Mental health strategic clinical network meeting :

Yorkshire and Humber SCN

Dr. Geraldine Strathdee, National Clinical director, Mental Health

Today’s discussion • How common is mental ill health• What are we trying to achieve• What are the priorities

• No health without mental health’ national strategy

• NHS Mandate

• Emerging SCN priorities across the country

• Progress update • How can we help and what can we learn from Y&H • We need your leadership, your expertise and your drive!

NHS | Presentation to [XXXX Company] | [Type Date]2

NHS | Presentation to [XXXX Company] | [Type Date]3

How common is mental ill health

How common are mental health conditions

Our children

1 in 5 under the age of 15

Only 25% can access care

50% bullied, leading to: •Depression•Low self- esteem•Suicide

1: 10 have unrecognised dyslexia, dyspraxia

The workforce

1 in 6 adults at any time

1: 10 have depression

Suicide is the greatest cause of male deaths < 35 yrs

Work related stress affects 1.5 million 5.6 million work days lost a year

Senior citizens

Dementia effects•5% over 65’s 10-20% over 80

1 in 6 over 65 suffer from depression

Major factors: •Social isolation •Physical ill- health

30% of >65s in Acute Trust beds have dementia

All communities

Over 300 spoken languages in UK; many cultural beliefs & mental health issues

Over-representation of black people in acute inpatient & forensic care

The prevalence of mental health & impact on outcomes Prevalence ICD conditions Outcome impact Primary care : 30-50% of daily workload

Depression & anxietySubstance misuseChildren's conditions

Premature mortality : 15-25 yearsQuality of life in LTCsRecovery from illness Patient safetyPatient experience

Acute care20%-40% of A/E in 40% acute beds 50% acute LTC outpatient clinics

Alcohol & drugsDepression & self harmDepression Dementia

Premature Mortality Quality of life for LTCsRecovery from illnessPatient safety Patient experience

Prisons & offenders70-80% especially young men

ADHD, ASDDepression Substance misuse PD

Premature Mortality

Specialist mental heath services

Psychosis Neurodevelopmental Substance misuse Personality disordersComplex multi axial

Premature Mortality : 15-25 yearsQuality of life in LTCsRecovery from illness Patient safety Patient experience

Depression : think about the causes & solutions follow.. opportunities for demand management, prevention & early intervention across Value care pathways

Elderly isolated &

people with dementia

Victims of domestic violence

Alcohol and drug addictions

Isolated women with

small children

Victims of school and employment

stress and bullying

Key life cycle: • Divorce

• Retirement• Redundancy• Menopause

Long term physically ill

Dyslexia, DysprexiaADHD, Autism, Asperger’s and

Learning Disabilities

People with schizophrenia and sight and

hearing problems

3. The top 10% of Mental health conditions: service redesign for prevention, earlier identification & better access & treatment for young eople The origins and causes of mental ill health The life span health & social determinants of mental health conditions

Genetic & biochemical

Organic brain & neurodevelopmental

Societal •

‘What could we do?’ ‘What should we do?’ ‘How should we do it?’

Family history Substance

misuse /mental ill health/ chaotic deprivation /

abuse: physical, sexual, emotional

School difficultDyslexia,

Dyspraxia, ADHD, Autistic

spectrum, Bullied

TruantingDrug use &

dealingPetty crime

In Care

Mental illness starts

Regarded as ‘bad’ or ‘strange’

Institutions career Expensive

placements Youth offenders

Acute psychiatric wards

Forensic units

Biochemical ‘causes’Caffeine, nicotine, alcohol, street drugsNeurotransmittersEndocrine disorders

Life span high risk events•Long term physical conditions•Unemployment •Adolescence•Pregnancy•Bereavement•Migration•Gang/ veteran trauma

What Outcomes do our service users ask us to support them achieve

From the patient’s

perspective

Safety “Will I be ok?”

Effectiveness “Will it do me any

good?”

