Welcome to. Northern England and the Five Year Forward View for Mental Health Thursday 2 February 2017 at the Radisson Blu, Durham
Introductions Chairs: Catherine Haigh, Chair of North East together and Dr Angus Bell, Mental Health Lead, Northern England Clinical Networks
Objectives An overview of the Northern England geography and population, as well as approaches to the commissioning and provision of care Share progress, achievements and challenges in meeting the Mental Health Five Year Forward View Update from national mental health programme Consider how we can support each other to improve mental health care Agreement about future working and communications
Hopes for the day Claire Murdoch, National Mental Health Director, NHS England
Understanding the landscape of Northern England
Our Geography Robin Mitchell, Clinical Director, Northern England Clinical Networks
Northern Clinical Networks
Northern Clinical Networks
Three STPs (and three main NHS providers)
Particular challenges Large geographical area Patchily developed transport network High levels of socio-economic deprivation
Our Population a brief overview of health determinants in Northern England and how these impact upon the mental health of the population Dr Angus Bell, Mental Health Clinical Lead, Northern England Clinical Networks
Big Drivers 5YFV Priority 2-2020/21 An integrated mental and physical health approach Health and Social Care Act 2012 - Parity of Esteem between mental & physical health NHS Mandate of 2012 requires the NHS to tackle disparities between mental and physical healthcare. World Health Organization Mental Health Action Plan - To promote mental wellbeing, prevent mental disorders, and reduce the mortality and disability for persons with mental disorders.
With the exception of London, all the areas with a rate of more than 2,000 years of life lost per 100,000 patients are clustered together in the north
Admission episodes for alcohol related conditions benchmarked against England (left) and regional average (right) Comparison with average Better Similar Worse
Excess weight in adults (overweight and obese) benchmarked against England (left) and regional average (right) Comparison with average Better Similar Worse
Smoking prevalence in adults (Annual Population Survey) benchmarked against England (left) and regional average (right) Better Comparison with average Similar Worse
Smoking 5YFV Smoke free in-patient services by 2018 We achieved that by March 2016 Jan 2017 Audit from TEWV 69% of patients with Psychosis smoke.
337 1365 304 1266 322 870 401 1697 396 1638 300 1281 304 1530 357 1364 366 1470 Under 75 Mortality Rates per 100,000 population (DSR) by Region Premature mortality from all causes (Persons)2012-14 Premature (<75) mortality in adults with serious mental illness: Rate per 100,000 1800 1600 1400 1200 1000 800 600 400 200 0 East Midlands East of England London North East North West South East South West West Midlands Yorkshire & Humber Data Source: http://fingertips.phe.org.uk/
403 1744 380 1804 410 1670 422 2244 484 1738 420 1122 390 1785 338 1565 391 1907 441 1686 394 1702 421 1392 344 2029 289 1682 Under 75 Mortality Rates per 100,000 population (DSR) by Local Authority 2500 Premature mortality from all causes (Persons)2012-14 Premature (<75) mortality in adults with serious mental illness: Rate per 100,000 population 2012/13 2000 1500 1000 500 0 Data Source: http://fingertips.phe.org.uk/
Clinical Network - a few examples Highlighted PH48 & through a partnership called Healthy Lifestyles and Harm Reduction supported the Trusts going smoke free March 2016. Formal evaluation in progress. Developed guidelines for screening & treatment of Psychosis across Psychiatry and Neurology Working with the Cardiovascular network to reduce cardiac mortality in Mental Health Sponsoring and developing a regional Obesity Strategy in Mental Health (more later) covering all ages and including those with a learning disability
Northern England, STP and local approaches to commissioning mental health Nicola Bailey, Chief Operating officer DDES, ND CCGs and Mental Health Lead for Northern CCG Forum And James Duncan, Director of Finance and Deputy Chief Executive Northumberland, Tyne & Wear NHS Foundation Trust
North East & Cumbria STP and local approaches to commissioning Mental Health Nicola Bailey Chief Operating officer DDES and ND CCGs Mental Health Lead for Northern CCG Forum
North East & Cumbria And what else can we bring to the STP party James Duncan, Director of Finance and Deputy Chief Executive Northumberland, Tyne & Wear NHS Foundation Trust
Poor mental health can drive a 50% increase in physical care costs Physical healthcare costs 50% higher for type 2 diabetics with poor MH Annual physical healthcare costs per patient, 2014/15 ( ) Additional costs due to increased hospital admissions and complications Annual physical healthcare costs per patient, 2014/15 ( ) 5,000 4,000 +50% 3,430 4,000 3,000 3,430 3,000 2,290 2,000 2,290 2,070 2,000 1,310 1,000 0 1,200 Mostly healthy Type 2 diabetes with good MH Type 2 diabetes and poor MH 1,000 0 720 460 270 270 250 370 Type 2 diabetes & good MH Type 2 diabetes & poor MH Other Complications Prescribing & OD Excess inpatient Primary care Presence of poor mental health responsible for 1.8bn of spend on type 2 diabetes pathway Note: Does not include spend on prescribing psychiatric drugs and other mental health services Source: Hex et all, 2012; APHO Diabetes Prevalence Model for England 2012; Long-term conditions and mental health: The cost of co-morbidities, The King's Fund
