Adult Mental Health Update

Adult Mental Health Update Amy Clark Programme Manager, Adult Mental Health - EIP and improving physical health in SMI NHS England amy.clark10@nhs.net

Contents 1. Expanding access to IPS 2. Reducing Acute Mental Health Out of Area Placements (OAPs) 3. Improving Physical Health in SMI

Expanding Access to IPS Lauren Melleney Project Manager, IPS, NHS England lauren.melleney@nhs.nett

The Mental Health FYFV target NHS England has committed to doubling access of Individual Placement and Support (IPS) by 2020/21 enabling people with SMI to find and retain employment. 2016/17 2017/18 2018/19 2019/20 2020/21 Baseline audit of IPS provision undertaken STP areas selected for targeted funding 25% increase in access to IPS 60% increase in access to IPS 100% increase in access to IPS

IPS Baseline Figure (NHS Benchmarking & Centre for Mental Health) Region STP # accessing IPS London NCL 40 London NEL 246 London NWL 772 London SWL 510 London Total 1568 Midlands and East The Black Country 31 Midlands and East MKBL 101 Midlands and East Nottinghamshire 123 Midlands and East Northamptonshire 139 Midlands and East Shropshire, Telford & Wrekin 141 Midlands and East Lincolnshire 196 Midlands and East Staffordshire 328 Midlands and East Suffolk and NE Essex 1417 Midlands and East Mid & S Essex 1965 Herefordshire and Worcestershire 155 Midlands and East Total 4996 North Greater Manchester 39 North Cheshire and Merseyside 142 North West Yorkshire 790 North Total 971 South Devon 110 South Frimley 119 South Bath, Swindon & Wiltshire 174 South Cornwall & IoS 435 South Somerset 596 South Sussex & E Surrey 1206 South Total 2640 National Total 9775

Proposed Investment Strategy In order to distribute the transformation funding, we would like to conduct an allocation process across STPs in partnership with regional teams. We are looking to award funding in two targeted waves: o 2018/19 2019/20: Wave 1: Expansion at pace within an STP area that already have high performing IPS or employment support services; o 2019/20 2020/21: Wave 2: Increasing provision in STP areas that do not have any/ provision is limited. STPs who bid for Wave 1 funding will be expected to outline how they are already demonstrating, or close to demonstrating, best practice, and therefore can expand at pace (to IPS fidelity) as they already have the infrastructure and specialist knowledge in place to do so. These services will already show a history of commitment to supported employment. STPs who bid for Wave 2 funding will be expected to demonstrate that they are increasing provision in areas that do not have any/ little supported employment presently. Successful sites must also demonstrate how they will share knowledge and prepare provision within their STP geography prior to investment.

What types of services will we invest in? Consideration for all of the following: 1. Those IPS services which already established (e.g. Centres of Excellence) which can demonstrate how they will expand and/or strengthen their current IPS services to reach more people with serious mental illness and help then gain and retain employment. 2. Those services who already have supported employment services as part of their community mental health teams, and who can use the additional funding to boost them up to good IPS fidelity. 3. New services in areas of the country which do not have access to a supported employment service, but can demonstrate how they will successfully set up a new IPS service, and help reduce variation across the country. Wave 1 Wave 2

Reducing Acute Mental Health Out of Area Placements (OAPs) Programme update Ruth Davies Programme Manager, Adult Acute Mental Health Care, NHS England ruth.davies18@nhs.net NHS England December 2017

The national ambition FYFVMH Deliverable: The practice of sending people out of area for acute inpatient care due to local acute bed pressures eliminated entirely by no later than 2020/21 Linked Deliverables: By 2020/21, NHS England should expand Crisis Resolution and Home Treatment Teams (CRHTTs) across England to ensure that: a 24/7 community-based mental health crisis response is available in all areas these teams are adequately resourced to offer intensive home treatment as an alternative to an acute inpatient admission 400 million has been made available over 4yrs via CCG baselines to support this expansion. What do we know about current OAP activity? From recent data on OAPs, it is estimated that each year around 8,000 adults who need acute inpatient care are sent out of area. This translates to around 280,000 out of area bed days, at a cost to the mental health system of around 100 million. Around half of all placements are more than 100 kilometres from the person s home, and roughly 80% of the total costs are paid to non-nhs providers, funds which can be better spent on strengthening community-based acute mental health services and other alternatives to admission. Reduction in OAPs will be a key metric for measuring the progress of STPs and it is one of the 16 KPIs across the NHS England mental health programme. It is also a key deliverable for all mental health providers, and NHS Improvement has included an indicator on OAPs in the revised Single Oversight Framework for Mental Health Trusts.

