The Long Path to Primary Care Mental Health : Dr David Smart GP NHS Northamptonshire
Common Mental Health Common 2007 Prevalence 16.2% > Elderly / Deprivation > South Asian women Life time 25% 8% pop warrant treatment from healthcare professional 20% increase 93-07 women aged 45-64 Costly Depression 7.5Bn Anxiety 8.9Bn Medically Unexplained Symptoms 18Bn 20% days lost from work due to anxiety / depression. Critical Mental ill health largest cause disability 22.8% Cardiovascular 16.2% Major cause mortality working age 2/3 suicides in depressed people 10% depression chronic Postnatal depression affects child development PTSD associated drug alcohol and homelessness (Looked after children) Early intervention helps
Common Mental Health Curable? 50 % don t attend PHCT > 33% not recognised > practice nurses > if Long Term Condition Eu DEPRES -30% achieve remission 10 year follow up 50 % recurrence 2 nd episode= 70% 3 rd episode= 90% Antidepressants do work for more severe symptoms 33% stop <3m >50 % stop 6m <15% have a choice of IAPT IAPT recovery rates vary Not all CBT Self help,psycho-education, peer support, exercise, groups, IPT, EMDR, debt counselling STAR*D 50% remission after 2 treatment levels Collaborative care better outcomes especially comorbid LTC
AREAS FOR INTERVENTION No health without mental health- Economic case Parity of esteem between mental and physical health services 1. Early identification and intervention as soon as mental health problems emerge 2. The promotion of positive mental health and prevention of mental disorder in childhood and adolescence 3. The promotion of positive mental health and prevention of mental disorder in adults 4. Addressing the social determinants and consequences of mental health problems 5. Improving the quality and efficiency of current services
Humana Review: priorities for users and carers More choice of treatments / interventions Improved information Better primary care mental health More talking therapies Culturally aware services Integration of physical / mental health Stronger involvement of carers Improved respite care
Helen 28-year-old Part-time teacher struggling with work Nine-month-old child delivered by emergency Caesarean section Health visitor asked me to see her as concerned Fleeting thoughts of self harm, not actively suicidal, no risk to child Severity scale moderate to severe anxiety and depression Marital discord with arguments considering separation Previous triathlon runner Husband recently seen with stress at work, low back pain Her sister is also a patient with recurrent depression
Skills Time Attitudes Resources Systems
Helen - Outcome What I think helped Screening Team approach (HV) Psycho-social prescribing- (accessible public mental health) Accessible psychological therapies Antidepressants GP with an interest in follow-up What she thought helped Husband understanding her more (he read surviving abuse book) Feeling understood Space to talk Calming down living in the now Back to gym, space for herself as well as her appearance I am now the mother of my children I wish to be and the wife my husband married
E l e c t r o n i c I n t e g r a t e d C a r e P a t h w a y Delivery of an Integrated Mental Health Care Programme 2003-6. DRAFT Home Treatment team Acute Hospital Mental Health teams Pendered Assessment Team Draft format/basis for service model Need Local Action Points 2003-6 NB for * see "Mental Health Action Plan for Northampton 2003-6" May 2003 CMHT Shared care Gateway Workers GPs with /Nurse special interestconsultant Shared care Graduate Workers Support Workers Formalised Liaison/ Referral processes Link to voluntary sector Duty system Formalised Liaison/ Referral processes Triage Formalised Liaison/ Referral processes PMHCT Counsellor/Helath Visitor/ PCMHNs Links to education PHCT Primary care mental health nurses(pcmhns) development of commissioned voluntary services PCT Link Worker Role 3. Specific evidence based therapy provided by appropriately trained mental health professional. Short to medium term interventions. Group interventions. Medication. Referral to Graduate Workers, Counsellors, triage - dependent upon degree of dysfunction. 2. Primary care mental health nurses, shared care and other trained members of the PHCT. Medication prescribed by GP. Referral to voluntary sector, self-help groups. 1. A range of interventions targeted at an individual, community and organisational level. 5. Interagency team approach. Possible inpatient care. Psychosocial interventions. Ongoing care as required. Shared care models. Onward referral to functional teams. 4. Psychotherapy and/or drug therapy from appropriately trained professional plus liaison with other agencies as required. Long term or episodic care. If not treatable at time of referral, advice on management plus support to primary care with the option to re-refer. Referral to triage. 