Mental
health
strategic
clinical
Yorkshire and Humber SCN
Dr. Geraldine Strathdee,
National Clinical director, Mental Health
network
meeting
:
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!
2 NHS | Presentation to [XXXX Company] | [Type Date]
How common is mental ill health
3 NHS | Presentation to [XXXX Company] | [Type Date]
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 selfesteem
•Suicide
1: 10 have
unrecognised
dyslexia,
dyspraxia
The workforce
Senior citizens
All communities
1 in 6 adults at any
time
Dementia effects
•5% over 65’s 1020% over 80
Over 300 spoken
languages in UK;
many cultural
beliefs & mental
health issues
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
1 in 6 over 65
suffer from
depression
Major factors:
•Social isolation
•Physical illhealth
30% of >65s in
Acute Trust beds
have dementia
Overrepresentation 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
Acute care
20%-40% of A/E in
40% acute beds
50% acute LTC outpatient
clinics
Prisons & offenders
70-80% especially young men
Specialist mental heath
services
Depression & anxiety
Substance misuse
Children's conditions
Premature mortality : 15-25
years
Quality of life in LTCs
Recovery from illness
Patient safety
Patient experience
Alcohol & drugs
Depression & self harm
Depression
Dementia
Premature Mortality
Quality of life for LTCs
Recovery from illness
Patient safety
Patient experience
ADHD, ASD
Depression
Substance misuse
PD
Premature Mortality
Psychosis
Neurodevelopmental
Substance misuse
Personality disorders
Complex multi axial
Premature Mortality : 15-25
years
Quality of life in LTCs
Recovery 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
Isolated
women with
small children
People with
schizophrenia
and sight and
hearing
problems
Victims of
domestic
violence
Dyslexia, Dysprexia
ADHD, Autism,
Asperger’s and
Learning Disabilities
Victims of school
and employment
stress and
bullying
Key life cycle:
•Divorce
•Retirement
•Redundancy
•Menopause
Long term
physically ill
Alcohol and
drug addictions
3. The top 10% of Mental health conditions: service redesign for
prevention,
earlier
identification
better access & treatment for young
The origins and
causes
of mental ill&health
eople
The life span health & social determinants of mental health conditions
Genetic & biochemical
Organic brain &
neurodevelopmental
Societal
•
Life span high risk
events
•Long term physical
conditions
•Unemployment
•Adolescence
•Pregnancy
•Bereavement
•Migration
•Gang/ veteran trauma
Biochemical ‘causes’
Caffeine, nicotine, alcohol, street drugs
Neurotransmitters
Endocrine disorders
Family history
Substance misuse
/mental ill health/
chaotic deprivation
/ abuse: physical,
sexual, emotional
School difficult
Dyslexia,
Dyspraxia, ADHD,
Autistic
spectrum,
Bullied
‘What could we do?’
Truanting
Drug use &
dealing
Petty crime
In Care
Mental illness
starts
Regarded as ‘bad’
or ‘strange’
‘What should we do?’
Institutions career
Expensive
placements
Youth offenders
Acute psychiatric
wards
Forensic units
‘How should we do it?’
What Outcomes do our service users ask
us to support them achieve
What Outcomes do our patients ask us to
achieve in partnership with them
Safety
“Will I be ok?”
From the
patient’s
perspective
Effectiveness
“Will it do me any
good?”
Experience
Efficiency
Was it fast, safe
, near home ,
back to work
asap
“Access, information &
treatment experience”
Least restrictive settings
Professor Bruce Keogh, Medical Director of the NHS
Parity :
NHS Mandate: what does it mean in practice
• I was struck the other day when I saw a patient - who has been off work for
From
a
London
GP
…………………
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
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.
The economic impact: 2012
Figure 1: Morbidity among people under age 65
Physical illness (e.g.
heart, lung, musculoskeletal, diabetes)
Mental illness
(mainly depression,
anxiety disorders,
and child disorders)
successful outcome. The second point is the level of cost-effectiveness as measured by cost
per QALY. This involves two further factors. First there is the severity of the condition which
is averted, and second the cost per case treated. The concept of severity used by NICE is that
each medical condition involves a reduction in the quality of life, and a successful treatment
thus increases the number of Quality Adjusted Life Years (QALYs). The cost per QALY is
then the (inverse) measure of the cost-effectiveness of the treatment. The informal cut-off
Mental health has among the most clinically and cost
effective treatments of any sector
but access is low and a post code lottery
22
Annex B: Prevalence of adult mental health conditions and % in treatment,
England 2007
% of adults
diagnosable
(1)
% of (1) in
treatment
(2)
% of (1) receiving
counselling or
therapy
15.0
24
10
PTSD
3.0
28
10
Psychosis
0.4
80
43
Personality Disorder*
0.7
34
ADHD
0.6
25
4
Eating disorders
1.6
23
15
Alcohol dependence
5.9
14
6
Drug dependence
3.4
Anxiety and/or depression
Cannabis only
2.5
14
7
Other
0.9
36
22
Any condition
23.0
* Includes Anti-social P.D. and Borderline P.D.
