OUTLINE PROPOSAL BUSINESS CASE Name of proposer: Dr. David Keith Murray, General Practitioner, Leeds Student Medical Practice, 4, Blenheim Court, Blenheim Walk, LEEDS LS2 9AE Date: 20 Aug 2014 Title of Proposal: Acute Primary Care Mental Health Support for the Student Population. Description of proposal: Background Mental health is a key issue for the student population. Students represent a vulnerable group of people, for the following reasons; They are living away from home, usually for the first time They are away from their usual support mechanisms, i.e. their family, friends at home They face the pressure of tuition fees, often working in addition to studying They live in shared accommodation which can exacerbate/highlight a pre-existing mental health disorders/traits They are exposed to new elements of peer pressure, for example alcohol and drug use Widened access policies have enabled students to attend University who in the past would not have had this opportunity. This group often needs much more support with mental health issues. Improving support for these patients would reduce the burden of A&E admission, crisis assessment episodes, and potential self-harm and suicide attempts. New interventions would hopefully impact on the number of students suffering disruption to their academic career or dropping out from University completely. The Leeds Student Medical Practice (LSMP) has for many years noted that the mental health needs of the 35,000 young people it serves are specific and often require an immediate response. The current Community Mental Health services with their standard and often long wait times do not appear to be meeting the needs of these patients. This assumption is now increasingly supported by evidence from patient feedback. The University of Leeds is currently reviewing its provision for the mental health of the student population. The review has been prompted: (a) by a material change in the numbers and needs of students over the last two decades, and (b) because University services are operating in a context of increasing pressure on NHS and other community-based 1
provision, which fail to address the needs of students and the annual rhythm of a programme of degree study. As part of this review, the University of Leeds has held a series of meetings in a Consultation on the future provision of support for the emotional, psychological and mental health needs of students. There have been three meetings seeking information on the current provision and gaps in provision from groups including patients represented by the Students Union, the International Office, Accommodation Services, University Student Counselling Services, Accommodation Services and the Chaplaincy. Feedback given during the third meeting of the series indicated that the inquiry team had consistent messages from earlier contributors from different fields. Positive areas of care were identified for those students who were able to access help. Support from the University Student Counselling Service and the one Mental Health Support Advisor helps a few people, but both services lack capacity at busy periods in the year (current caseload of this one worker is approximately 600). The University Student Counselling Service has tried to meet this demand by reducing the number of appointments it offers to each client in a course of counselling. The figures suggest that the Mental Health Support Advisor is running with a caseload significantly greater than an equivalent NHS colleague. The University is able to ask students to provide a letter from a doctor which can encourage some students into seeking help who may not have previously done so. A key problem for students is being able to access help in a timely manner. They face an academic timetable which requires them to be able to turn problems around quickly as losing only a few weeks of study can lead to the loss of an academic year or a withdrawal from University with a consequent waste of time and financial pressure. In times of difficulty, the student is able to access a General Practitioner at the time of need. Changes in the appointment systems at LSMP have increased appointment times from 10 minutes to 15 minutes allowing more time to address mental health issues. These changes have also led to each day in term time starting with over 200 free appointments that day. Patient feedback through NHS choices and other sources has been mostly very positive about this. The difficulty comes when onward referral to mental health services is required. Current services The first port of call is the Primary Care Mental Health Worker Service delivered by Leeds Community Healthcare (IAPT service). The student has to self-refer via a call-centre. Unfortunately the offer is often of an appointment in 3-6 months time and not at the time of need. The added problem with this time delay is that this often then takes the appointment into the next academic holiday when the student may be elsewhere in the country. Students report that they then end up being discharged from Mental Health services and not receiving any help. Having three Universities within Leeds West leads 2
to approximately one third of the population being under the age of 25. Despite this, Leeds Community Healthcare Mental Health service does not provide any specific service for the student population. For more severe and enduring problems the Community Mental Health Team (CMHT) provided by Leeds and York Partnership NHS Foundation Trust provides the next tier. This is however a service with its own constraints; it has recently seen a reduction of services at Malham House Day Hospital close to the University, with a shift of service delivery to more distant parts of Leeds North West. At present the Malham House Consultant is off work with a long term sickness absence and the Registrar is off work on maternity leave. Only one locum has been engaged to cover the Consultant. Feedback from students indicates that it is not unusual for CMHT to assess a patient as unsuitable for their service and to suggest referral to another service. This may be back to the Primary Care Mental Health Workers of a Third Sector provider. Delivery of care for eating disorders is through referral from CMHT to the Yorkshire