Challenge for the NHS and local councils and communities Dr - - PowerPoint PPT Presentation

Challenge for the NHS and local councils and communities

Dr Geraldine Strathdee, National Clinical Director for Mental Health. @DrG_NHS 17 November 2014

Local champions : this discussion

• Developing positive mental health in our society
• The myths we are busting about mental health
• The cost to people & communities of NOT

tackling the cause & addressing mental ill health

• The cost to people and communities of NOT

providing help until it is very late

• Giving you some key facts and ammunition!
• What support as leaders do you need from us
• Your questions & discussion ……..

Mental health:

the basis of a humane and wealthy society

If you as local champions arm your self with the facts and get influencing commissioning, you can make a huge difference to your communities

The myths we are busting about MH in England

• Mental health just happens or not! You can’t learn it!

– No, it’s NOT. Like physical, academic or creative achievement, It can be taught & learnt.

• Mental health is a long term condition

– No, it’s NOT! Its so often in England an untreated acute condition

• Mental health is all too complex & scary!

– No it’s NOT! Its the people we all know with depression/anxiety, eating disorders, perinatal depression, OCD, alcohol, psychosis episodes etc.

Mentally ill people don’t want to work

That’s so NOT true. They can and do want to work . But they cant do it if they cant get our very cost effective, treatments to get well first

• Mental health has no evidence based treatments

– No it’s NOT! We have over 100 NICE guidelines , HTAs, Quality standards etc – We have highly powered, robust, cost effective treatments if given early – The neurobiology & science & economics are not understood

• Mental health has no data to help commission locally appropriate services

– NO, we now have the Mental health intelligence network like caner or CVD – (http://fingertips.phe.org.uk/profile-group/mental-health/profile/severe-mental-illness/data) – We have robust economic cost evaluations for every single mental health condition

The national mental health strategy

Three areas to focus on for overarching national vision Tackling causes, building health literacy & prevention in individuals

and communities Addressing common mental health conditions & integrating physical and mental health in:

• Primary care,
• Acute ( physical focus) trusts
• Community providers,
• Social care

The complex specialist population

1.

2. 3.

In your communities, how much social wealth is lost due to NOT

tackling the causes of mental ill health and providing providing early access Do you know this for your city? See how London did it ..

The report is available to download from – www.london.gov.uk/mentalhealth

Tackling causes Building health literacy Prevention

Employment

Family friendly, productive practices, Creating wealth Can every large, medium & small employer be a positive employer? What can GPs and CCGs do?

Schools:

4 Rs: reading , writing, ‘arithmetic & Resilience

Building resilience , addressing dyslexia Training school nurses & form tutors Engaging school governors

College students: & Adult education

Building resilience & Physical & mental health literacy in future leaders

Transport hub related :

Preventing isolation in older people Reducing avoidable suicides and Reducing detentions

1

Fire chiefs

70% of avoidable fires, domestic accidents, & RTAs

Police commissioners

Commissioning parenting Safer neighborhoods Alcohol

A few ‘heavy hitters’ in prevention

• Aim for zero physical, sexual, emotional abuse
• f children in England & your community
• Support people to get ‘good’ employment as

that promotes positive mental health

• Tackle bullying early & dyslexia in schools
• Support parenting, relationship building,

resilience training

• Roughly half of all lifetime mental disorders start by the mid-teens and three-

quarters by the mid-20s.

• Later onsets are mostly secondary conditions.
• Severe disorders are typically preceded by less severe disorders that are seldom

brought to clinical attention” Kessler et al, Current Opinion Psychiatry, 2007

Why is prevention & early intervention crucial Key age range for onset

Investing in prevention and early intervention Is your area, & your taxpayers aware that not investing in evidence based care is losing the local economy money

For each £ spent you save

• £8 from early interventions for parents of children with conduct

disorder

• £84 from school-based social and emotional learning programmes
• £14 from school-based interventions to reduce bullying
• £10 from work-based mental health promotion (after 1 year)
• £5 from early diagnosis and treatment of depression at work
• £18 from early intervention for psychosis
• £10 from early intervention for pre-psychosis
• £12 from screening and brief interventions in primary care for

alcohol misuse

• £4 from debt advice services

The national mental health strategy

Three areas to focus on for overarching national vision

Addressing common mental health conditions & integrating physical and mental health in:

• Primary care,
• Acute ( physical focus) trusts
• Community providers,
• Social care

The complex specialist population

2

3.