Note: The conditions are not mutually exclusive.
18
Table 5: Cost-effectiveness of some treatments for mental and physical illnesses
Mental illness
Depression
Social anxiety disorder
Post-natal depression
Obsessive-Compulsive
Disorder
Physical illness
Diabetes
Asthma
COPD
Cardio-vascular
Epilepsy
Arthritis
Treatment
Numbers
Needed to
Treat
Cost per
additional
QALY
CBT v Placebo
CBT v Treatment As Usual (TAU)
Interpersonal therapy v TAU
CBT v TAU
2
2
5
3
£6,700
£9,600
£4,500
£21,000
Metformin v Insulin
Beta-agonists + Steroids v Steroids
Ditto
Statins v Placebo
Topirimate v Placebo
Cox-2 inhibitors v Placebo
14
73
17
95
3
5
£6,000
£11,600
£41,700
£14,000
£900
£30,000
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 pathways
we have commissioned unique whole care pathway health & social care information
for every CCG
In this CCG/ borough, what are the social determinants of mental ill
health
How common are mental health conditions in this area
What are the high risk groups to target for risk stratification and
prevention
What % age of people with these conditions are GP QOF identified
( and coded)
What funding is spent on mental health in primary care, social care
and specialist mental health hospital beds & community services
What evidence based services are available in this borough
Are standards of services meeting NICE NCB, QOF, COF, CQC,
Monitor, Outcomes domains, Operating framework, PbR
What are the key high risk prevention & top 10% QIPP opportunities
Clinical and economic best commissioning tools
What are the top 4 service ‘Best buys’
Model service specification examples
Economic modelling tools to design and reengineer effective
models for local needs
The evaluation and shared learning indicators
CCG MH shared learning & provision network
Expert clinical reviewers & implementers
2. Primary mental health care in England
internationally:
GP roles
clinicianaround the many roles of
they are usingIndividual
systems thinking
GPs
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
Primary care service
organization
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 model
Hungary 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
GP Master class series
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.
AHSNs working with SCNs and LETbs
UCLP practice nurse master classes
• 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
23 NHS | Presentation to [XXXX Company] | [Type Date]
Acute and unplanned care emerging thinking
Admissions to Acute
Care in acute mental
health beds
£
Emergency Department
Mental health liaison team
£
( dementia, alcohol, psychosis, self harm
all ages )
£
Intermediate tier
Single Crisis number
coordinating tele triage, tele
health + 24/7 community Home
treatment team & community
alcohol detox,
£
£
£
Primary Care
& self- care
5. Integrated physical and mental health care Long term conditions
Mental health raises costs in all sectors
Chris Naylor, Kings fund
• Overall, international research finds
180%
that co-morbid MH problems are
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.
% increase in annual per patient costs
(excluding costs of MH care)
associated with a 45-75%
160%
140%
120%
100%
80%
Depression
Anxiety
60%
40%
20%
0%
Co-morbidity is the norm
Lancet, Barnett, Mercer et al 20
2012 publication Compendium of examples of cost
effective programmes for people with physical
illnesses in acute trust, primary care settings
The Ian Galton challenge:
Dementi
a
MH
The MH intelligence network will include dementia & neurology CCG
commissioning & quality improvements
 x
 x
 x
The SCN website: sharing intelligence & updates
 x
 x
 x
Mandate : 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
an integrated dementia, MH and neurological plans
Neurolog
y
Our integrated support processes:
Particular service models and clinical pathways we are working on in an integrated way
The 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
 x
Dementia 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
Integrated physical and Mh care factsheet series between NCDs and MH field experts
x
x
Medically unexplained symptoms common pathway : would love to support neurological
MUS & IAPT
x
x
x
x
Specialist commissioning group in brain injury are including MH assessment
x
x
Many of the outcomes we achieve for people
with schizophrenia and psychosis are
unacceptable
• 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.
www.rethink.org
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, empowering
g
Key partners & network members to build
synergies
( not inclusive
)
Patients and families
AHSC + LETbs
LAs, Social care
PHE
Care 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
Acute care
20%-40% of A/E in
40% acute beds
50% acute LTC outpatient
clinics
Prisons & offenders
70-80% especially young men
Specialist mental heath
services
Depression & anxiety
Substance misuse
Children's conditions
Premature mortality : 15-25
years
Quality of life in LTCs
Recovery from illness
Patient safety
Patient experience
Alcohol & drugs
Depression & self harm
Depression
Dementia
Premature Mortality
Quality of life for LTCs
Recovery from illness
Patient safety
Patient experience
ADHD, ASD
Depression
Substance misuse
PD
Premature Mortality
Psychosis
Neurodevelopmental
Substance misuse
Personality disorders
Complex multi axial
Premature Mortality : 15-25
years
Quality of life in LTCs
Recovery from illness
Patient safety
Patient experience
The route map to delivering the MH strategy