Centre for Eating Disorders (YCED). The limitations of their capacity mean that they have stringent exclusion criteria from the service and they see only the most severe of cases. Psychology is accessible following onward referral from CMHT but only after a 26 week waiting time. The student with a mixture of mental health and drug or alcohol problems often has difficulty accessing mental health help as mental health services are often reluctant to take them onto their caseloads until the drug and alcohol problems have been separately addressed elsewhere in the system. Drug and Alcohol services are delivered by either the Leeds Addiction Unit or BARCA (a third sector organisation). Third sector organisations provide another route for onward signposting from Mental Health services who assess a patient as not suitable for their services. The problem with this re-routing is that it s not unusual for the student to get to third sector services as perhaps a third step in their journey to find help, and then find a small voluntary organisation that has closed its waiting list due to demand. Present Mental Health services are not structured in a way that addresses the acute problems students present with. The only acute offer to the majority is on-line information but patient feedback is that at time of crisis an on-line offer is a hollow offer. Work is commencing to address these concerns between the Leeds Student Health and Wellbeing partnership and the city-wide mental health commissioners. This includes a review of the access issues for the student population. Difficulties in timely access to appropriate mental health support leads to inappropriate use of Accident & Emergency and secondary care services caring for overdose and self-harm. Repeated General Practice appointments are used as an interim support measure whilst waiting for access to mental health services. This impacts upon 3
access for patients with other problems. The Proposal This business case presents a proposal to develop a Student Mental Health service that would integrate the University of Leeds and LSMP to deliver care to this group of patients that is appropriate, timely and accessible. This proposal seeks to secure funding to employ Mental Health workers attached to the LSMP. A successful model has already been developed at LSMP where nurses consult alongside GPs with the ability to hot-transfer any problem needing GP input. The empowerment and development of skills of the nursing team has facilitated the development of excellent access and very positive patient feedback. This proposal aims to develop and support the Mental Health workers in the same way. With flexible working hours they could be accommodated within existing premises. In addition, due to the nature of the student timetable and in order to match capacity and demand across the academic year, there is the option to offer some posts on term-time only contracts. This proposal is focused on utilising the 2.64 attached to the Better Care Fund where the proposal for the remaining 37 West Leeds practices has been to commission appropriate case co-ordinators to improve the care for the over 75 population which is not relevant for the LSMP population. (There is only one patient over the age of 75 registered at the practice). In order to avoid the problems outlined above, this proposal aims to innovate in service delivery. The aim is for a service model with appointments mirroring the same day service at LSMP which would provide more timely intervention. There is belief that by offering help earlier, patients can avoid their problems becoming more entrenched and requiring longer durations of input. This business case proposes that Mental Health Workers would work alongside General Practitioners and see patients in the same timely manner that the GP does. GPs consulting alongside Mental Health Workers provide the safety net of rapid escalation to a clinician if indicated. Patients will be seen in the same way as they are seen by the General Practitioner, and will not be excluded on the basis of being assessed as not suitable for our service. Where problems such as drugs, alcohol or psychosis dictate a specific onward referral, patients will be supported until they are fully engaged with the appropriate service. The majority of the consultations will involve a meeting with the worker who will determine the most appropriate level of support. Some may move towards support from computer based resources others may move towards therapeutic CBT based help. As part of its review in the provision of the mental health needs of the student population, the University of Leeds is also proposing to develop a more integrated approach to mental health and well-being. The University has indicated that they would consider a match funding 4
arrangement with the Leeds West Clinical Commissioning Group to deliver this approach which would be configured to meet student needs and address periods of peak demand. A meeting is planned on 29/9/14 to discuss this with Leeds University. Leeds Metropolitan University has invested in and developed its own Student Wellbeing Team for its specific population. Leeds Metropolitan University Students would not be excluded from the proposed service but a higher proportion of the practice population comes from the University of Leeds. Strategic fit: It is also acknowledged that this service would complement the role of the Student Mental Health Advisor at the University of Leeds who supports students with more severe and enduring problems. Priority Health Goal D of the strategy is: Improving the mental health of the population This is aiming to tackle unmet need in the mental health of the student population. Priority Health Goal G of the Strategy is: Commissioning an effective response to urgent care needs. Present Mental Health services do not meet the urgent mental health care needs of this population. Organisational Development: Effective Partnerships Working with the University provides an opportunity to use the resources and organisational memory of both the NHS and academic organisations. Organisational Development: Effective Use of resources - Securing matched funding doubles the value of the NHS pound. This proposal aligns with Better Care Fund and