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
NHS | Presentation to [XXXX Company] | [Type Date]23
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
e
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
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