Long-term Conditions and need for integrated physical and mental health provision There is a strong association between long-term physical illnesses (such as diabetes, heart disease, and COPD) and mental health problems. This comorbidity leads to poorer outcomes, decreasing quality of life, and increased utilisation of resources. People with long-term conditions use disproportionately more primary and secondary care services. People with one long-term condition are two to three times more likely to develop depression than the rest of the population. People with three or more conditions are seven times more likely to have depression In chronic heart disease, depressed patients have higher rates of complications and are more likely to undergo invasive procedures. People with chronic obstructive pulmonary disease (COPD) who are also depressed have longer hospital stays and increased symptoms.
A history of transforming services across the whole pathway Working in partnership across multiple organisations A history of managing with flat cash Extensive work in supported self management and recovery Care co-ordination across pathways engrained into our way of working
NHSE, NE&C\NY&H STP NTWND\DDTRHW Secure Services Tier 4 CYP services Adult Eating Disorder services Secondary providers holding budgets for tertiary services Recovery Purposeful & Productive Community Services Transforming care for people with LD Physical healthcare of people with Mental health problems or a learning disability TEES, CDD, Northumberland\N Tyneside, Newcastle\Gateshead, S Tyneside\Sunderland, North Yorkshire NE&C CCGS Crisis Concordat Community Perinatal mental health Core 24 Liaison Appropriate access to inpatient care Reducing out of area placements EIP access & waiting times IAPT - access, prevalence & recovery CYP eating disorder access & waiting times CYP transformation Future in Mind Primary Care Mental Health Dementia Diagnosis Parity of Esteem
Collaboration at STP which could make a significant impact What Why STP Benefits realised Children and young people mental health Requires multi-agency buy in particularly across local authority and CCG. Requires addressing wider determinants of health in addition to improvements to clinical care Improved early access to evidence based care, improved outcomes, long term, likely reductions to demand for adult mental health services Perinatal mental health collaboration between mental and physical care providers over maternity provision Better outcomes for mothers and children including reduced pre-term birth, infant death, improved school attainment, improved mental health, reduced costs relating to health and social outcomes of child.
What Why STP Benefits realised Dementia/ innovative care packages Long term Conditions Employment/ Health join up including IPS and IAPT Requires co-ordination between local authority, NHS, care homes, acute providers and others. Coordinate the integrated pathway across primary, acute, mental health and social care Pooled shared budgets with Job Centre+ and CCGs, outcome based commissioning jointly with LA/ CCG for health/ work impact Improved health outcomes, improved quality of life, reduced social isolation, shifting from fragmented to connected care, potential reduced costs in secondary care COPD and integrated pathway (A and E attendance/ hospital admission and bed stays) A and E frequent attenders (chronic pain/mus) Improved employment and health outcomes, reduced overall government spend on population, improved quality of life
Overview of where NE&C is against five year forward view key deliverables and where we plan to be
A Billion for a million by 2020/21 70,000 more children will access evidence based mental health care interventions Intensive home treatment will be available in every part of England as an alternative to hospital No acute hospital is without all-age mental health liaison services, and at least 50% are meeting the core 24 service standard At least 30,000 more women each year can access evidence-based specialist perinatal mental health care The number of people with SMI who can access evidence based Individual Placement and Support (IPS) will have doubled Inappropriate out of area placements (OAPs) will have been eliminated for adult acute mental health care 10% reduction in suicide and all areas to have multiagency suicide prevention plans in place by 2017 280,000 people with SMI will have access to evidence based physical health checks and interventions New models of care for tertiary MH will deliver quality care close to home reduced inpatient spend, increased community provision Increase access to evidence-based psychological therapies to reach 25% of need, helping 600,000 more people per year 60% people experiencing a first episode of psychosis will access NICE concordant care within 2 weeks There will be the right number of CAMHS T4 beds in the right place reducing the number of inappropriate out of area placements
