Epidemiology of Mental Health in
Brighton and Hove
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Population approx
250,000
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High levels of self harm
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Consistently in top three
suicide rates and drug
related deaths in the
country
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2480 patients with a
diagnosis of psychotic
SMILES background to
development
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Reconfiguration of MH services in 2008,
with Community Mental Health teams bring
divided in to Access and Recovery services
This was to incorporate the Recovery and
well being agenda and was also in
response to the introduction of IAPT
Patients who didn’t meet the threshold for
Recovery services but still had severe and
enduring mental health problem, were
increasingly being discharged to primary
care
Looked at what was happening
across the city for QuOF
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Huge variation in physical health templates – almost all
did BMI, BP, Smoking , Alcohol, Lipids. Less good
results for side effects, diet, exercise or sexual health
Absence of risk screening and recovery planning on
annual care plan - only 30% asked about suicide risks
No care plans recorded as being given to patient
• ..and more detail,
• ..and more detail,
• ..and more detail until
we covered
everything.
• No nasty surprises!
Eligibility for the LES
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Practice must score 85% for MH9 [annual review
including health promotion]
Patients 18 + in stable accommodation and
registered with a GP participating in the scheme
Diagnosis of SMI including schizophrenia, bi
polar affective disorder and personality disorder
Low risk, or omnipresent and well managed risk.
Patient, GP and consultant all in agreement for
transfer of care
Eligibility for the LES
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Practice must score 85% for MH9 [annual review
including health promotion]
Patients 18 + in stable accommodation and
registered with a GP participating in the scheme
Diagnosis of SMI including schizophrenia, bi
polar affective disorder and personality disorder
Low risk, or omnipresent and well managed risk.
Patient, GP and consultant all in agreement for
transfer of care
Two tier approach Level two
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All patients are discharged from secondary
care to maintain through put in services
Annual care plan and bi annual review with
Nurse and GP using standard template
Reviewed by Liaison Nurse at least every
twelve weeks
Referral from primary care to CRHTT if
needed
Fast track back to recovery if mental
health becomes unstable
Barriers to usual discharge
processes identified in primary care
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GPs (and sometimes service users) did not
understand why patients were being discharged
Sometimes not clear plan of care for patient
Sometimes no relapse signatures /risk
management plan
GPs unfamiliar with mental health medication,
and apprehensive about responsibility for this
patient group
Limited resources to support with medication
issues and risk management issues
Fractured relationships between primary and
secondary care
The client
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20 year history of psychotic disorder
Stable on treatment
Insight, motivation, confidence
Lives alone in one bed flat, sub let scheme
Supportive family
Discharged to SMILES
Worked with SMILES for 2 years
The work we do
• Recovery planning
• Wellness and Recovery Action Plan
• Work and learning, part time work,
relationship, needing to move home
• Regular meetings with SMILES nurse
• 6 monthly supported GP reviews
• Physical health monitoring at GP surgery
SMILES drop in group, The Recovery Star
A closed group for SMILES users once a
month
Recovery Star Model
10 Ladders of change
Each session focuses on a area for change
Open and supportive discussion
Personal experience of services
Rehearsing the plan for difficult times
What would we do differently?
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It was a very detailed spec
– to the point that we got
a bit lost in it at times!
More service user
participation and
consultation earlier in the
process -although this
hasn’t been problematic
Lots of time spent scoping
and initial patient lists
soon became defunct in
terms of suitability
Ways forwards
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Physical health template now universally
available for all GP IT systems and
recommended by CCG for standard QuOF
template for all practices
Planning to pilot and introduce Clozapine
monitoring as part of shared care
agreement under LES.
Opened Clinical Network Mettings to all
practices and invited staff form Recovery
Looking to include more practices
Ways forward
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May consider skill mix/peer support if we
grow the project
Broadening the eligibility by
diagnosis/referral route
Considerations about how to support
clients in practices that don’t want to get
involved,
?Shared care arrangement for patients on
depots who are still under secondary care