National Perspective - Parity of
Esteem – valuing mental and physical
health equally
Joanna Powell
1 April 12014
A few of our drivers
2
NHS | Presentation to North Region |1 April 2014
• The Secretary of State must continue the promotion in England of a
comprehensive health service designed to secure improvement –
Health and (a) in the physical and mental health of the people of England, and
Social Care (b) in the prevention, diagnosis and treatment of physical and mental illness.
Act 2012
• By March 2015, we expect measurable progress towards achieving true parity
of esteem, where everyone who needs it has timely access to evidence-based
services
•NHS England’s objective is to put mental health on a par with physical health,
and close the health gap between people with mental health problems and the
NHS
Mandate population as a whole
•Every community to have plans to ensure no one in crisis will be turned away,
based on the principles set in the MH Crisis Concordat
Putting
People
First
3
• Parity Included in Priority 8 on the NHS England Balanced Score Care
• Deliverable 11 against key deliverable: Put mental health on a par with
physical health, and close the gap between people with mental health
problems and the population as a whole. Extend and ensure more open
access to IAPT by March 2015, particularly for children and young people, and
for those out of work
NHS | Presentation to North Region |1 April 2014
The Vision
What Parity will mean to me:
The patient
“Person
centred,
coordinated
care”
My family and I all have access to
services which enable us to maintain
both our mental and physical wellbeing.
If I become unwell I use services which
assess and treat mental health disorders
or conditions on a par with physical
health illnesses.
NHS | Presentation to North Region |1 April 2014
What is often like now for me?
My mental health is not
assessed at GP
registration & in annual
Health checks
Only 33% of GPs & 1%
of practice nurses are
trained to assess and
make an mental health
diagnosis
I can access treatment
if I am one of the lucky
15% & I wait 2 years if
I have psychosis
I have a 1: 10 chance
only of getting NICE
evidence based
psychological
therapies so my life
outcomes are poor
I am seldom offered
psychological
therapies if I come
from a BAME
community or am older
I have a 25% chance
of being prescribed
medicines at too high a
dose
Only 7% of people
with mental illness gain
employment due to
stigma & ineffective
treatments
I am likely to die 10-20
years early as my
physical health needs
are not assessed or
treated
When I am in a mental
health crisis I do not
know what number to
ring, so I can end up in
a police cell
I am not helped to self
manage & I am treated
with contempt and
stigma
NHS | Presentation to North Region |1 April 2014
When I go to A/E only
40% of staff know how
to assess my needs.
so I come back often
and suicidal
If I am from a BAME
community I am much
more likely to be
forcibly detained under
the Mental Health Act
The NHS England vision of parity
My mental health, as
well as my physical
health are assessed at
GP registration & in
annual Health checks
My GP and practice
nurse are trained to
make an early diagnosis
I can access treatment
within weeks & not
years, or never, as
happens now
I receive NICE evidence
based psychological
therapies as a routine,
not just a 1: 10 chance
of getting it
I am offered
psychological therapies
even if I come from a
BAME community or am
older
I am prescribed
medicines safely and
helped to take them well
I have a care plan that
includes effective
interventions to recover
& get employment
When I am in a mental
health crisis I dial one
number, and get taken to
a healthcare assessment
Centre
When I go to A/E I am
assessed by staff trained
in MH awareness &
assessment in line with
NICE
My family are well
supported in caring for
me
I an supported to self
manage and continue to
be part of my community
and contribute to it
Every experience is a
kind, compassionate,
educating, skilled
encounter
NHS | Presentation to North Region |1 April 2014
Parity of Esteem Programme
• Facilitate NHS England to work to reduce the disparity which
currently exists in health outcomes for those with mild,
moderate or severe mental health illness
• Support integration and personalisation by promotion of
whole person care which values everyone’s mental and
physical health needs equally
NHS | Presentation to North Region |1 April 2014
PoE Programme - key messages
Cultural change is at the heart of the POE Programme
Strategic aim – for POE to be everyone’s business
• It cuts across all NHS OF Domains
• It is closely aligned to other major transformational programmes
– e.g. integration, person centred care planning and
personalisation
• It does however also have to focus on reducing the many
disparities which exist between Mental and physical health
How will the programme be delivered?