Reduction in demand for secondary and tertiary children and young peoples services, reduction in waiting times, and delivery and monitoring of successful outcomes OUR STP Delivery of milestones in MH5YFV, including coordinated drive to reduce suicide across the STP area Reductions in admissions and length of stay due to more effective integrated management of coexisting physical and mental health conditions to support the out of hospital and acute optimisation programmes Development of resilience through improved support of primary care, access to housing and employment, supporting those in employment, offering options in crisis support, and development of the recovery college approach Reduction in admissions from care homes arising from poor management of mental health in older people
Perinatal Some well established services and transformation funding of comprehensive at scale provision Dementia Good referral and diagnostic rates, further work to define and implement high quality post diagnostic support IAPT Improving access and recovery performance, recognise the capacity and workforce challenge to achieve 25% access targets OUR COLLECTIVE DELIVERY CYPs Large challenge in terms of access, capacity, workforce for evidence based practice, CYP IAPT improving overall provision Crisis and liaison services Liaison services in all areas working towards fidelity to FYFV with ambitious transformation bids submitted EIP Good performance in terms of quick access to assessment and intervention but also workforce shortages CBTp Integrated physical and mental health pathways Liaison services are developing and commitment to fundamentally change approach to integrated healthcare and innovative examples of good practice
Views of a Transformation Journey in Mental Health
Starting point (2008/9) angry GPs & patients care in silos (variation, inequity & boundaries) 1/8 th of referrals at the appropriate team CMHT waits >12 months. No discharges Crisis team (answer machine) focus on assessment of severity poor integration. Late communication Gary Taylor enquiry (2007): medical culture, remarkable lack of communication, toxic
Areas of transformational work Crisis intervention (IRS) CMHT and Community Pathways IAPT and counseling services LTC in IAPT Street triage, MUS Children & Young People s MH Inpatient facilities and PICU Dementia facilities/ services
Key elements of transformation Whole system approach Outcome /value for patient focus (vs diagnosis) Immediate access, single/double point Transparency, continuity (seamless pathways) Availability of clinical records at all times Skills up front. Scaffolding & true consultancy Discharge up front (pt autonomy vs dependency) Holistic (treatment /recovery /positive living)
Process Collaborative Hands on Engagement of major stakeholders Incentives
Key results transformed service user and referrers experience no major risks in benefits realisation plan excellent access. Good (short term) outcomes 40-50% beds reduction adult wards 80% reduction in PICU beds & 136 facility use >50% drop in urgent admission rate for MH acclaimed services (many awards) accreditation (Liaison; IAPT); outstanding CQC
Psychiatric Decision (PDU) The PDU is an ambulant assessment area which provides a calming environment for the assessment and development of treatment plans for more complex service users who are in crisis and are accessing emergency services. The reduction in time pressure enables the service user to think through more clearly the nature of their crisis and the sort of help they need to recover, both over the short and long term, and gives clinicians time for more thorough, ongoing assessment. This enables treatment plans to be tailored to the needs of the service users, making full use of community services, and is less likely to result in an inpatient episode. The aim of the PDU is to provide an environment and atmosphere that is conducive to enabling service users to relax, and to provide high quality, thorough assessment, leading to well developed, service user-centred treatment plans. This will enable the service user to both manage their immediate crisis and place them onto a (usually community based) pathway, leading to more robust recovery. Between March and August 2014, the Street Triage team brought 297 patients directly to A&E. In the same time frame in 2015, Street Triage decreased the number of patients going to emergency departments by 39% through the use of PDU.
Other areas where mental health might look to deliver specific benefits as part of their STP footprint Leadership Demand management and care close to home Multidisciplinary teams Integration with social care and multiple agencies Mental Health has met a lot of challenges that acute care is now facing, e.g., living within a fixed (block) budget, closing beds, treating people closer to home and out of hospital. MH leaders should play a key role in supporting STPs to address financial challenges and need for new care models. Mental health interventions often have an impact on reducing the wider costs of care for a population therefore links must be made with other leaders in the health economy to secure the importance of high quality evidence based mental health interventions. Mental health providers are used to working in MDTs and may wish to share and co-develop integrated models of care including risk management/stratification with others in the STP, particularly in plans to address long term conditions. Mental health can act as a facilitator in local health economy plans to collaborate with social care and other agencies such as leisure, employers, arts, voluntary sector organisations etc. Mental health providers and commissioners are often working in this way already.