THE KEY FACTS about access to treatment: Parity and Human Rights: improving Information, access and waiting times to evidence based, outcome measured care, & advancing person centric new treatment methods 26% of adults with mental illness receive care 92% of people with diabetes receive care

By condition….

% in treatment Anxiety and depression 24 PTSD 28 Psychosis 80 ADHD 34 Eating disorders 25 Alcohol dependence 23 Drug dependence 14 Mental health problems are estimated to be the commonest cause of premature death Largest proportion of the disease burden in the UK (22.8%), larger than cardiovascular disease (16.2%) or cancer (15.9%) People with psychosis die 14-20 years earlier of untreated illness Depression associated with 50% increased mortality from all disease 59% triple amputees can be treated to get back into employment 7% SMI get evidence based care to get paid work…….

Supporting employment: Mental health perspective

• Mental ill health is common across the world and prevalence and incidence increases in

economic recession( Marmot, 2012), so England can expect more

• Mental ill health accounts for 30% - 50% of the daily of GPs and primary care but
• Less than 40% of GPs are given any access to post graduate training in mental health & less than

1% of practice nurses who lead the reviews of those with Long term conditions The current model of primary care in England is

• GP as gatekeeper for almost all assessments and care
• The skill mix in the primary care team is predominantly physical health focused & trained i.e.

doctors, physical trained nurses, etc

• Only 40% of GPs, and less than 1% of practice nurses & < 5% of health visitors and < 5% of

midwives, who provide the care for people with Long term conditions have any post graduate MH training ( and some have no undergraduate training)

• 30-50% of the daily work of primary care is people with mental ill health , often those with

co occurring LTCs, So we have a major mismatch between demand and supply

• It is arguable if we can make the transformational changes in employment support needed

with the current model of care and investment in primary care MH and

• The current monocular physical health focus in long term conditions which impact adversely
• n health and employment outcomes

18% 23% 46%

Focus on Mental Health and Work (1)

Source: Data & figures from the Annual Report of the Chief Medical Offi2013 – Chapter 10, ‘Mental health and work’, (Max Henderson, Ira Madan); Labour Force Survey, 2013; and OECD, 2014, ‘Mental Health and Work, UK’.

• Mental illness costs the UK economy £70 - £100bn per year – 4.5% of GDP (OECD estimate)
• Since 2009, the number of working days lost to ‘stress, depression and anxiety’ has increased by 23%
• Since 2009, the number of working days lost to ‘severe mental illness’ has doubled
• 60-70% of people with common mental disorders (such as depression and anxiety) are in work but this can be seen

as a risk factor for future employment difficulties

• Co-morbidity of mental disorder and physical disorder is common; of the 15 million people in England with a long-

term (physical) condition, 30% also have mental illness.

• In 2013, almost 41% of Employment and Support Allowance recipients had a ‘mental or behavioural disorder’ as

their primary condition :

What primary care MH models support employment

The models being adopted across the world, & in our most innovative primary care at scale areas include:

• Direct access to psychological therapists or primary care based mental health liaison teams or

new GPwSI in mental health ( this is growing in areas where there are GP recruitment challenges )

• First assessment by MH trained staff, to reduce the current lengthy 4-stage access to treatment

process which compares adversley with the 2 stages process to access physical health care & to both increase and speed up access

• Primary care 'at scale ' one stop shop integrated larger premised/ cottage hospitals: One stop shop

(aka polyclinics) with embedded primary care team, Mental Health Team, employment / CAB specialists , housing & social care ( see LIFT Swindon & London health commission ideas)

• Spend to save integrated physical and mental health CBT based rehabilitation ‘clinics/ group are

reducing acute trust crisis presentations, referrals, admissions and long term conditions clinics attendances, unnecessary diagnostics and operations: CCGs can then use the money saved to invest in primary care psychological services

• Adult education/ joint NHS funded programmes on How to e.g. manage your stress” are attracting

increasing interest in prevention .

• some examples of the future models : Depression case Managers as in Kaeser in Seattle

• 2. Primary care mental health

learning from the best of international primary care MH leaders

& role modeling collaborative partnerships

Registration & annual checks: integrated thinking: this should include MH

– All registrations and annual heath check include 1 min self completion behavioral health assessment

Primary care team skillmix

– 30% -50% of the daily work.