So far, to support this ambition we have 1. established a national definition which recognises that both distance travelled and continuity of care are key issues; 2. launched a new data collection to establish a baseline position for England; a better understanding of local variation and a means of monitoring progress towards delivering our commitment; 3. developed clinical pathways and commissioning guidance with the National Collaborating Centre for Mental Health to support whole system transformation needed to sustainably eliminate out of area placements UEMHC and acute mental health care pathways to be published shortly; and 4. established a joint NHS England and NHS Improvement national and regional support programme, setting the aim for clear local trajectories and plans for eliminating OAPs.

Joint NHS England and NHS Improvement national and regional oversight and support: Key deliverables The overarching objective of this programme is to ensure people are able to access least restrictive care as close to home as possible. This objective is underpinned by the following key deliverables: All areas to have robust, clinically-led, multi-agency plans in place by April 2018 for reducing OAPs, including quarterly level trajectories (provisional plans by December 2017); Reliable national data held on acute OAP activity by no later than April 2018 (this requires accurate data submission by no later than Jan 2018); Around a One-third year-on-year reduction in OAPs delivered nationally from April 2018 to 2021 (this high-level aim will be reviewed once all local plans and trajectories are confirmed). STPs have been asked to collate the information for OAPs trajectories and plans, with demonstrated input from CCGs and providers. Plans will include: Baselines and trajectories for STPs and each provider in the patch (opportunities to refresh trajectories going forwards) Details of new local investment e.g. in CRHTTs, other crisis/community based services, LA services etc. Leadership & Governance in place at senior levels, including senior clinical leadership for acute pathway/flow management Specific details on actions to address DToCs locally Identification of particular local pressures further support needs from NHSI and NHSE www.england.nhs.uk 11

Current Joint Support offer Resource pack: Which includes case studies and good practice guidance, has been shared with STP SROs for Mental Health. STP data packs: Data packs have been developed for every STP with a bespoke cut of nationally available information. These are intended to prompt local discussions, and to supplement existing local intelligence to inform the local planning process. Webexes to support data submission: focused on improving the quality of acute Out of Area Placements (OAPs) data Launch of NHS Improvement s quality improvement and support network for mental health: Led by National Clinical Director for Mental Health, Tim Kendall. The first meeting is planned for 5 December and will focus on OAPs. All mental health provider Medical Directors (as well as regional Medical and Nursing Directors) have received invitations to this and are encouraged to attend. Clinical and operational expert resource: Bespoke expert support will be available for areas in developing trajectories and clinically-led action plans. This will take the form of facilitated workshops with local system leaders to help identify key issues and solutions, in order to refine local action plans. We have secured input from clinical leaders who led the successful OAPs elimination programmes in Sheffield, Cheshire and Wirral. National OAPs network: The joint national NHSE / NHSI programme overseeing OAPs implementation will establish an informal national OAPs network following the initial review of trajectories and plans in December. This will provide an opportunity to share learning between local, regional and national programmes, and tailor further support offers. We encourage involvement from NHSE and NHSI regional and sub-regional teams, NHS clinical networks as well as people in local providers, commissioners and STPs.

Key questions for local systems seeking to address OAPs - taken from areas who have successfully transformed their acute mental health systems Whole system priority 1. Is there agreement at all levels that OAPs are a priority / Board-level responsibility? 2. Is there a Clinical and/or Service Director who is personally responsible? 3. Is the whole system coming together in partnership to redesign pathways and agree processes? inpatient staff, CRHTTs, social care, AMHPs, CMHTs, voluntary sector, patients, IAPT, primary care 4. Is there a financial risk/benefit sharing agreement in place between providers and commissioners? 5. Is there a long-term plan? whole system transformation may take over 2 years to sustainably and safely eliminate OAPs NHS and LA service provision 6. Have core community mental health services been strengthened? 7. Is there a system-wide approach to 24/7 crisis and home treatment services that interface with key external stakeholders, particularly A&E, police and ambulance? 8. Has there been investment in alternatives to admission through innovative models such as crisis recovery cafes and intensive home-based services? 9. Are there well-resourced, personalised social care packages and are AMHPs integrated with NHS teams? 10. Is there adequate housing locally, including specialist supported housing for mental health? Senior clinicians leading intensive focus on pathways, length of stay, bed management, patient flow 11. Are admissions therapeutic and purposeful (not simply risk-driven containment )? 12. Is discharge supported by high quality community services that are engaged in discharge planning from the point of admission? 13. Are services using real time data, including info on bed availability, capacity of HTTs, and other alternatives? 14. Is there readily available information on patients who have passed discharge dates, when reviews are planned and new discharge dates given? 15. Is there an agreed principle that bed / HTT must always be available where that is the right choice, with a similar bed management approach to HTT as for inpatient beds?

