Mental Health Needs Assessment
and Strategy Review
Dr Andrew O’Shaughnessy
Consultant in Public Health
NHS Airedale, Bradford and Leeds
November 2011
Mick James
Mental Health Commissioning Lead
NHS Airedale, Bradford and Leeds
Background
• Rolling programme of HNAs in Public Health
• Began 2008
• Sexual Health, Children, Smoking, Alcohol,
Obesity…
• Next up Substance Abuse, ASD, Dementia
• Process focus on commissioning
• Updated annually
• Live approach – Observatory
Thanks to AL and DC
Health Needs Assessment
The elements of health care needs assessment
Incidence
Effectiveness and
and/or
cost-effectiveness
prevalence
Strategy
Partnerships
Commissioning
JSNA
Prioritisation
Reorganisation
Existing
services
Cost-effectiveness allows us to consider the relative priority of different needs
Data Issues
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Multiple data sources
Differing methodologies
Differing samples
Differing numerator populations
Differing denominator populations
Data gaps
Local improvisation to derive estimates
Policy statements
Maintains utility
NB Observed vs Expected
Appendix B
Taxonomy
Diagnosis
• Affective disorders
• Bipolar disorders
• Psychotic disorders
• Personality disorders
• Others e.g. suicide
Demographic
• Gender
• Age group
• Young
• Working age
• Older people
Overall Burden of Illness
Broad Epidemiological Perspective
Corresponding Epidemiology
in Bradford & Airedale
Adults
20% of working-age women are affected by depression or anxiety
29,420
7% of working-age men are affected by depression or anxiety
13,000
3% of women can be assessed as having a personality disorder
5,950
5% of men can be assessed as having a personality disorder
9,500
1.9% have a psychotic disorder such as schizophrenia or bipolar affective
disorder during their lifetime
8,530
Children (0-15yrs)
10% of children have a diagnosable mental health condition
11,310
Source: Estimated from New Horizons and ONS mid 2008 population estimates
Children 1
Boys (%)
Age
All 5-16 year olds
(%)
Girls (%)
5-10 year olds
11-16 year olds
5-10 year olds
11-16 year olds
Conduct disorder
6.9
8.1
2.8
5.1
5.8
Hyperkinetic disorder
2.7
2.4
0.4
1.4
1.5
Emotional disorder
2.2
4
2.5
6.1
3.7
Less common disorders
2.2
1.6
0.4
1.1
1.3
Any disorder
10.2
12.6
5.1
10.3
9.6
Source: Mental Health of Children and Young People in Great Britain, ONS 2004
Children 2
Age Range
5-10 years
11-15 years
5-15 years
Number of Children
Prevalence
Number with a mental health disorder
Female
21,057
5.1
1,074
Male
22,048
10.2
2,249
All 5-10
43,105
7.7
3,319
Female
17,501
10.2
1,785
Male
18,195
13.1
2,384
All 11-15
35,696
11.7
4,176
All
78,801
9.6
7,565
Source: CAMHS Needs Analysis Review 2007
Older People
• There are an estimated 4,080 older people with Bipolar I disorder in
Bradford District
• There are an estimated 1,912 older people with Personality Disorder
in Bradford District
• There are an estimated 270 older people with schizophrenia in
Bradford District
• Affective Disorders:
Age
group
Population
(F)
Population
(M)
Any
neurotic (F)
Any neurotic
(M)
65 to 69
9,984
9,038
1,519
604
70 to 74
9,337
7,354
1,139
643
75+
18278
15507
2514
1180
Total
37,599
31,899
5,172
2,428
Affective Disorders
Female ~ 32,000
Male ~29,000
Bipolar Disorders
• Lifetime prevalence (i.e. those who have the disorder for at least part of their
lifespan) of Bipolar I disorder is approximately 1.3%
• Prevalence of Bipolar spectrum disorder (including Bipolar I,II and cyclothymia
much less clear but may be between 2.6% and 6.5%
• Bipolar spectrum disorders often go unrecognized and undiagnosed – hidden
and unmet need
Males
Females
All
0-16
790
770
1560
17-64
3370
2010
5380
>65
2050
2030
4080
Total
6210
4810
11020
Psychotic Disorders
• ~1,700 adults of working age and 270 older people with
schizophrenia in Bradford District
• Larger numbers with schizophrenic disorder
• NB broad taxonomy of psychosis
16-64yrs
65+yrs
Numbers for Bradford adults (+16yrs)
Female
797
153
(95% CI)
Male
895
115
All adults
1731
272
Diagnosis
Schizophrenic
disorder
One year
Lifetime
2332 (1477 to 3537)
5635 (311 to 9211)
Personality Disorders
Type of personality
disorder
Female
Male
All adults
16-34
35-54
55-74
All
16-34
35-54
55-74
All
16-34
35-54
55-74
All
-
527
1630
2312
1554
1706
1247
4622
1524
2235
2911
6757
Avoidant
136
988
88
1245
636
1115
-
1778
831
2104
86
2845
Schizoid
407
-
969
1423
565
131
873
1600
970
131
1883
2845
Paranoid
204
329
-
534
636
1378
83
2133
831
1709
86
2489
Borderline
340
461
-
711
141
1574
-
1778
416
1972
-
2489
Antisocial
340
0
-
356
565
1115
-
1778
970
1183
-
2134
Dependent
-
-
44
0
353
-
-
356
416
-
0
356
Schizotypal
68
66
44
178
-
0
-
0
139
131
86
356
Histrionic
-
-
-
-
-
-
-
-
-
-
-
-
Narcissistic
-
-
-
-
-
-
-
-
-
-
-
-
1154
1911
2775
6047
3673
3805
2202
9601
4710
5785
4965
15648
Obsessive-Compulsive
Any personality disorder
Source: Psychiatric Morbidity survey 2000 (from clinical interviews).