• Specific improvement / change projects
• Business as usual to support POE generally*
• Ensure alignment with other organisations and groups
NHS | Presentation to North Region |1 April 2014
PoE Programme
•
•
•
•
•
Current top priorities
Data, Information and Intelligence
Development of capability and skills in commissioning –
including need to focus on cultural change / behaviour of
commissioners change
Delivering improvements to clinical services (including
IAPT and increasing timely diagnosis and post diagnostic
care for dementia)
Addressing and improving crisis Care
Improving physical health for people with serious mental
illnesses
Discrete improvement project – Business as
Collaboration with system partners
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NHS | Presentation to North Region |1 April 2014
usual –
An emerging common narrative
1. What’s the issue?
2. Where are we now?
3. Where do we want to be?
4. How do we get there?
Increasing
and more
complex
care needs
Poor
outcomes
for people
with mental
illness
Person
centred,
coordinated
care
‘House of
Care’ model
Our mandate from the government requires us to close the
gap between mental and physical health services – to
achieve parity
NHS | Presentation to North Region |1 April 2014
Mental illnesses are very common
1.2m people in England
have a learning disability
There will be over a million
people with dementia by
2021
In any one year 1 in 4 British
adults experience at least
one mental disorder
10% of 5-16 year olds have a
mental disorder
5.4% of men and 3.4% of
women have a personality
disorder
Among people under 65,
nearly half of all ill health is
mental illness
Between 8% and 12% of the
population experience
depression in any year
Among people under 65, nearly half
of all ill health is mental illness
% of morbidity in the UK: Physical v Mental illness1
Rates of morbidity in each age group
(Equivalent life-years lost per 100 people)2
e.g. mainly
depression, anxiety
disorders, and child
disorders
e.g. heart disease,
cancer, diabetes
Morbidity from physical illness
rises steadily throughout life,
whereas mental illness
especially affects people
aged 15-44
NHS | Presentation to North Region |1 April 2014
Source: 1&2: Based on WHO, 2008. Further calculations by Mike Parsonage . see: LSE (2012) how mental illness loses out in the NHS
Yet, only a quarter of all those with mental
illness such as depression are in treatment
% of population
with condition
% of people
with condition
in treatment
Adults
Schizophrenia or bipolar
disorder
1%
80%
Depression
8%
25%
Anxiety disorders
8%
25%
Conduct disorder or ADHD
6%
28%
Depression & / or anxiety
disorders
4%
24%
Autistic Spectrum Disorder
1%
43%
Children (5-16)
How does this compare to treatment levels for those with long term physical health problems?