Q2 17/18 (July-Sept) Reported OAPs North region and north STPs N.B. The information below is collected through a provider level dataset. STP figures are derived from the patients registered GP address and are therefore an approximation only. Total number of inappropriate OAP days over the period* Inappropriate OAPs started in period Total Cost For Inappropriate OAPs in Period Percentage of OAP days with an external provider** Percentage of Percentage OAPs days with a Adult Acute private provider Percentage Acute Older adults Percentage PICU North region 17,345 535 3,746,190 79% 61% 66% 12% 22% Northumberland, Tyne and Wear Durham, Darlington and Tees, Hambleton, Richmondshire and Whitby West, North and East Cumbria Lancashire and South Cumbria West Yorkshire Humber, Coast and Vale Greater Manchester Cheshire and Merseyside 200 15 67,415 76% * 81% * * 1,055 30 * * * 33% 67% * 175 * 95,301 100% * * * * 2,580 65 1,215,100 95% 60% 50% 8% 42% 6,005 140 804,072 88% 70% 78% 4% 19% 2,435 65 538,469 57% 49% 57% 32% 11% 3,915 170 801,398 94% 82% 74% * 23% 205 25 127,881 100% 83% 100% * * South Yorkshire 770 30 96,552 36% 31% 50% * 50% and Bassetlaw *Inappropriate OAPs are those solely due to unavailability of a local bed ** External OAPs are those outside of the person s home provider (either another NHS or and independent sector provider). OAPs can be internal this usually occurs where across large provider footprints where the location of the admitting unit disrupts the person s continuity of care. www.england.nhs.uk 14

Improving physical health care for people with SMI amy.clark10@nhs.net York, December 2017

Physical health in SMI: a case for change People with SMI face stark health inequalities and are less likely to have their physical health needs met, both in terms of identification of physical health concerns and delivery of the appropriate, timely screening and treatment. Compared to the general population, individuals with SMI (such as schizophrenia or bipolar disorder): Face a shorter life expectancy by an average of 15 20 years. Are three times more likely to smoke. Are at double the risk of obesity and diabetes, three times the risk of hypertension and metabolic syndrome, and five times the risk of dyslipidaemia (imbalance of lipids in the bloodstream). Why? Lack of clarity around responsibilities in healthcare provision in primary and secondary care. Gaps in training among primary care clinicians. Lack of confidence across the workforce to deliver physical health checks among people with SMI. 16

Mental Health Five Year Forward View Objective NHS England should ensure that by 2020/21, 280,000 more people having their physical health needs met by increasing early detection and expanding access to evidence-based physical care assessment and intervention. CCGs are to offer NICErecommended screening and access to physical care interventions to cover 30% of the population with SMI on the GP register in 2017/18, moving to 60% population from the following year. This is to be delivered across primary and secondary care. Goal: To improve access to: physical health checks AND follow up interventions for people with SMI To improve the quality of: physical health checks AND follow up interventions for people with SMI17

Secondary care what does the PH SMI CQUIN require? i. The % of patients with psychoses that receive a comprehensive range of cardio metabolic assessments and access to evidence based interventions where needed Internal provider sample submitted to National Audit provider for the CQUIN ii. Patient care plans or comprehensive discharge summaries shared with GPs Assessed through an internal audit undertaken by providers Weighting: 80%** Weighting: 20%** In 15/16 EIP settings were brought within scope and for 16/17 Community Mental Health Services (Patients on CPA) were also brought within scope. **Weighting refers to pay-out ie. each element contributes towards a percentage of potential pay-out for this indicator. This does not take into account milestones that are assessed locally 18 1 8