N.B crossover with other types of mental illness e.g. OCD vs. OCPD
Hospital Admissions
• Data were collected from Bradford District Care Trust
• 60% no diagnosis code so necessary to estimate total
admissions by age and disorder type
• 2008 and 2009 (combined) there were 3,291 admissions
(~1,600 pa)
• Psychotic disorders (n=485 per year) and Affective disorders
(371) account for half of all annual admissions to BDCT
• Significant numbers of admissions for drug (98) and alcohol
(129) dependency
• Older people: Dementia is the largest diagnosis type
accounting for over 40% of admissions, with affective
disorders comprising a further 30%
• N.B. admissions elsewhere and “composite” admissions –
actual admission burden likely to be higher
Hospital Admissions
Ethnicity
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People from minority ethnic groups living in the UK are more likely to
– Be diagnosed with mental health problems
– Be admitted to hospital with mental health problems
– Experience a poor mental health treatment outcome.
There may also be low levels of reported and diagnosed mental health
disorders due to negative stigma. This results in low engagement with services
Rates of affective disorders 15-20% higher within the S. Asian pop. of England
Black groups have lower prevalence for affective disorders than the general
pop
African Caribbean people are 3 to 5 times more likely to be diagnosed and
admitted to hospital for schizophrenia than other groups.
Evidence is inconclusive as to whether South Asian groups have higher rates
of schizophrenia than whites, although they have better rates of recovery
No relationship between any of the QoF MH indicators and South Asian
ethnicity in B&A
Those from South-Asian ethnic groups in B&A have higher levels of satisfaction
with their financial situation than those from the White group
Prescribing
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587,000 prescribed items per year in Bradford District
Cost of £5.9 million per year
Antidepressants comprise more than half
Substantial variation in prescribing across the District
Benchmarking 1
• Bradford’s relatively deprived population,compared
nationally, may be expected, at the population level, to
generally suffer higher levels of bipolar and psychotic
disorders
• Almost two thirds of those in need receive either
enhanced or standard CPA in Bradford, compared to one
third in our peers and England as whole
• In Bradford District 10,440 people claim mental health
incapacity benefit. This is 3.5% of the working age
population, compared to 1.7% nationally
• In 2008/2009 there were 32,111 patients with diagnosed
depression on GP depression registers. This is 6.1% of
total patients on lists compared to 7.7% in Yorkshire and
Humber and 8.1% in England
Benchmarking 2
• The rate of access to mental health services for adults is below our
PCT peers and England for older people but above the England
average for adults of working age
• Bradford has a lower proportion of contacts with psychiatrist /
psychologist / psychotherapists, at 14% compared with our PCT
Peers at 24%
• In Bradford patients are more likely to be admitted than those in
contact with services in similar PCTs or in England as a whole
• Approximately 1,400 people were detained under the Mental Health
Act 1983. The proportion formally detained for at least one day is
similar to our PCT peers but above the national average
Local Geographic Variation
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Residents from City and South and West Alliance areas were slightly more likely to
report feeling downhearted and depressed
Levels of life satisfaction are lowest in the South and West Alliance area
Substantial variation in QoF prevalence between practices, with greatest variation
between practices in the City Care and South and West Alliance
Of the 13 practices achieving less than 90% of mental health reviews for patient, 9
are in City Care Alliance. Patients within these practices are also less likely to have a
comprehensive mental health care plan or be followed up for non-attendance of 15
months reviews
Antipsychotics drug prescribing rates and cost per head of population are similar
across the 4 alliances. South and West alliance has the highest prescribing rate (0.16
items per head) with Airedale alliance the highest cost per head (£5.19)
However, there is a huge range in prescribing of antipsychotic drugs between
practices ranging from 0.02 items per head (£0.41) to 0.6 items per head (£11.40).
City Care Alliance has the lowest number of items and cost per patient for
antidepressants (£2.14 per head of population) and hypnotics and anxiolytics (£0.86).
For hypnotics and anxiolytics, prescribing rates and cost are broadly similar across
other alliances
S&W alliance has the highest number of items per patient for anti-depressants,
although Airedale and YPCA/BANCA alliances have higher costs per patient,
suggesting variation in the type and quantity of drugs prescribed by GPs
Strategy Review
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Need to review local strategy
Changing Commissioning landscape
Public Health changes
Health and WellBeing Boards
Integration
Personalisation
Joint Commissioning
Alcohol, Substance Abuse
CCG Context
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Strategic planning
Commissioning plans
Partnership working
Prevention and Management
Focused workstreams
– IAPT Need/Capacity planning
– Antipsychotic prescribing in Primary Care
– Antipsychotics in Dementia
– Guidance Taxonomy
– Autism HNA
– Dementia HNA
Next Steps
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Complete the HNA triangle
In tandem with commissioners as part of MH strategy
development:
– Analysis of need and service provision with gap
analysis
– Use of evidence and guidance to identify
approaches to address these
– Assessment and application of published clinical
and strategic guidance on mental health and wellbeing.
– Focused review of published research literature as
required
– Engagement with partners including clinicians in
Primary and Secondary Care