5. Severe mental health problems with significant impairment of functioning (social/ cognitive/ occupation/ interpersonal/ financial). SMI's *3.1 4. Complex mental health problems, most likely long-standing and recurrent, significantly impairing quality of life and some functions. Reference: "Integrated Mental Health Services, Primary/ Secondary Care Interface", Northamptonshire Healthcare NHS Trust 3. Moderate mental health problems which are not likely to improve without specialist therapy, but which do not prevent most day-to-day coping. 2. Relatively common transient or mild to moderate mental health problems characterised by distress but with a limited effect on functioning. 1. Promotion of mental health for all. Reference: "PCT Mental Health Promotion Strategy" Physical health checks * 1.6 Link Worker Role* 2.6 Suicide prevention Nurse Consultant* 2.3 Reference: "Talking Therapy Services in Primary Care", Dr D Smart & Mr A Howard, April 2003 Reference: "Possible Model of Mental Health & Primary Care", Dr D Smart, March 2003 Primary secondary care interface group Graduate Workers* 2.2 Links to education *2.1 Self empowerment Talking therapy service CD Roms Primary Care Mental Healthcare Nurse / Health Visitor* 2.4 Get Set Go * 1.5 Activity referral programme * 1.7 Maternal Health ICP * 1.2 Access wall chart *1.1 Link to voluntary sector * HP Link to Local Authority Services * HP Electronic ICP* 4.4 Core curriculum *4.1 Carer support *3.2 User support* 3.2 Audit* 4.3 Clinical Supervision *4.6 Governance Pack *4.5 Access to education & training * 1.4
Why was this plan not implemented? Jenkins, Klein & Parker, BMJ, July 2005 - Top heavy systems of mental health care are coupled with relatively underdeveloped systems of primary care.. While access to essential medicines is usually possible, access to evidence based psychological interventions is still limited. This arises from poor awareness of the international evidence base on diagnosis, effective services, and interventions. National strategic framework mental health 1999 NHS reorganisation- loss of relationships/gp influence Stigma / discrimination, not sexy?
Changing Minds Depression care training centre,1997 post defeat depression campaign. Interagency training centre Values-based education 10 essential shared capabilities Trailblazers New ways of working Nurse consultant primary care mental health Graduate workers Health visitor with special interest Wellbeing Partnerships Waller Trust Libraries Adult Education Exercise on prescription Public health Improving Access to Psychological Therapies
Integrating mental health in Primary Care Does Primary Mental Health Care Exist? Five High Impact Changes Screening Severity Risk Assessment Shared Management Plan Follow up Appointment Quality and Outcome Framework Continuity vs Team Resources Counsellors Link Workers Graduate Workers Antidepressants GPs /Practice Nurses Systems of Care Changing Minds- Well Being Teams Improving Access to Psychological Therapies Developing a Common Mental Health Pathway Collaborative Care?
The Wellbeing Service Network C O M M U N I T I E S STEP 1: GP Surgeries STEP 2: Choice Appointment & Follow Up Cross Cutting Services Citizens Advice Bureau Criminal Justice System Adult Education Peer Support Welfare Rights Job Centre Plus Housing Advice Parental Services Drug & Alcohol Crisis Support Wellbeing Team Review (May 2009) Increasing Access to Psychological Therapies (Sept 2009) STEP 3: CBT, Psychology & Counselling STEP 4: Step Down Project
Stepped Care Model for Anxiety and Depression (Adapted from NICE guidance, 2004 and 2007) Step Provider Interventions Step 1 GPs and other Primary Care Practitioners Screening and Structured Watchful Waiting Step 2 Well Being Teams Holistic assessment of needs and strengths Range of psychological and social interventions Recovery orientated and evidence based Step 3 Well Being Teams Increased intensity/duration - Senior Practitioner/ Consultant Nurse input and psychology Step 4 Well Being Teams Specialist Services Collaborative work between Well Being Teams and Specialist Services Step 5 Specialist Services Crisis Resolution, Inpatient Care, CMHT
Learn2b is investigating the impact of Adult Learning on physical and emotional wellbeing There is a significant increase in overall wellbeing and an improvement in HADs scores post learn2b Greatest improvements on the REF were that people had more confidence in their ability to cope, and felt that they had more meaningful activities and enjoyment in their life after attending a Learn 2b course. The REF measures which showed the least improvement after attending a Learn 2b course were people s ability to practice their spiritual beliefs and the level to which people felt supported by their family.