Experience“Access, information & treatment experience”

Efficiency Was it fast, safe , near

home , back to work asap

Least restrictive settings

What Outcomes do our patients ask us to achieve in partnership with them

Professor Bruce Keogh, Medical Director of the NHS

Parity : NHS Mandate: what does it mean in practice From a London GP…………………

GPs are trying to do everything for everyone, too much of 21st Century care is being provided through 19th century organisational models………Professor Michael Porter is a world authority on strategy in business, & has spent the past decade working in healthcare systems in dozens of countries.

• I was struck the other day when I saw a patient -  who has been off work for 3 months waiting for CBT. He is depressed and was just told to go on sick leave-  no medication, just a referral for CBT in the distant future.

• When I saw him , what upset me most was that if he had broken his leg, he would have been treated asap, given rehab, told to go to work on crutches and would not have just been abandoned.

• I want to make it impossible for mental health problems to be treated as second class illnesses - with patients with treatable conditions languishing on waiting lists or worst still with no treatment at all

Clare Gerrada

The economic impact: 2012

Mental health has among the most clinically and cost effective treatments of any sectorbut access is low and a post code lottery

What are the priorities & progress

• No health without mental health’ national strategy• NHS Mandate & Suicide prevention strategy• Emerging SCN priorities across the country

• AHSNs• LETBs• New funding streams

Emerging System priorities ..a system based on value, equalities & shared learning

1. CCG: building capacity and capability in mental health leadership

2. Primary care mental health

3. Care of people with psychosis : ‘industrializing’ improvement

4. The acute care pathway and suicide prevention

5. Integrated physical & mental health care pathways

6. Mental health intelligence informatics network programme• new model of information led commissioning & integrated provision • Whole pathway commissioning of Tiers 1-4

Underpinning Value based commissioning and care• Outcome measurement• Service specifications aligned to PbR and Choice • Reducing burden to free up time to care

CCG GP Mental health leadership programme

Knowledge based leadership for high impact and improving outcomes ….……a new model of leadership

Personal leadership development

Mental health Informatics competency

Expert ‘what good looks like’ immersion week

Commissioning Information and best practice

The national care pathways priorities What do we want to commission with partners

Prevention & health promotion

Early identification &

early intervention

Timely Access to services offering choice, quality outcome focus

Care at home or in the least restrictive settings,

Crisis response that is easy to

access & expert

Parity for people with physical & mental health

Integrated physical & mental health & social care

Where every contact is a kind enabling, coaching experience

Step 1: Information for Commissioning value based care pathwayswe have commissioned unique whole care pathway health & social care information for every CCG

What are the key high risk prevention & top 10% QIPP opportunities

Are standards of services meeting NICE NCB, QOF, COF, CQC, Monitor, Outcomes domains, Operating framework, PbR

What evidence based services are available in this borough

What funding is spent on mental health in primary care, social care and specialist mental health hospital beds & community services

What % age of people with these conditions are GP QOF identified ( and coded)

What are the high risk groups to target for risk stratification and prevention

How common are mental health conditions in this area

In this CCG/ borough, what are the social determinants of mental ill health

Clinical and economic best commissioning tools

Expert clinical reviewers & implementers

CCG MH shared learning & provision network

The evaluation and shared learning indicators

Economic modelling tools to design and reengineer effective models for local needs

Model service specification examples

What are the top 4 service ‘Best buys’

2. Primary mental health care in England internationally: they are using systems thinking around the many roles of GPs

GP

role

s Individual clinician

Primary care multi disciplinary team

Leadership & organization of the practice

GP as community leader & prevention

GP as Commissioner

International learning : Primary care mental health service

organization: a ‘stratification’ approach & federated models e.g. ‘ (Kaeser, Scandanavia, US Vets

Prim

ary

care

ser

vice

or

gani

zatio

n Demand management : reduce employment and school

and community causes

Prevention targeting of High risk groups

Self assessment & self management

Mild Common conditions

Moderate primary care repeat attenders & LTCs

Long term severe mental illness

An example of a federated modelHungary Depression & suicide reduction Training, systems redesign, whole team sustainable approach Szanto et al ( 2007

Training for 28 GPs serving 73,000 people.

5 year Depression-management educational program for GPs

In addition to training individuals, services were reorganised and expertise commissioned to support primary care in a sustainable way.

