Briefing May 2017 Issue 293 Mental health and community providers lessons for integrated care Key points In 2015 a group of nine mental health and community provider NHS trusts came together, hosted by the Mental Health Network (MHN), to share learning and explore how the multispeciality provider model can drive the delivery of integrated mental and physical healthcare. This briefing explores how mental health and community provider organisations are approaching this challenge and distills the key points and lessons learned from the wide-ranging discussion: A number of mental health providers took on the provision of community services from their local primary care trusts under the transforming community service programme. The mental health taskforce makes a number of recommendations aimed at better integrating provision of mental and physical healthcare. Case studies illustrate how providers are using the opportunity of delivering both mental health and physical health services under the same organisational banner to improve outcomes for service users. Culture, education and development, plus aligning incentives are all key to enabling successful integration of services. Background People with mental health problems commonly experience poorer physical health. Long-term severe mental illness is particularly associated with higher levels of physical illness and significantly reduced life expectancy. However, as many including the King s Fund 1 have pointed out, integration initiatives in the health sector have often paid less attention to the opportunities presented by further integrating mental and physical health services. Yet there is a significant business case to be made for doing so. Thirty per cent of people with a long-term physical health condition also have a mental health problem. 2 It is thought that between 12 per cent and 18 per cent of all NHS expenditure on long-term conditions is linked to poor mental health and wellbeing between 8 billion and 13 billion in England each year. 3 In the case of Type 2 diabetes, 1.8 billion of additional costs have been attributed to poor mental health. Yet fewer than 15 per cent of people with diabetes have access to psychological support. Pilot schemes show providing such support can improve health outcomes and cut costs by 25 per cent. 4 Organisations that deliver both mental health and physical care are on fertile ground to improve both individual outcomes as well as contribute to wider societal and economic savings by providing more holistic care.
Policy context Over the last decade, a number of policy initiatives have laid some of the groundwork for greater integration. Transforming Community Services Mental health care has traditionally been delivered by a broad church of providers who have historically focussed on the delivery of mental health as a specialism. A number of NHS mental health trusts and foundation trusts took on community services from their local primary care trusts under the transforming community services (TCS) programme, which was established in 2009. 5 Greater competition was introduced at the same time as the TCS programme. This aimed not only to support patient choice but to ensure fairer competition between providers. As a consequence service contracts have become increasingly fixedterm rather than open-ended to allow for periodic market testing. These combined agendas opened the door for mental health organisations to diversify provision. In an earlier MHN briefing, Mental health and community services: A marriage made in heaven?, 6 we explored the implications of mental health organisations delivering a more diverse portfolio of services. The paper identified promising opportunities and examples of good practice, as well as reflecting some concerns about the potential for mental health to become marginalised in new organisational structures. Five Year Forward View for Mental Health In recent years, there has also been an increased focus on the potential for community-based services to reduce pressure on the acute sector. There is greater recognition that improving mental health crisis care is a significant part of the solution, yet in practice the emphasis often remains on reducing general acute pressures, largely emergency department attendances and lengths of stay. The NHS s Five year forward view 7 calls for doing far better at organising and simplifying the (urgent and emergency care) system, with the aim of helping patients to get the right care, at the right time, in the right place by making more appropriate use of primary care, community mental health teams, ambulance services and community pharmacies. The report of the mental health taskforce 8 set out a wide range of recommendations to improve services, amongst them calls for mental health care and support to be more deeply embedded within the wider healthcare system. Recommendations for greater investment in liaison psychiatry, perinatal mental health services, the physical health screening for people with mental health problems, and the trialling of other service models, are all targeted at achieving greater joined-up care for people with physical and mental health needs. 9 Further initiatives A range of initiatives have been introduced to ostensibly help support better integration and placebased care, including the Better Care Fund, integrated care pioneers, primary and acute care systems (PACS) and multispeciality community provider (MCP) vanguards, sustainability and transformation plans (STPs) and devolution deals. 10 Calls for mental health care and support are for them to be more deeply embedded within the wider healthcare system. 02