(in comparable western countries: 94% diabetes, 91% hypertension, 78% heart disease)
NHS | Presentation to North Region |1 April 2014
People with poor physical health are at higher
risk of experiencing mental health problems…
% of people
affected by
depression
People who experience
persistent pain are four
times as likely to have an
anxiety or depressive order
as the general population
NHS | Presentation to North Region |1 April 2014
Mental health problems impose a total
economic and social cost of over £105bn a
year
•
£14bn is already spent on mental health services
•
Nearly a third of people with long term physical conditions have at least
one co-morbid mental health problem. This can exacerbate the person’s
physical condition and increase the cost of treatment by between 45%
and 75% at a cost to the NHS of an estimated £10bn per year
•
Medically unexplained symptoms cost the NHS some £3bn per year
•
Mental illness has a significant impact on public finances: estimated that
the costs of depression through lost working days are 23 times higher
than the costs to the health service
•
1 in 4 unemployed people has a common mental health problem
•
Childhood mental health problems can have a significant economic
effect on society. It is estimated that a child with a conduct disorder will,
by the age of 28, have generated costs (such as to the health,
education, benefits and criminal justice systems) ten times as high as a
child without conduct problems
NHS | Presentation to North Region |1 April 2014
…and new service models emerge with
huge potential to improve outcomes
Examples:
Common
mental health
disorders
Mental illness
• Improving Access to Psychological Therapies (IAPT) programme had major impact
in it’s first 3 years:
•
treating more than 1 million people in IAPT services
•
more than 680,000 people completing a course of treatment
•
recovery rates consistently in excess of 45%
• Personalised Health Budgets: the national pilot programme indicated that personal
health budgets “had a significant positive impact on care-related quality of life,
psychological wellbeing and subjective wellbeing” of the people taking part. People
with mental health problems reported improvements in their physical health, and
people with physical health problems likewise reported better mental health
New service models that put
patients in control
Severe mental
illness
• Suicide prevention strategy : Findings from three mental health promotion pilot
projects to address the raised suicide risk in young men show that:
• multi-agency partnership is key to promoting young men’s mental health;
• community locations, such as job centres and young people-friendly venues,
are more successful in engaging with young men than more formal health
settings such as GP surgeries;
• front-line staff feel better able to engage with young men if they receive training;
• community outreach programmes are seen by young men as more acceptable
and approachable than services provided in formal healthcare settings.
NHS | Presentation to North Region |1 April 2014
The current design of our health system
doesn’t ensure ‘whole-care’ packages
Most people with Serious Mental
illness don’t receive physical health
checks
There are significant delays in
diagnostic treatment for people
with learning disabilities
NHS | Presentation to North Region |1 April 2014
We run a national programme of
health checks within school, but we
only check physical health
National audit of schizophrenia –
only 29% of service users getting
proper metabolic monitoring
The House of Care - The House supports
National Voices ‘I’ statements
My goals/outcomes
e.g.
•
Communication e.g.
•
All my needs as a person were
assessed and taken into
account.
Information e.g.
Emergencies e.g.
•
•
I had systems in place
so that I could get help
at an early stage to
avoid a crisis.
Transitions e.g.
When I went to a new
service, they knew who I
was, and about my own
views, preferences and
circumstances.
I could see my health and
care records at any time to
check what was going on
Decision-making e.g.
•
•
I always knew who was the
main person in charge of my
care.
Care planning e.g.
•
I had regular reviews of my
care and treatment, and of
my care plan.
I was as involved in
discussions and decisions
about my care and
treatment as I wanted to be.
Planning Guidance 2014/15 -18/19
Headlines
• Outcomes drive everything we do
• Significant financial challenge: no change is not an
option
• 2014/15 – transformation year in preparation for 2015/16
(Better Care Fund)
What’s new?
• Support available to support commissioners
• Operational (2 years) strategic (5 years) plans
• Integration / collaborative working a key feature
• Monitor / NHS TDA (providers and commissioners)
• Local authorities (Better Care funding)
• Unit of planning to support Health and Social Care planning
NHS | Presentation to North Region |1 April 2014
The 6 Characteristics of
sustainable services (emerging from Call
to Action)
• Citizens included in all aspects of service design and
change and patients fully empowered in their own care
• Expanded primary care
• A modern model of integrated care
• Access to the highest quality urgent and emergency care
• A step-change in the productivity of elective care
• Specialised services concentrated in centres of
excellence.
NHS | Presentation to North Region |1 April 2014
Planning Guidance 2014/15 18/19
Level
Summary
Relevance to POE
Ambition for
NHS
• 7 measureable
ambitions
• 6 service
characteristics AND
• 3 key measures
QOL / LTC ambition - IAPT and dementia
referenced Trajectory for Dementia diagnosis
and Trajectory for IAPT coverage and recovery
POE expected to be reflected in CCG plans for
delivery of 6 characteristics AND is a key
measureable
Steps CCGs
are expected
to undertake
in order to
deliver these
ambitions
Local ambitions linked
to the 7 measureable
ambitions
Planning fundamentals
National conditions
Integration /holistic
care
POE is a planning fundamental
Acute Care -Plans not to have a negative impact
on the level and quality of mental health services.
