:Providerdatareturn,2016/17CarnallFarraranalysisNote:Hospitalnursingincludesoutpatient,daycare,inpatients,othermedicalstaffnotenteredforSPFTasWTEnotenteredforsecondedoragencystaff
AgencyandbankusebystafftypeWTEMarch17
8.4
0.0
217.2
80.7
4.0
5.2
6.8
4.0
36.3
19.9
0.0
0.0
Consultants
Othermedicalstaff
Nursing:Hospital
Nursing:Community
Psychology&Psychotherapy
AHPsSaBP
SPFT
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7676
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Althoughtherearefundstodevelopnewservices,thesupplyofprofessionalsisstillconstrained
6%
13%
14%
12%
Transformationareas
Coreacute
Corecommunity
Overall
Medical staff%vacancies,2016
10%
12%
12%
11%
12%
6%
7%
8%
Nursing&midwiferystaff%vacancies,2016
AHP&technical staff%vacancies,2016
Source:Steppingforwardto2020/21:ThementalhealthworkforceplanforEnglandJuly2017- HealthEducationEngland
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7777
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21%
21%
21%
37%
Howwellarecarerssupported?
SOURCE:CarnallFarraranalysis
38%
24%
22%
12%
3%
NotsupportedatallInadequatelysupportedNeithersupportednorunsupportedAdequatelysupportedVerywellsupported
Howcouldcarersbebettersupported?
• Timelyaccesstoservices:especiallyduringoutofhoursandwhencrisiscareisrequired
• Morepeersupport:recognisecarers’valueandexperienceandofferopportunitiesforthemtosharetheirexperienceandsupporteachother
• Betterunderstandingandcommunication:listentocarersabouttheirconcernsandexperienceandinvolvethemincareplanning
• Improvetransparencyofinformation:tohelpcarerstonavigatethesystemandgetinformationandadvicewhenrequired
• Provisionofrespitecare: toallowcarerstotakebreak
• Improveconsistency:both intypesofservicesandqualityofcare
Carersareanimportantpartoftheinformalworkforcebutover60%donotfeelsupportedbystatutoryorganisations
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7878
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Thereisasignificantrelationshipbetweenemploymentandmentalhealthand84%ofcontactsinsecondarycarehavenorecordedemploymentstatus
SOURCE:Mentalhealthandwork,RoyalCollegeofPsychiatrist2008,Providerdatareturns2017,NHSDigital2017,CarnallFarrar analysis
1710
96
55
43
HWLHEHS
EastSurreyH&R
CrawleyCWSHMSB&H
ProportionofpeopleonCareProgrammeApproachaged18-69recordedasinemploymentinSussexandEastSurreyPercent
ProportionofpeopleincontactwithsecondarymentalhealthservicesinemploymentPercent
’Workgivestheworkerasocialidentityandstatus;socialcontactsandsupport;ameansofstructuringandoccupyingtime;activityandinvolvement;andasenseofpersonalachievement’(Warr,1987).
‘Thesocialexclusionthatserviceusersexperienceasaresultofmentalillhealthisreducedbyworkandaggravatedbyunemployment’(SocialExclusionUnit,2004).
‘…thatasmanyas90%ofworklesspeoplewhousementalhealthserviceswishtowork’(Grove,1999;Seckeretal.,2001).
84%
UnknownRetiredUnemployedEmployedStudentOther
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7979
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SOURCE:Quantitativeresearchwith3,509Englishadults,Shelter2017,Providerdatareturns2017,NHSDigital2017,CarnallFarraranalysis
1in5Englishadults(21%)saidahousingissuehadnegativelyimpactedupontheirmentalhealthinthelast5years
Housingaffordabilitywasthemostfrequentlyreferencedissuebythosewhosawhousingpressureshavinghadanegativeimpactupontheirmentalhealth
3in10ofthosewhohavehadahousingproblemorworryinthelastfiveyears,notonlysaidthatithadhadanegativementalimpact,butthattheyhadnoissuewiththeirmentalhealthpreviously
ProportionofpeopleonCareProgrammeApproachrecordedasinsettledaccommodation inSussexandEastSurreyPercent
ProportionofpeopleincontactwithsecondarymentalhealthservicesinstableaccommodationPercent
74%
UnknownCareHomeTemporaryAccommodationMainstreamHousingSupportedAccommodationShelteredHousingHomelessOther
7941
2523
1716
119
EastSurreyHWLH
CrawleyEHSH&RHMSB&HCWS
Housingpressureisanimportantfactorcontributingtomentalhealthissuesandnotwellmonitoredas74%ofsecondarycarecontactshaveanunknownstatus
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8080
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Contents
Depressionandanxiety
Dementiaandcognitiveimpairment
Youthservices
Psychosis
Resourcesandenablers
Nextsteps
Nationalandlocalcontext
Physicalandmentalhealthintegration
Crisis
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SOURCE:TheCareAct2014
TotransformthedeliveryofmentalhealthcareforthewholeofSussexandEastSurrey,oursolutionsneedtoreachacrosstraditionalhealthandsocialcareboundariesandrecognisetheimportanceoftheCareAct,aswellascontributionsandchallengesfacedinthesocialcaresystem.
