Developing Integrated Mental Health Services
Professor Mervyn Morris
CCMH
BCU
31st MAY 2013
Where are we?
UK West Midlands Region
SCOTLAND
LONDON
WHERE PRINCE WILLIAM AND KATE LIVE
Birmingham* mental health services
Key Facts (2008-9)
 Population
 1.2 m (including Solihull)
 Number of staff
 3,924
 Number of beds
 722
 Community Teams
 79
 Service users seen
 48,459
*Birmingham and Solihull NHS Mental Health Foundation Trust
Location of City’s 3 Premiership Football teams
ASTON VILLA
(Benteke)
West Bromwich Albion
(Lukaku)
Birmingham City
PRIMARY CARE
(SUB) ACUTE
Primary Care Liason
ACUTE
HOME
TREATMENT
Birmingham Model
Functional Map
CONTINUING NEED
Rehab / Recovery
CONTINUING NEED
ASSERTIVE OUTREACH
Residential based care:
Hospital Beds, Day services, Crisis Houses,
Belgium Functional Map of Adult Services
PRIMARY CARE F1
(SUB) ACUTE F1/2a
Primary Care Liason
ACUTE
F2a
HOME
TREATMENT
Birmingham Model
Functional Map
CONTINUING NEED
F3
Rehab / Recovery
CONTINUING NEED
F2b
ASSERTIVE OUTREACH
Residential based care: F4
Hospital Beds, Day services, Crisis Houses,
Total mental health beds per 100 000 population
(WHO Mental Health data From Atlas, 2011)
1:700
1:5000
What was Birmingham’s message?
• It is possible to develop a full range of mental
health services in the community that replaces the
need for current levels of hospital provision.
• Community services can develop different
functions in the same way as hospitals and, like
hospitals, can develop an integrated approach.
• The community creates new opportunities
because people and problems are ‘in vivo’.
• The community creates different challenges
because the system has less control than hospital.
Three levels of an integrated system
• Practitioners work in teams, not as individuals
= Collaboration = Integrated Care
• Teams work as part of an organisation of healthcare
= Co-operation = Integrated Pathways
• Health organisations work with other non-healthcare
organisations
= Co-ordination = Integrated Agencies
Integrated Care – Integrated Pathways – integrated Agencies
• Each team member, both as a person and by
professional training, has a different view of the
person, their problems and their situation.
• Diverse thinking is important in making sense and
finding solutions, but it is also important that the
team works together (collaborate) to identify a
common strategy and goal.
Integrated Care –
Integrated Pathways – integrated Agencies
• It is important for the person, their family, and
people they look to for help to know what service is
available and how to access it.
• Once connected to the service, everyone involved
knows what help will be offered, and what
continuing mental health service is available next.
• Teams co-operate to agree who is responsible in
what situation to prevent gaps in service, ensuring
continuity of care.
• An integrated pathway has similarities to a stepped
care model.
Integrated Care – Integrated Pathways –
Integrated Agencies
• Not all support for people with mental health
problems is available from mental health services.
Access to social care, social support, social
housing, welfare payments, all require involvement
of other agencies.
• Co-ordination with other agencies ensures
common agreement about longer term support and
planning, ensures maximum use of resources, and
prevents delay.
Integrated Home Treatment
• Specifically targeted to people who would
otherwise go to hospital
• 24 hours, 7 days a week, frequent, flexible visiting
• Multi-professional team; doctors and nurses, social
worker, occupational therapist, psychologist,
community support workers
• Rapid response, within 2 hours
• Pathway from and back to community care
• Gatekeeper to hospital
• Crisis houses developed as alternative to hospital
• In-reach to hospital for early discharge
PRIMARY CARE
COMMUNITY MENTAL HEALTH TEAM
Primary Care
Continuing Need:
Liaison
Rehab and Recovery
HOME
TREATMENT
TEAM
CONTINUING NEED
ASSERTIVE OUTREACH
TEAM
Residential based care:
Hospital Beds, Day services, Crisis Homes
‘Acute’ Care core pathway
PRIMARY CARE
COMMUNITY MENTAL HEALTH TEAM
Primary Care
Continuing Need:
Liaison
Rehab and Recovery
HOME
TREATMENT
TEAM
CONTINUING NEED
ASSERTIVE OUTREACH
TEAM
Residential based care:
Hospital Beds, Day services, Crisis Homes
‘Acute’ Care core pathway
Data on 3 new teams, Birmingham 1995
Impact on Bed Usage
Admissions
Admission
Home Treatment Home Treatment Reduction %
1 Year Pre
1 Year Post
One
94
44
53%
Two
96
50
48%
Three
50
37
26%
District
Overall reduction in n. Admissions = 43%
Data on 3 new teams, Birmingham 1995
Impact on Bed Usage
Occupied Bed Days
OBD*
Home Treatment Home Treatment Reduction %
1 Year Pre
1 Year Post
One
3,036
1,953
36%
Two
3,667
1,662
55%
Three
1,823
1,290
30%
District
Average reduction in n. bed days = 40%
*OBD = OVERALL BED DAYS
What have we learnt from supporting
development in other countries?
• There is existing community innovation and
expertise that needs to be recognised and valued,
but ultimately to be of value, becomes integrated.
• Community and hospital psychiatry can have
theoretical and ideological and differences, and
this can impact on developing integration at all
levels.
• The way funding of services works is a big
challenge; usually different services are paid for
from different sources. It also means involving
different government and local agencies.
Developing Community Mental Health
You can:
• Develop a more differentiated community service,
that reflects the traditional differentiation found in
psychiatric hospitals.
• Develop evidence to prove the care traditionally
provided in hospitals can in many cases be
provided in the community, more cost effectively,
and with better patient outcomes.
• Can make community care work for all types of
‘disorder’ and a higher level of ‘severity’.
Some possible questions for Brussels..
• What is your overall vision for your services?
• Can you describe your services using functional
mapping? What stage are you at?
• What does a functional map identify that you need to
do in a short and long-term plan? Where are the
gaps?
• What is the priority at each level for developing
services; teams, pathways, agencies?
• What is practically possible.. next?