Integration / holistic care - Dementia services
particularly important
Assurance process – POE to be included see
above
Underpinned by CQUINS for Dementia and Mental Health - DES for dementia and
learning disability - Quality Premium for IAPT Standard contract sanctions– MH
MDS focus Informed by baseline data provided in State of the Nation Report
NHS OF – IAPT indicator
NHS | Presentation to North Region |1 April 2014
High quality care for all, now
and for future generations
• High Quality – ‘Driven by quality in all we do – our patients
rightly expect the best possible service’
• For all – ‘…whether need is for mental or physical help
and support. We must put the greatest effort in providing
care for the most vulnerable and excluded in society’
• For now – ‘Need to get better at sharing good practice
rapidly across the NHS’
• For future generations – ‘Strategic plans developed in
partnership working between commissioners, providers
and local government to deliver models of care that will be
sustainable in the longer term’
NHS | Presentation to North Region |1 April 2014
Previous events - objectives
South (January)
Midlands and East (February)
Understand the National priorities SCNs, Regional and Area Teams to work
together to support ongoing CCG engagement
Foster good working relationships Secure regional and local focus and leadership
within SCN communities
for IAPT, Dementia and the MCA
SCNs to identify work priorities
Better equip local teams to offer targeted
support to those localities or commissioners
who have significant distance to travel in the
delivery of the above priority work streams
Identify and share good practice
Share and disseminate learning
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NHS | Presentation to North Region |1 April 2014
Outcomes from the South
event
24 NHS | Presentation to [XXXX Company] | [Type Date]
NHS | Presentation to North Region |1 April 2014
In summary
• The NHS Mandate clearly sets out priorities for the system
• We all need to collaborate in order to deliver the mandate
• NHS England National Support is there to support you
and your local CCGs to deliver the NHS mandate
• What do you and your local CCGs need us to do to help
you to deliver the mandate?
NHS | Presentation to North Region |1 April 2014
Thank you
Joanna Powell, Domain Team Lead
Jo.powell2@nhs.net
Mental Health CQUIN
Improving physical healthcare to reduce premature mortality in people with
severe mental illness (SMI)
Indicator 1: 65 per cent of funding
for demonstrating, through a
national audit process, full
implementation of appropriate
processes for assessing,
documenting and acting on cardio
metabolic risk factors in patients
with psychoses, including
schizophrenia.
Indicator 2: 35 per cent of funding
for completion of a programme of
local audit of communication with
patients’ GPs, focusing on patients
on the Care Programme Approach
(CPA), demonstrating by Quarter 4
that, for 90 per cent of patients, an
up-to-date care plan has been
shared with the GP
The CQUIN guidance for 2014/15 was reissued in February on NHS England
website
NHS | Presentation to North Region |1 April 2014
Mental Health CQUIN
The following cardio metabolic parameters are assessed and
actively managed;
•
•
•
•
•
Smoking status
Lifestyle (incl. exercise, diet, alcohol and drugs)
Body Mass Index
Blood pressure
Glucose regulation (HbA1c or fasting glucose or random
glucose as appropriate)
• Blood lipids
NHS | Presentation to North Region |1 April 2014
NHS England Parity of Esteem
Work-packages
Discrete improvement project – Business as usual –
Collaboration with system partners
NHS | Presentation to North Region |1 April 2014
Data, Information and Intelligence
Product
National Mental Health
Intelligence Network
Parity of Esteem Dashboard
Improving the quality of MH data
in the national reporting and
learning system (NRLS)
Purpose
To bring together key users and holders of mental health
data and intelligence, to oversee improvements in data
availability and flow The aim of which is to put mental health
and wellbeing intelligence into the public domain to enable
local decision makers to improve mental health and
wellbeing across England.