ChallengesandprincipleshighlightedintheCareActthatweneedtoaddressformentalhealthinclude:
• Pressuresonadultsocialcare/localauthorityfunding
• Capacityandqualityissuesinthesocialcareprovidermarket
• Thesocialimpactofdementiaoncarers,familiesandcommunitieswillgrowmorewiththedemographicpressuresandwillrequiretargetedinvestmenttomanage
• TherewillneedtobeaHousingstrategyformentalhealthserviceusersatbothSTPandCountyCouncillevel
• TherewillneedtobeadementiastrategyatbothSTPandCountyCouncillevel
• Personalisation/choiceandcontrol/greaterresilienceisasignificantculturalshiftawayfromtheprofessionalexpertmodel
• SafeguardingcitizensandpatientsthroughtheCareActisacoreprincipleofthiscaseforchange
• OurentirehealthandcaresystemneedstodevelopaclearandconsistentunderstandingofstatutoryrolesandresponsibilitiesinrespectoftheCareAct.
TheCareActprovidesastrongcasefortransformationofwholecaresystemsandwillbeusedtoinformourmentalhealthstrategicframework
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• 75%ofpeopleareabletoaccesstreatmentwithin6weeks,95%within18weeks;andatleast50%achieverecoveryacrosstheadultagegroup
• 25%ofpeoplewithcommonmentalhealthconditionsareabletoaccesspsychologicaltherapies
• Atleast60%ofpeoplewithfirstepisodepsychosisstartingtreatmentwithaNICE-recommendedpackageofcarewithaspecialistearlyinterventioninpsychosis(EIP)servicewithin2weeksofreferral
• Adoublinginaccesstoindividualplacementandsupport(IPS),enablingSMIpatientstofindandretainemployment
• Accesstoliaisonanddiversionservicesreached100%ofthepopulation;closealignmentwithpolicecustodyhealthcareservices.
• Outofareaplacementswillbeeliminatedforacutementalhealthcare
• Savings fromdecreasedoverallbedusagewillbereinvestedincommunity-basedcare
• ArmedforceschampionsandaspecificnamedclinicianwithanexpertiseinmilitarytraumainMentalhealthproviders
• Allacutehospitalswillhaveall-agementalhealthliaisonteamsinplace,andatleast50%ofthesewillmeetthe‘Core24’servicestandardasaminimum
• Allareaswillprovidecrisisresolutionandhometreatmentteams(CRHTTs)deliveringa24/7service
• Newmentalhealththerapistswillbeco-locatedinprimarycare
• Morepeoplewithaseverementalillnessreceivingafullannualphysicalhealthcheck
• Reductioninprematuremortalityofpeoplelivingwithseverementalillness(SMI)
• Reducedsuicidalrateby10%supportedbylocalmulti-agencysuicidepreventionplans
SOURCES:Thefiveyearforwardviewformentalhealth,NHSEngland2016
Thefiveyearforwardviewformentalhealthoutlinesseveralimprovementareasthatneedtobemetnationallythatrequirenewwaysofdeliveringservices
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ThiscaseforchangehasdeterminedchallengestomeetforadultandyouthmentalhealthcareinSussexandEastSurrey:
• IncreaseaccesstotherapiesforcommonmentalhealthdisorderswithanofferforpeoplewhoseneedsaretoocomplexforIAPTservices
• Providegreatercommunitysupportforpsychosisandallowthoserequiringsecondarycareinpsychosistoaccessitmoreeasily
• Coordinatehealthandcareorganisationplanningfordementiatoreducedelayedtransfersofcareandprepareforanageingpopulation
• Co-produceayouthserviceofferwithyoungpeople,coveringholisticsupportthatgoesbeyondtraditionalhealthandcaresupport
• ImprovecrisisplanningandcrisisservicecommissioningtoreduceconfusingentrypointsintoservicesandunnecessaryattendancesatA&Edepartments
• Addressphysicalandmentalhealthtogethertomeetholisticcareneedsofthepopulationandreducestigmabetweencurrentcareboundaries
• RebalancespendandcoststodelivermentalhealthservicestohelpreducetheSTPfinancialdeficit
• Createaworkforceplantoreducerelianceontemporarystaffbyattractingandretainingthebesttalent
SOURCES:Thefiveyearforwardviewformentalhealth,NHSEngland2016
Conclusions
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Nextsteps
SOURCE:[includeJSNAs,ONS,providerandCCGdatareturns]
Futureworkwillfocusonthreeareas:developopportunitiesagainstchallengesinthisdocument;produceastrategicframeworkformentalhealthinformedbythoseopportunities;createahighleveldeliveryroadmapthatwillsupportfutureplanningactivities.
1. Developopportunitiestoaddresschallengesinthiscaseforchange
Opportunitiestoimproveadultandyouthmentalhealthserviceswillbediscussedanddevelopedinanumberofforums.TheclinicalandprofessionalworkinggroupwillactasasourceofideasanddrawonexistinggoodpracticefromwithintheSTPandtheneedsofthementalhealth5YFV.Theworkshopon24Julywilldevelopopportunitiesbysegmentsidentifiedinthisreport.Thefinanceandmodellingworkinggroupwilldeterminethefinanceandactivityimpactofeachopportunity.
2. Createthementalhealthstrategicframeworkforadultandyouthservices
Thestrategicframeworkwillincludetheevidencebaseforopportunitiesdeveloped,includingthequalityandfinanceimpact.Whereactivityislikelytobereduced,reinvestmentoptionswillbeproduced.Investmenttodeliverthementalhealth5YFVwillbeestimated.Itwillincludeoptionsforfuturecommissioningandproviderarrangements.
3. Produceahighleveldeliveryroadmap
Futureplanninganddeliverywillbebasedonadeliveryroadmapwithprioritisedopportunities.Thiswillallowsubsequentplanstostartwithopportunitiesthatwillhavethemostimpactonqualityandspend.ItwilltakeaccountoftheNHSE2017/18mentalhealthimplementationplan.