Case studies MHN members who operate mental health and community-based services shared a number of case study examples where services are delivering mental and physical health services in a more integrated way. Oxleas NHS Foundation Trust Delivering integrated children s services Five years ago at Oxleas NHS Foundation Trust, family and service-user feedback led the trust to acknowledge that the division of services into categories such as community physical health nursing and child and adolescent mental health services (CAMHS) did not reflect the reality that about one third of young people with autistic spectrum disorder (ASD) and attention deficit disorder (ADHD) will have other significant comorbidities. To change this, the trust has adopted a joint multidisciplinary team approach and created a new care pathway. The integrated neuro development pathway is made up of professionals from a variety of specialities, including speech and language therapy, clinical psychology, community paediatrics and psychiatry across specialist children s services and CAMHS. The team undertakes ASD assessments, including where there may be co-morbid mental health difficulties and/or ADHD. There is a single point of referral and an integrated triage meeting. Children s needs are closely matched with professional capability and capacity to meet the child s needs as well as to offer a service within a reasonable period of time. The integration of community children s nursing services (physical health) and community mental health nursing staff (mental health) began in 2012 by the creation of an integrated community team approach within the trust. Both CAMHS medical and nursing staff and physical health, medical and nursing staff are embedded within the multidisciplinary team approach and now routinely put together joint strategies for the same patient. The trust reports that these strategies are proving far more effective and meaningful for both the child receiving the service and the professional delivering it. The trust continues that one of the most effective aspects of co-location has been to bring psychologists and community paediatricians into the same space. The team has embedded the open Rio approach across the directorate. There are still paper records and always the potential for duplication and confusion, but the availability of an open record accessible to all staff working with a family has been fundamental in breaking down professional boundaries and ensuring that the child s and family s needs are identified and met. Advanced dementia services team The advanced dementia services team recognises that the challenges that follow the onset of dementia are often predictable. With careful planning, these can be anticipated and impact lessened. The team works to anticipate events and situations which are likely to trigger emergency department visits. They then work with the carers and family to plan how they would cope and what assistance would be useful, rather than experiencing the event as unexpected and feeling overwhelmed. The service has resulted in a significant reduction in unproductive visits to the emergency department and supports people to remain at home for longer. There is emerging evidence that the work of the trust in developing pathways as alternatives to admission have led to significant reductions in admissions, for instance on the King s hospital site. One of the most effective aspects of co-location has been to bring psychologists and community paediatricians into the same space. May 2017 Issue 293 Mental health and community providers lessons for integrated care 03
Lancashire Care NHS Foundation Trust Lancashire Care NHS Foundation Trust provides mental health and physical health in equal measure, in terms of people and spend. The trust works with three local councils and eight clinical commissioning groups. The organisation works through four clinical networks. These are established as autonomous business units, and have laid the ground work to create real potential and opportunity to achieve the benefits of being a multi-speciality community provider at scale. Integrated neighbourhood teams In Central Lancashire, mental health and physical health had been working alongside social care through 11 integrated neighbourhood teams (INTs). Central to the way INTs work has been the end of referrals within teams and a reliance on co-location and excellent communication. Within Central Lancashire, the trust made a significant investment to place three mental health workers into physical healthcare teams. The trust reports that a six month pilot demonstrated: Improved awareness of mental health practices and confidence for physical health staff to respond appropriately if a mental health need was identified. An understanding of the wider determinants of health and wellbeing and relevant services. Better use of mental health services and more focused referrals to secondary mental health care. Potential cost and utilisation advantages. Although small-scale, the evidence from the pilot suggested that numbers of sessions utilised were reduced and fewer onward referrals to secondary mental health services were made. Highly visible and accessible mental health support to GPs, integrated neighbourhood teams, and physical health colleagues without the need for referrals. The Harbour inpatient facility physical healthcare team The Harbour provides over 150 mental health beds and is located in Blackpool. The service has been developed around a model of the complete integration of mental and physical health needs. Staff teams push beyond their traditional professional boundaries and focus on the whole person. The Harbour employs a permanent physical team to support treat and promote physical wellbeing of service users, carers and staff. Close working with acute partners has also led to a selection of inhouse and local supporting services including ECG, phlebotomy, podiatry, tissue viability, dietetics and speech and language therapy being delivered at the unit. The team at the Harbour are also in the process of involving specialists in diabetes. The team is now collecting regular data on the physical health (both acute and chronic) of the service users at the Harbour. This information will assist in future decision-making for services required to support health and wellbeing. Diabetes and depression The trust s talking therapies team provides joint diabetes and depression clinics. They, along with a growing number of other integrated providers, recognise that failing to acknowledge this comorbidity results in less effective care and wasted opportunities to improve care across traditional specialities. Staff teams push beyond their traditional professional boundaries and focus on the whole person. 04