Proposed Whole System Care Pathway STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Recognition Managing mild problems Managing moderate to severe problems Involvement of specialist services Inpatient care 3 rd sector organisations Primary Care practitioner A and E Individuals GP out of hours T R I A G E Local Enhanced Primary care service: a managed network: Managed counselling service Wellbeing teams Carers support workers 3 rd sector services STR workers Employment support (ISA 1) 3 rd sector organisations Specialist Assessment & interventions (ISA 2) CRHT Specialist secondary Services Complex and long term care Assertive outreach Early intervention No 63 Acute Tertiary Residential Nursing care
Commissioning Strategy - No Health Without Mental Health 2008 NHS Northampton Board Northamptonshire CC Cabinet Commissioning Team Developing Flourishing Communities Integrating physical & mental health JCB/ NHSN Commissioning Executive Managed Network Board (implement strategy) Wellbeing Service Network Redesigning Specialist Services Dementia Pathway
MH Commissioning System and Process NCC Nene Commissioning Localities Declaration of Wellbeing Joint Commissioning Board (S75) Integrated care Partnership Forensic services Learning Disability Residential & Domiciliary Individual Packages Care Maternal health Drugs and Alcohol Team Mental Health Strategy + Interfaces Children's services Public Health Carers Social Care Health and wellbein g board Service users outcomes MH Managed Network Board MH Clinical network board Specification PBR Providers Long Term Conditions KEY Urgent Care E d u c a t i o n Social Movement Of Wellbeing 23/03/2011 monitoring COMMISSIONING CYCLE contracting quality GOVERNANCE ENGAGEMENT COMMISSIONING DELIVERY
Community elderly care service (+dementia) Alcohol pathway Acute Trust Mental Health Liaison Service Common mental health Public mental health Happiness Ward Assessment Self Harm
C O M M U N I T I E S Integrating the Wellbeing Service Network & Community Nurses- Opportunity to develop Collaborative Care? STEP 1: GP Surgeries STEP 2: Choice Appointment & Follow Up Cross Cutting Services Citizens Advice Bureau Criminal Justice System Adult Education Peer Support Welfare Rights Job Centre Plus Housing Advice Parental Services Drug & Alcohol Crisis Support STEP 3: CBT, Psychology & Counselling STEP 4: Collaborative Care C O M M U N I T Y N U R S E S
Foresight: Mental Capital and wellbeing project mental capital trajectory
The mental health spectrum From: Huppert Ch.12 in Huppert et al. (Eds) The Science of Well-being Flourishing 20% Moderate mental health 50% Languishing 20% Mental illness 10%
The effect of shifting the mean of the mental health spectrum From: Huppert Ch.12 in Huppert et al. (Eds) The Science of Well-being Flourishing Moderate mental health Languishing Number of symptoms or risk factors Mental disorder
The New Task - Market Facilitation a Joint Endeavour The interventions commissioners make in order to deliver the kind of market believed to be necessary for any given community. Market intelligence The development of a common and shared perspective of supply and demand, leading to an evidenced, published, market position statement for a given market. Market intervention Market structuring The activities designed to give the market shape and structure, where commissioner behaviour is visible and the outcomes 26 they are trying to achieve agreed, or at least accepted.