The dashboard will present a range of information on
outcomes, experience and access to mental health
services. It will be available to the public and NHS
organisations.
To improve reporting of patient safety from providers to the
NRLS to support evidence based change in patient safety.
Update and next steps
A steering group and governance structure has been established.
The network is being developed using Expert Reference Groups.
The network will be formally launched in May 2014.
The potential contents of the Dashboard were discussed at the
PoE programme launch in December 2013. Dashboard will be
available from November 2014.
All 12 trusts with data reporting issues) to have developed and
agreed action plan by September 2014. Guidance on how
restraint should be reported produced by April 2014, implemented
by October 2014.
Implementation of the Friends
The FFT is important measure of how people feel about the The specific questions are currently being tested for
and Family test in mental health
care they receive. As per our mandate objective, we will
appropriateness across MH settings and pathways having
roll out the test in mental health by December 2014.
established pathways. Guidance will be complete by June 14,
with a view to going live by December 2014.
Improving data flow and linkages To improve data and intelligence infrastructure to improve
Working with the HSCIC, significant improvements have already
the timeliness, coverage and linkage of data on mental
been made to IAPT data quality and availability. Work will
health.
continue on other areas throughout 14-15.
State of the Nation Report (Parity To provide a baseline of prevalence and service information We have used existing nationally available data to build this
of Esteem)
to inform future progress of the Parity of Esteem
report. This work has highlighted gaps as well as providing a
Programme
baseline from which the Parity of Esteem Programme can build
from.
The report will be published early in 2014/15 and it is anticipated
that this tool will be of use to commissioners, providers and the
public.
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NHS | Presentation to North Region |1 April 2014
Commissioning skills and capabilities
(progress and deliverables)
Product
Commissioning Framework for CAMHS
CCG Leadership development
Mental health value packs/ toolkits
Financial Framework (including PbR)
Financial strategy
Purpose
High quality CAMHS requires close working between local
commissioning partners. The objective is to deliver an
evidence based, outcomes focused service specification
which facilitates this collaboration.
To deliver focused, skills based training for mental health
commissioners. The training is based on a development
programme ran in London in 2012-13.
To develop practical resources for commissioners,
including:

Value packs highlighting variation, providing service
models and supporting economic cases.

Innovative contract models for outcomes.
To ensure that the range of financial levers and incentives
are being effectively harnessed to support parity of
esteem. This includes PbR, the standard contract, CQUIN,
and the quality premium.
To ensure that mental health is fully integrated into the
longer term financial strategy work.
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NHS | Presentation to North Region |1 April 2014
Update and next steps
The work on the service specification has begun, and will be
available by December 2014 to support the 15-16
contracting round.
The programme will be delivered throughout 2014-15,
each CCG will be offered a place.
The project has been scoped and is being discussed with
the Commissioning Assembly. Toolkit will be delivered by
December 2014.
A number of financial and contracting tools were issued as
part of the 13-14 planning process, including sanctions
within the standard contract, a national mental health
CQUIN scheme, and CCG Quality Premium.
In terms of PbR, mental health services were covered by
care clusters for 2014-15, which were subject to local
pricing. We are piloting currencies for IAPT and CAMHS
which could potentially inform future tariff setting.
Mental health services are included in the Call to Action
modelling work. We have commissioned cost benefit
analysis of mental health interventions We will ensure that
costs and benefits of mental health interventions are
included in the economic study of the impact of data and
participation in the NHS.
Improving clinical services (progress and
deliverables)
Product
Adult IAPT
Purpose
To ensure delivery of the Mandate objective of 15% access to
IAPT services, with a 50% recovery rate.