Barriers and enablers Oxford Health NHS Foundation Trust Oxford Health NHS Foundation Trust, as part of the Oxfordshire Mental Health Partnership, operates an ambulance triage service (ATS). Based at South Central Ambulance Service, the triage service operates between 6pm and 5am, filtering emergency (999) and nonemergency (101) calls from the public. The service helps to provide access to mental health support. Care coordinators can be contacted and increased calls for emergency support via the ATS can be a valuable relapse indicator and a sign of changing need. The trust reports that there has been a 25 per cent drop in the volume of emergency ambulance journeys involving mental health patients, plus callers receive a service that addresses their issues. Results are a 25 per cent drop in the volume of emergency ambulance journeys involving mental health patients, plus callers receive a service that addresses their issues. Workforce, culture and estate Many local areas can demonstrate good practice, which see staff from different disciplines co-located and working together very successfully to deliver more holistic physical and mental health assessments and treatment. Developing the right culture between professional groups and teams is vitally important to develop a common sense of purpose in delivering whole person care. Training and development is crucial. Curricula must have, as the King s Fund 11 has pointed out, a sufficient common foundation in both physical and mental health. At a national level, more must be done to embed new ways of working across medical, nursing and allied health professional education and ongoing development. Increasingly, integrated providers such as Oxleas NHS Foundation Trust are offering joint mandatory training for their staff and have a strong belief in equipping staff to transfer skills across professional groups. The importance of the estate and bringing different staff groups together in the same location to share skills, knowledge and to develop joint strategies is also key. Information and technology is also crucial to facilitate communication and manage risks to vulnerable people. Stability Whilst rarely afforded in the health and care sector, stability is key to integrating services successfully. Providers are often implementing new policies, initiatives and programmes at any one time and recently this has included the vanguard programme, the development of STPs, and various devolution deals. Significant changes elsewhere in the system, for example in social care, can heavily impact on the local area of provision and impede efforts to integrate services. For example, large reductions in some local authority budgets have impacted massively on the provision of social care and housing services. We heard from a number of provider representatives that practitioners value the benefits of integration but also that mental health services need to retain their edge and distinctiveness. Some practitioners May 2017 Issue 293 Mental health and community providers lessons for integrated care 05
References are concerned about losing their specialist focus and depth of knowledge and the implications of a generic health approach. Therefore working to ensure that services are integrated, but also to maintain a deep learning and focus that specialist perspectives can give, are key. Investment and payment mechanisms Whilst providing more integrated services offers the chance to realise efficiencies in the system, getting this right requires upfront investment. Mental health services have been historically underfunded. There was a 600 million real term fall in NHS mental health funding (8.25%) over the course of the last parliament. 12 Separate payment mechanisms, incentives and budgets for the delivery of physical and mental health services can act as a significant barrier to integration, although the development of new payment systems may offer opportunities to redress this challenge. MHN viewpoint Treating physical and mental health needs together as part of a whole-person approach to care presents the opportunity to improve outcomes and reduce health inequalities. Mental Health Network members who are delivering mental health and community services have demonstrated that there are numerous opportunities presented by this model for integrating physical and mental health services more closely and realising some of those benefits. 1. Naylor et al (2016), Bringing together physical and mental health: a new frontier for integrated care. (London: King s Fund). 2. Cimpean D, Drake RE (2011), Treating comorbid medical conditions and anxiety/ depression, Epidemiology and Psychiatric Sciences, vol.20, pp.141 150. 3. Naylor C et al (2012), Long-term conditions and mental health: The cost of co-morbidities. (London: King s Fund). 4. Mental Health Taskforce (2016), The five year forward view for mental health. 5. Department of Health (2009), Transforming community services: enabling new patterns of provision. (London: Department of Health). 6. Mental Health Network (2013), Mental health and community services: A marriage made in heaven? 7. NHS England (2014), The five year forward view. 8. Mental Health Taskforce (2016), The five year forward view for mental health. 9. Mental Health Taskforce (2016), The five year forward view for mental health. 10. King s Fund (2015), Devolution: What it means for health and social care in England. 11. Naylor et al (2016), Bringing together physical and mental health: A new frontier for integrated care. (London: King s Fund). 12. McNicoll A (20 March 2015), Mental health trust funding down 8 per cent from 2010 despite coalition s drive for parity of esteem, Community Care. As new models of care develop, including through the MCP and PAC vanguards, we must ensure that mental health is considered a key priority. Without that, opportunities to reduce health inequalities and improve life chances for those people experiencing mental health problems risk being lost. 06
Mental Health Network The Mental Health Network is the voice of mental health and learning disability service providers for the NHS in England. We represent providers from across the statutory, independent and voluntary sectors. We work with government, NHS bodies, parliamentarians, opinion formers and the media to promote the views and interests of our members and to influence policy on their behalf. The Network has 68 member organisations, which includes 93 per cent of statutory providers (NHS foundation trusts and trusts) and a number of independent, third sector and not-for-profit organisations. Our membership also includes housing associations to reflect the link between mental wellbeing and safe, affordable accommodation. For more information about our work, visit www.nhsconfed.org/mhn or email mentalhealthnetwork@nhsconfed.org May 2017 Issue 293 Mental health and community providers lessons for integrated care 07
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