Leeds Transformation Board principles of cross organisational working, placing well-being at the centre of our services and taking a proactive approach to problems: Rather than fishing an ever-increasing number of people out of the water, let s stop them jumping into the water in the first place Dr Ruth Caleb, Brunel University, July 2014 (refer to Appendix 2 Westminster Briefing). Patient Engagement: LSMP patient feedback has identified the gaps in the current service. In addition the University of Leeds has held a series of meetings in a Consultation on the future provision of support for the emotional, psychological and mental health needs of students. This consultation has also provided confirmation as to the current gaps in service. These meetings have involved a wide spectrum of patients including representatives from the Students Union, the International Office, Accommodation Services, University Student Counselling Services, Accommodation Services and the Chaplaincy. There is proposed further patient engagement including: 1. Meet & Greet questionnaire in the LSMP waiting room 5
2. Feedback via Virtual Patient Reference Group 3. Request feedback from Student Minds (see Appendix 1 for feedback compiled from a recent research project conducted on Integrating Care for Eating Disorders at Home and at University ). Impact / benefits: Improved patient care The aim is to provide mental health support at the time of need. Consultation rate data can be recorded and measured from the EMIS system. Cost saving to the health economy There is likely to be reduced impact of this population on A&E and General Medical services. A review of A&E data identified mental health problems as the most common reason for the top ten A&E attenders in the practice. Reducing A&E contact by one per day would be viewed as a success. Demand management - Providing help at the time of need is likely to lead to a more rapid resolution of mental health problems and avoiding longer courses of therapy delivered only once problems have become entrenched. Population need The University s consultation on the future provision of support for the emotional, psychological and mental health needs of students has identified the gaps in care. The Joint Strategic Needs Assessment recognises the effect of both mental health and alcohol on the city. This population contributes significantly in both areas. The transitions report produced by Student Minds identified gaps in treatment for Eating Disorders. The Health Communities Student Survey completed with support of Public Health Leeds documented significant rates of Depression & Low Mood in the population highlighting higher rates in ethnic minority students. This proposal supports collaborative working with the University and presents an opportunity for match funding to support this group of patients. Options A number of options have been considered - Option 1 Secure funding to employ Mental Health workers attached to the Leeds Student Medical Practice (LSMP). A successful model has already been developed with nurses consulting alongside GPs who have the ability to hot-transfer any problem needing GP input. The empowerment and development of skills of the nursing team has facilitated the development of excellent access and very positive patient feedback. This proposal would develop and support the Mental Health workers in the same way. With flexible working hours they could be accommodated within existing premises. However due to the (potential) limited nature of this funding, the risk of employment sits with the practice as a small organisation. Option 2 Secure funding to expand current IAPT (Improving Access to Psychological Therapies) capacity provided by Leeds Community Healthcare. This option would provide funding to enhance the current IAPT offer 6
and provide a timely service more suited to the needs of students. However, there is no guarantee that this funding would be directed to support the student population from LSMP. In addition the access criteria would remain the same and the problems of assessed as unsuitable for our service would remain. There is however a benefit in so much as employment risk remains with a large organisation rather than LSMP. Option 3 Secure funding to expand the current University of Leeds Student Mental Health Advisor service. There is currently one Student Mental Health Advisor provided by the University of Leeds. Additional funding would enable expansion of this service. This would work collaboratively with the existing Student Mental Health Advisor and the University Student Counseling service. Again, there is a benefit in this option as employment risk remains with a large organisation rather than LSMP. However this option would not allow for the ability to upscale rapidly to a GP or the consulting alongside model. Option 4 There is the possibility to include the further 2.36 of the Better Care Fund allocated to development of the Integrated Health & Social Care teams. This would be of greater benefit to this population as adding a further 2.36 would enable recruitment of a further 2WTE Primary Care Mental Health Workers or 4 WTEif the University were able to match this further step. This would however remove funding from the Integrated Health & Social Care teams. High level cost / savings: Option 1 is presented as the preferred option within this business case. Option 1 costs Recurrent pay: 0.4 WTE Band 4 admin 10,269 4.5 WTE Band 6 MH workers 166,590 Non Pay travel, PC etc 7,941 Total 184,800 All pay costed at mid-point of the salary pay scale with 24.4% on costs included. Year(s) of funding Date of business case review Potential funds available 2.64 x 35,000 (Leeds Student Medical Practice registered list) = 92,400 Match funding from Leeds University = 92,400 Total potential funds available = 184,800 2014-15 CCG BCF allocated funds then recurrent through BCF from 2015/16 19/8/14 Recommendations 7
to proposer Proposed funding stream Proposed approval body Better Care Fund CCG Governing Body Appendices (available from Jayne Bathgate upon request) 1. Student Minds University Challenge: Integrating Care for Eating Disorders at Home and at University 2. Stress and Mental Wellbeing in Higher Education, Westminster Briefing, 22nd July 2014 8