Headline national findings 2016/17 The table below shows the national figure for the % of patients in each setting who received the full set of checks and follow up interventions in each year of the CQUIN scheme. It shows that since 2014/15 the number of people receiving the full set of physical health checks and follow up care in inpatient mental health settings has increased. However the rate of increase slowed between 2015/6 and 2016/17 This is the first year in which the CQUIN scheme has covered community mental health teams and the audit data shows a promising start Inpatient Community 14/15 39% 15/16 56% 16/17 60% 42%

PSMI CQUIN: learning from high-performing areas Common drivers for improving physical health care provision to people with SMI, as highlighted by high-performing areas: A collaborative environment and joint working; Co-production of interventions; The availability of IT systems; Clear steer, focus and support on a local-level; The availability of the appropriate resources, e.g. standardised template for checks see case study below; Opportunities for training. 20

Primary care role in improving physical health From April 2017, 41m entered CCG baselines for the purposes of increasing the delivery of NICE-recommended screening, bolstering access to physical health interventions and ensuring that high quality training is in place for staff responsible for undertaking the screening. The table below highlights the year-on-year investment available for the delivery of physical health checks and the subsequent system-level savings that could be realised: CCG baseline allocations for improving the physical healthcare of people living with SMI Expected savings: physical healthcare for people with SMI 2016/17 2017/18 2018/19 2019/20 2020/21-41m 83m 83m 83m - 27m - 81m - 108m 108m Commissioning options include: 1. Local Enhanced Service via GP contract 2. Enhanced primary care service e.g. commissioned from secondary mental health provider 21

The recommended physical health assessments for people on the GP SMI register 22

Case Study: Bradford Template Following a clinical audit across local general practices in Bradford and Airedale, the physical healthcare of people living with SMI was identified as not being consistently monitored. Bradford District Care NHS Trust, in collaboration with the Yorkshire & Humber Academic Health Science Network (AHSN), designed, developed and implemented a standardised Bradford Physical Health Review Template. Methodology: Assembled a working group, including GP MH leads, consultant psychiatrists and data quality specialists. Piloted the template across two MH Trusts and two CCGs. Ensured the electronic template is compatible with a range of datasets. Developed framework for training across primary and secondary care to support implementation. Local incentive scheme to increase use of the template. CCGs can run quarterly reports centrally under EMBED. Outcomes: The template is available through the SystmOne, EMIS and RIO platforms. The template is regularly used by 610 organisations and 74 CCGs. Implementation of the template has resulted in a 372% increase in physical health checks in one Trust alone. Usage of the template has led to an increase in timely detection of CVD risks, as well as an overall improvement in the delivery of health assessments. It is estimated that the delivery of 47,713 health checks could lead to potential cost savings of 11.3 million over the next 10 years in the Yorkshire and Humber region alone. 23

Questions for discussion 1. What areas of good practice are you aware of in relation to improving physical health care provision for people with SMI that would you like to showcase? 2. Are there any concerns and issues in relation to improving physical health care provision for people with SMI you might require support on? 24

Proposed approach to trajectory setting The proposed methodology for establishing CCG- and STP-level trajectories for the delivery of physical health checks and interventions relies on health checks and interventions delivered cumulatively both in primary and secondary care settings: a) Total numbers of physical health checks in primary care from 2017-18 Measured from 2018-19 CCG-level collection b) Additional numbers of PH checks in secondary care from 2017-18 Modelled to CCG- and STPlevels from provider-level 2016-17 PSMI CQUIN data Total number of physical health checks 140,000 nationally by 2017-18 280,000 nationally by 2018-19 a) Further work is required to establish a methodology to collect data to inform the primary care element of these trajectories. The methodology will likely rely on a CCG-level collection, given the spectrum of commissioning arrangements that may be in place to support the delivery of this ambition across various localities. The baseline is assumed to be zero in primary care (although checks have been completed historically these have not been comprehensive assessments). b) The secondary care component of CCG- and STP-level trajectories for the delivery of physical health checks can be extrapolated from data derived from provider-level 2016-17 PSMI CQUIN scores. The secondary care baseline will be taken from 2017-17 CQUIN data. 25