Practice nurses were also trained

A Depression Treatment Clinic & psychiatrist telephone consultation service was established.

Conclusion: GP-based intervention produced a greater decline in suicide rates cf with the county & national rates..

Key conclusion was that additional service reorganisation such as depression case managers should be tried.

The importance of alcoholism in local suicide was unanticipated and not addressed

Shared whole pathway learning

Oxleas NHS Foundation Trust runs a series of free evening masterclasses on mental health and learning disability issues for primary care professionals.

The aim of the series is to:• Provide GPs with updates on the

current evidence-based treatments for common mental health conditions

• Share information on new assessment tools

• Share best practice care pathways

• Topics have included depression, dementia & child & adolescent mental health issues.

GP Master class series

AHSNs working with SCNs and LETbs

• 2. 5 hour Masterclass for practice nurses • Masterclass developed by a practice nurse mental health

expert with RMNs• Train the trainer model : 1 specialist MH nurse trainer per

CCG • 2.5 hour master classes in each `CCG area for 20 PNs• 800/1400 London practice nurses trained in 6 months • New modules in depression, suicide prevention, planned

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UCLP practice nurse master classes

Emergency DepartmentMental health liaison team( dementia, alcohol, psychosis, self

harm all ages )

Single Crisis number coordinating tele triage, tele

health + 24/7 community Home treatment team &

community alcohol detox,

Admissions to Acute Care in acute mental

health beds

Primary Care& self- care

Intermediate tier

Acute and unplanned care emerging thinking

£

£

£

£

£

£

5. Integrated physical and mental health care Long term conditions Mental health raises costs in all sectorsChris Naylor, Kings fund

• Overall, international research finds that co-morbid MH problems are associated with a 45-75% increase in service costs per patient(after controlling for severity of physical illness)

• Between 12% and 18% of all expenditure on long-term conditions is linked to poor mental health and wellbeing – at least £1 in every £8 spent on long-term conditions.

Heart F

ailure

Stroke

Heart d

iseas

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Diabete

s

Hypert

ensio

n

Arthriti

sCOPD

Cance

r

Asthma

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

DepressionAnxiety

% in

crea

se in

ann

ual p

er p

atie

nt c

osts

(e

xclu

ding

cos

ts o

f MH

car

e)

Co-morbidity is the norm

Lancet, Barnett, Mercer et al 2012

2012 publication Compendium of examples of cost effective programmes for people with physical illnesses in acute trust, primary care settings

The Ian Galton challenge: an integrated dementia, MH and neurological plans

Dementia MH Neurology

Our integrated support processes:The MH intelligence network will include dementia & neurology CCG commissioning & quality improvements

x x x

The SCN website: sharing intelligence & updates x x xMandate : we are working on it as part of a shared governance agenda & the delivery of ICD dementia diagnosis and improved care and IAPT and liaison crisis services

x x

Particular service models and clinical pathways we are working on in an integrated wayThe acute and unplanned care programme : inputs to ensure care for people with dementia, self harm, relapsing psychosis & alcohol related d neurological and dementia conditions e.g. Korsakoffs and Wernicke

x x x

Integrated care pathways for alcohol and young onset dementia & cognitive impairment x x xDementia DES

integrated care pathways for delirium and dementia better diagnosis and assessments?

Pt safety: supporting NHS E to implement patient safety for falls and medicines optimisation x x xIntegrated physical and Mh care factsheet series between NCDs and MH field experts x xMedically unexplained symptoms common pathway : would love to support neurological MUS & IAPT x xSpecialist commissioning group in brain injury are including MH assessment x x xICD coding in HES and MHMDS: drive up quality in recording diagnosis and better more rapid discharge summaries? x x xOthers: PQ what we are doing re ASD and Asbergers services x x

Many of the outcomes we achieve for people with schizophrenia and psychosis are unacceptable

www.rethink.org

• Excess mortality – people dying 15-20 years earlier.

• Poor social outcomes – only 8% in employment.

• Overrepresentation of people with schizophrenia/psychosis in prison or amongst homeless population.

• Very high levels of stigma and misunderstanding.

• Cost to society of £11.8 billion.