– But 1.3rd of GPs and o what % of staff with NICE training psychological health training are needed Supporting hard pressed primary care : the basics

– Clinicians decision support templates – Annual checks : zero exclusion of SMI using Family and 3rd sector outreach

Primary care at scale initiatives

– integrated ‘Living well’ care stroke, diabetes, pain, COPD, bariatric surgery care – Named workers in primary care

Population based commissioning for local need

– Enhanced SMI care in inner cities and high psychosis areas – Enhanced MUS care – Alliance commissioning models for integrated alcohol and long term commissioned care

More details @ 70 Case studies that are changing England’s primary care mental health

http://www.slcsn.nhs.uk/scn/mental-health/london-mh-scn-primary-care-commiss-072014.pdf

ACUTE TRUSTS : People with long term physical health conditions die early is heir Comorbidities- common, costly in current silo models of care and commissioning and tariff system incentives inappropriate

0% 20% 40% 60% 80% 100% 120% 140% 160% 180%

% increase in annual per patient costs (excluding costs of MH care)

Depression Anxiety

Comorbidities & mental ill health becoming the norm

Co-morbid MH problems are associated with a 45-75% 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.

The national mental health strategy

Three areas to focus on for overarching national vision The complex specialist population

3.

Commissioning care early, closer to home, in the most high impact rehabilitation, least restrictive care settings

High secure

CCG NHSE LA N/A Commissioner: Locked rehabilitation

Bed + assertive outreach / rehab. team

Open rehabilitation

Bed + rehabilitation / recovery team

Residential rehabilitation

Accommodation + rehabilitation team

Supported accommodation

Accommodation + intensive community treatment team

Own tenancy

Support from community / primary care teams

Low secure

Bed + comm. forensic team

Medium secure Spectrum of MH services

• Early intervention

psychosis teams 24/7

• Raid Liaison mental health

services 24/7 days

• Crisis Home treatment

teams 24/7 days

• Multi disciplinary , multi

agency teams

• Partnerships around

housing

The 7 core effective care interventions in the treatment of mental health conditions

1. Right information 2. Right physical health care 3. Right medication 4. Right psychological therapies 5. Right rehabilitation, training for employment 6. Right care plan addressing housing, work, healthcare, self management 7. Right crisis care

2 2

Mental health : Is the problem that we have no evidence or value based guidance?  Mental health has over 100 NICE Health Technology appraisals, NICE guidelines, Public health related guidelines and Quality standards…..  The problem is not lack of guidance  The problem is that we have not focused on how we learn and disseminate from those that can and have implemented  The standard of Care has unacceptable major variation across England

Psychosis: National audit of Schizophrenia 2013 and 2014 show the gap between the

standards and the current pattern of care in England

–Current services: –- Standard care means that duration of untreated psychosis is

now 8-30 months: with lifelong poor outcomes –- Only 29% receive Cardio metabolic assessment & only 25% receive treatment –- 34% do not have NICE psychological therapies –- 16% of medicines prescribed do not adhere to guidelines. –- The Variation ranges from 0-70% across England

Future services:

• Early intervention

psychosis teams which: Treatment in the first critical 8 weeks

• full NICE compliance
• home based care
• recovery to employment

Key messages for local champions and commissioners

Understand:

• how your community can build positive mental health & resilience

Identify & prevent:

• the preventable causes of mental ill health in your area & act to prevent

Get the facts into your local JSNA

– Based on facts, intelligence, not myths

– Ensure that all 16 areas of mental health are included in your local JSNA

• Commission: for

– for early intervention & recovery & citizenship – Whole people not just body or mind or social parts – evidence based care and better outcomes, value based care

New access and waiting times standards

• New mental health access waiting times standards are being introduced

during 2015/16. A question has arisen about how and when these standards should be incorporated into the NHS Standard Contract. The new standards are

• 75% of people referred to the Improved Access to Psychological Therapies

programme will be treated within 6 weeks of referral, and 95% will be treated within 18 weeks of referral.

• More than 50% of people experiencing a first episode of psychosis will be

treated with a NICE approved care package within two weeks of referral.

• In both cases, the policy intention is that “the standard comes into effect

from April 2015 with the expectation that the target should be achieved by April 2016”.