Additional resources Appendix A: Supporting PSMI CQUIN information and toolkits Appendix B: Resources for service users and carers Appendix C: Training programmes Appendix D: Other useful resources

Appendix A: Supporting PSMI CQUIN information and toolkits (1/2) Previous 2016/17 CQUIN audit information including FAQs: http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/cquin.aspx 2017-19 PSMI CQUIN spec: https://www.england.nhs.uk/nhs-standard-contract/cquin/cquin-17-19/ Lester UK Adaption: Positive Cardio-metabolic Health Resource: http://www.rcpsych.ac.uk/pdf/rcp_11049_positive%20cardiometabolic%2 0Health%20chart-%20website.pdf CQUIN toolkit developed by Rethink Mental Illness: CQUIN ward poster, the integrated physical health pathway 2014, the self assessment of readiness for implementation tool (SARIT), information leaflets, GASS, medications information etc. https://www.rethink.org/about-us/health-professionals/cquin-downloads 27

Appendix A: Supporting PSMI CQUIN information and toolkits (2/2) NICE implementation products: Baseline assessment tools, NICE pathways, online learning modules, and local practice examples can be found on the tools and resources tab of the guideline. https://www.nice.org.uk/guidance/cg178/resources The Health Active Lives (HeAL) Leaflet: Aimed at prescribers, particularl for prescribing for first episode psychosis. https://www.getselfhelp.co.uk/docs/healthyactivelives.pdf Top ten tips on how Leicestershire Partnership NHS Trust achieved the PSMI CQUIN: http://www.rcpsych.ac.uk/pdf/lphr%20toptentips%20cquin.pdf 28

Appendix B: Resources for service users and carers Health and Wellbeing Booklet, South Essex Partnership University NHS Foundation Trust: http://www.rcpsych.ac.uk/pdf/wellbeing%20booklet%20new.pdf My physical health, Rethink Mental Illness: https://www.rcpsych.ac.uk/pdf/rethinkphchecklist.pdf. 29

Appendix C: Training programmes RAAMPS: Recognising and Assessing Medical Problems in Psychiatric Settings: A simulation course aimed at getting a multidisciplinary team to engage with patients and address the physical health needs of the patient http://www.rcpsych.ac.uk/pdf/wellbeing%20booklet%20new.pdf Breaking down the barriers programme. UCLPartners (UCLP), Health Education England (HEE): A mental and physical health awareness package delivered to mental health practitioners http://uclpartners.com/what-we-do/clinical-themes/mental-health/breakingdown-the-barriers/ Yorkshire and Humber e-learning package, Yorkshire & Humber Academic Health Science Network (AHSN): Free online e-learning module for primary care professionals in addressing the physical health needs of people with SMI to improve clinical outcomes http://www.yhahsn.org.uk/new-elearning-package-launched/ 30

Appendix D: Other useful resources (1/2) Bradford tools and templates: Bradford SystmOne screenshots: www.tpp-uk.com/mhpr Shared care protocol for patients on anti-psychotic medications, Bradford District Care NHS Foundation Trust: http://emsenate.nhs.uk/downloads/documents/antipsychotic_physical_health_ Monitoring_Shared_Care_Guideline_May V5 2015_3.pdf Smoking Preventing ill health by risky behaviours alcohol and tobacco, CQUIN 2017-19 NHS England https://www.england.nhs.uk/nhs-standard-contract/cquin/cquin-17-19/ Smoking cessation in secondary care: mental health settings: https://www.gov.uk/government/publications/smoking-cessation-in-secondarycare-mental-health-settings 31

Appendix D: other useful resources (2/2) NICE guidance smoking cessation in secondary care in mental health settings: self assessment tool: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/4 83699/Selfassessment_tool_for_mental_health_NICE_PH48_NICE_endoresement_correc tions_v_1.1.xlsm Public health NHS Health Check, Public Health England Designed to to detect early signs of stroke, kidney disease, heart disease, type- 2 diabetes and dementia, and is offered to all adults without a pre-existing condition, aged 40-74. Offered every 5 years. http://www.nhs.uk/conditions/nhs-health-check/pages/nhs-health-check.aspx Know your Heart, British Heart Foundation: Interactive learning tol, designed to help people learn about how their hearts work, how to keep your heart healthy and lower your risk of getting cardiovascular disease https://www.bhf.org.uk/heart-health/how-your-heart-works/know-your-heart 32