Value based Integrated care pathways design: commissioning for 60% volume, 60% spend; top 10%

Depression: is the most common MH condition in PC, acute, MHT, addictions, adolescents , veterans

• 30-50% of the daily work of GPs is MH related, especially depression• Post graduate training for GPs, PNs, HVs, PC has been less available and tailored to PC mental health• 78% of people who commit suicides have seen their GP in the month before the suicide• Long term conditions: 70-80% of all healthcare & depression is the common comorbidity in 25-40%• Untreated depression in COPD, CHD, cancer, stroke, diabetes, means patients die early & cost more• 60-90% of those who misuse alcohol and drugs have depression• Children and young people can be helped to develop resilience against depression• Transport hub suicides are high in London and can be prevented• RCGP & AHSCs are keen to develop new population & pathway based approaches to depression in all

sectors

The young people with psychosis & complex needs in high cost top 10% tier• 95% patients are treated in the community, but 60% spend is on beds • The Top 10% patients who account for 50-60% spend are not well recognized,

helped by caseload zoning and risk stratification• Our detention rates are rising year on year despite CTOs• 70-80% of those in MSUs and LSUs are young black men with long LOS• Substance misuse is a very common comorbidity which triggers 60% high risk events e.g.

suicide , homicide, partner impact, but the commissioning & provision are not understood

3. The care of people with psychosis • In 2012, the National schizophrenia Commission & National Audit of Schizophrenia found: • examples of good practice • Wide variation in standard• National data shows changes away from demonstrated models of evidence based care • The need to ‘industrialise improvement in 5 core areas of care:• Physical health • Safe optimised medicines• Psychological therapy• Inpatient care• Care plans that are personalized, empoweringg

Key partners & network members to build synergies ( not inclusive)

Patients and families AHSC + LETbs LAs, Social care

PHECare pathway

partners ,police, ambulance, British Transport system

3rd sector policy and provision leaders

CCG & Commissioning leaders

RCGPs, RCN, RCPsych , etc

Information transparency programme

2012 publication Compendium of examples of cost effective programmes for people with physical illnesses in acute trust, primary care settings

Prevention and Early intervention (Knapp et al, 2011)highly effective treatments: major economic benefit

For every one pound spent the savings are: Parenting interventions for families with conduct disorder : £8

Early diagnosis and treatment of depression at work: £5 in year 1

Early intervention of psychosis £18 in year 1

Screening & brief interventions in primary care for alcohol misuse £12 Yr 1

Employment support for those recovering from mental illness: Individual Placement Support for people with severe mental illness results in annual savings of £6,000 per client (Burns et al, 2009)

Housing support services for men with enduring mental illness: annual savings: £11,000–£20,000 per client (CSED, 2010).

Proportion in UK with mental disorder receiving any intervention (Green et al, 2005; McManus et al, 2009)

• 28% of parents of children with conduct disorder

• 24% of adults with common mental disorder

• 28% of adults screening positive for PTSD

• 81% of adults with probable psychosis received some form of treatment compared to 85% in 2000.

• 65% of adults with ‘psychotic disorder’ in past year

• 14% of adults dependent on alcohol

• 14% of adults dependent on cannabis only

• 36% of adults dependent on other drugs

• Less than 10% of older people with depression receive adequate treatment

The prevalence of mental health & impact on outcomes Prevalence ICD conditions Outcome impact Primary care : 30-50% of daily workload

Depression & anxietySubstance misuseChildren's conditions

Premature mortality : 15-25 yearsQuality of life in LTCsRecovery from illness Patient safetyPatient experience

Acute care20%-40% of A/E in 40% acute beds 50% acute LTC outpatient clinics

Alcohol & drugsDepression & self harmDepression Dementia

Premature Mortality Quality of life for LTCsRecovery from illnessPatient safety Patient experience

Prisons & offenders70-80% especially young men

ADHD, ASDDepression Substance misuse PD

Premature Mortality

Specialist mental heath services

Psychosis Neurodevelopmental Substance misuse Personality disordersComplex multi axial

Premature Mortality : 15-25 yearsQuality of life in LTCsRecovery from illness Patient safety Patient experience

The route map to delivering the MH strategy