New approaches to implementing
mental health programs in
primary care
Professor Helen Lester
Academy 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)
Self care 1-2 million
Shared care
300,000
Primary care
3.75 million
Specialist services
600,000
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)
Musculo-skeletal
20%
Nervous system
10%
CVD and RD
9%
Mental disorder
38%
Injury
6%
Others
17%
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 5: Inpatient
care, crisis team
Step 4: Mental health
specialists including
crisis team
Step 3: Primary care team,
primary care mental health
worker
Step 2: Primary care team,
primary care mental health
worker
Step 1: GP, practice nurse
Risk to life, severe
self-neglect
Treatment-resistant, recurrent,
atypical and psychotic
depression, and those at
significant risk
Moderate or severe
depression
Mild depression
Recognition
Medication,
combined
treatments, ECT
Medication, complex
psychological interventions,
Case management and
collaborative care
Medication, psychological
interventions, Case
management and collaborative
care
Watchful waiting, guided
self-help, computerised CBT,
exercise, brief psychological
interventions
Assessment
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 (211)
 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
100.0%
99.0%
98.0%
97.0%
96.0%
95.0%
94.0%
93.0%
92.0%
91.0%
I
a
As
th
m
SM
Ca
nc
er
Ep
ile
ps
y
Hy
po
th
yr
oi
d
PD
CO
be
te
s
Di
a
BP
A
/T
I
CV
A
LV
D
CH
D
90.0%
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)