New approaches to implementing mental health programs in

primary care

Professor Helen LesterProfessor Helen Lester

Academy Health, Orlando, June 2007Academy Health, Orlando, June 2007

What I’m going to talk about

Background to UK Mental Health issues Two stories of programme implementation

1. Stepped care models for depression and Access to Psychological Therapies (IAPT) schemes

2. Health checks in primary care for people with serious mental illness

NHS budget for 2006–07 is $190 billion 1.33 million employees Services are free at the point delivery Primary care has a gate keeping role

Primary care policy context

Primary care has been viewed as increasingly important in mental health policy terms since 1999

NSF (1999) and 5 year review (2004) National Plan (2000) Tackling Health Inequalities (2003/6)

Primary care 3.75 million

Self care 1-2 million

Shared care 300,000

Specialist services600,000

Treatment of depression: the problem

Prevalence of 2.1-9.8% (NICE, 2004) 40% of people have a chronic relapsing illness

(Lloyd, 1996) 5,000 deaths p.a. Economic costs particularly in terms of

unemployment and state benefits

Incapacity Benefit recipients by medical condition in the UK (2004)

Nervous system10%

Mental disorder38%

Others17%

Injury6%

CVD and RD9%

Musculo-skeletal20%

The evidence base: NICE guidance on depression (2004)

Uses a stepped care framework

Recognises that depression can be a chronic illness and therefore borrows from chronic disease management models of physical health problems (Wagner, 2004)

Over view of the stepped care system

Step 1: GP, practice nurse

Step 2: Primary care team, primary care

mental health worker

Step 4: Mental health specialists

including crisis team

Step 5: Inpatient care, crisis team

Step 3: Primary care team, primary care

mental health worker

Recognition

Mild depression

Treatment-resistant, recurrent, atypical and

psychotic depression, and those at significant risk

Risk to life, severe self-neglect

Moderate or severe depression

Assessment

Watchful waiting, guided self-help, computerised

CBT, exercise, brief psychological interventions

Medication, complex psychological

interventions, Case management and collaborative care

Medication, combined

treatments, ECT

Medication, psychological interventions, Case management and collaborative care

The implementation gap?

The NICE guidance has few ‘teeth’ in terms of implementation

Lack of therapists so 6-9m waiting lists for people from step 2 onwards…

Recent implementation levers

Bad publicity

- ‘NHS failing to act on talking therapies clinical guidance, says new report’

- ‘Depression: the great happiness pill betrayal’

Pledge to IAPT as part of the 2005 Labour election manifesto

The vision: Lord Layard and the LSE’s ‘New Deal’

High profile media coverage 10,000 more therapists by 2013 Cost of $120 million Working in teams in 250 centres Centrally funded and commissioned Providing 16 weekly sessions lasting 1 hour ‘Should more than pay for itself’ Focused on return to work issues

The practical strategy: IAPT programme 2 very different demonstration sites Some new monies but mainly service

reconfiguration Cooperation between sectors Mental health champions Doncaster is using a high volume low intensity

model with case managers as part of a stepped care framework

Newham is using specialist CBT providers 10 new sites this Summer recognising the

advent of different funding mechanisms for commissioning within the NHS

Early findings

Doncaster: Need: 2,000 people referred in 5m Referral pathways: 95% from GPs Workload: Mean number of sessions = 3 (2-

11) Stepped care model: 10% of people stepped

up to CBT Outcomes: access (including waiting times)

and inclusion (including employment) Waiting times: 1 week

Serious mental illness in primary care: the problem

Lifetime prevalence of 3.48% (Perala et al, 2007)

Often starts at a young age so a lifetime of consequences

Societal exclusion including 4% employment rates

Higher morbidity and standardised mortality rates (151) than the general population (Social Exclusion Unit, 2004)

Serious mental illness in primary care: the evidence base

Variable/poor health promotion and health prevention in primary care (Brown 1997; DRC 2005)

SMR of 156 (Harris and Barraclough, 1998) GPs’ view that the work is too specialised Patients’ view that primary care is the

cornerstone of care (Lester et al, 2005)

Implementation gap

NICE guidance (2002/7) includes roles for primary care but has few teeth

Educational gaps (only 2% of practice nurses and 30% of GPs have postgraduate mental health experience)

Primary care practitioners can be as narrow minded as the rest of the world

Implementation levers

Networked grass roots support for change led by local and national mental health champions

Financial incentives in primary care through the Quality and Outcomes Framework (2004)

The vision: Quality and Outcomes Framework

25% of GPs’ income relates to a set of evidence based quality indicators that apply to primary care

Chronic disease management (18 areas- 4% of the overall points/money focused on SMI)

Practice organisation (5 areas) Additional services (4 areas) Patient experience (consultation length and

patient surveys)

The practical strategy: reorganisation of care for people with SMI

Register of patents with a psychosis Lithium levels monitored and therapeutic Annual relevant physical health check up and

medication review Liaison with secondary care e.g.- Follow up if the patient doesn’t attend- Care plan to include social networks, early

warning signs and crisis plans

Early findings: points achievement in 2005/6

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

CHDLV

D

CVA/TIA BP

Diabe

tes

COPD

Epilep

sy

Hypot

hyro

id

Cancer

SMI

Asthm

a

Generalisable lessons Alignment of an agreed problem + evidence

base + policy levers + a clear vision + practical strategy

Variable amounts of new monies

Reconfiguration and co-operation e.g. across the interface has occurred with some new but mainly existing staff rather than whole new systems

“Although vision is important for initiating change, it is not enough to organise and maintain a system of care. Vision must be translated into practical strategies.”

(Alan Rosen,The mental health matrix.1999)