Update and next steps
We have produced an IAPT recovery plan, and have worked with the HSCIC
to improve data flows. The CCG planning guidance gave a very strong
message on IAPT, requiring all CCGs to have credible plans for at least 15%
access. These plans will be robustly tested and monitored by area teams.
CYP IAPT
To work with 60% coverage of CAMHS services for 0-19 year
olds by March 2015
Current coverage is 54%. In March 2014 the programme will advertise for
new sites to join the programme and take coverage beyond 60%.
Choice in mental health
To implement choice in mental health services To ensure that We are working with the DH to ensure that choice is implemented from April
people with mental health conditions have similar access to
2014. We anticipate choice to be fully embedded by April 2015
services as people with a physical disability.
Employment and mental health
We know that employment is an integral part of recovery
from mental ill health. This pilot programme explores
integrated psychological and employment support.
Mental Capacity Act
Waiting time standards for MH
We are working with DWP and the Cabinet Office to design and implement
two projects:

The Psychological Wellbeing at Work pilots proposed by RAND
Europe;

A pilot testing IAPT on employment outcomes (subject to DWP
funding).
These pilots will run from May for 6 months.
To embed the principles of the mental capacity act into the
We are working with system partners to ensure that assessments of mental
health and care system, resulting in empowered and engaged capacity are undertaken as appropriate, and that the act is being supported
users with tailored care.
by commissioners.
While this is challenging due to the complexity of pathways
and lack of data, we are developing costed options for
consideration as part of the 15-16 Mandate discussions.
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NHS | Presentation to North Region |1 April 2014
A joint steering group has been established between NHS England and DH.
This work is expected to have developed options by June 2014.
Improving clinical services (progress and
deliverables) - 2
Product
Improvements in Direct
Commissioning
Purpose
Parity of Esteem for victims of rape and sexual
assault.
Update and next steps
Parity of Esteem to be included in the commissioning of
healthcare provision for Sexual Assault Referral Centres
(SARC) and therapeutic pathways commissioned in the
community through Clinical Commissioning Groups and Local
Authorities.
Integrated service provision and support for
Substance Misusers
Through The Gate Programme which is a ministerial cross
department programme with Ministry of Justice and DH with
an early adapter led by NHS England North West Health &
Justice Area Team commissioning integrated service provision
and support for Substance Misusers Through the Gate on
prison release to the community.
Awareness raising of the needs of Veterans and
Mental Health Veterans
Improving outcomes for people within the
criminal justice system
33
NHS | Presentation to North Region |1 April 2014
Parity of Esteem has been an opportunity to highlight the
needs of Veterans and Mental Health Veterans provision and
responsibility of commissioning through Defence Medical
Services and CCGs.
Health and Justice Direct Commissioning is now working with
the Health & Justice Oversight Group. Interventions that are
key to ensure that Parity of Esteem are understood and
integrated throughout and are to be included in the £25m
Liaison & Diversion programme
Improving crisis care (progress and
deliverables)
Product
Systematic review of crisis care
pathways
Programme of support to
commissioners
Purpose
Assess effectiveness of a range of models of mental
health crisis care
Aid commissioners, based on the evidence from the
review and gap-analysis, to commission for best
practice in their communities
Update and next steps
Negotiating with DH to commission the review.
Mental health scoped in Urgent
and emergency care review
Integrate mental health crisis care as required
across urgent and emergency care services
Roll-out of new liaison and
diversion services
Assume NHS England’s new responsibility for these
services from April 2014
Mental health crisis care is part of workstreams in
the review, scoping under way for taking work
forward
An extra £25m has been made available in 2014/15
for the liaison and diversion services. This has
resulted in 10 trial sites been commissioned by NHS
England. Trial sites will commence 1/4/2014; Rollout as agreed to 50% coverage for 2015/16
Will work through Commissioning Assembly to codesign appropriate materials
September 2015 a full business case will be
submitted to HM Treasury to secure funding for
additional funds to support full roll out.
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NHS | Presentation to North Region |1 April 2014