An Integrated Psychological Medicine Service for Devon Symptom Management Devon Partnership NHS Trust Supporting you to live well IN PARTNERSHIP WITH: Royal Devon and Exeter NHS Foundation Trust Northern Devon Healthcare NHS Trust Plymouth Hospitals NHS Trust Northern, Eastern and Western Devon Clinical Commissioning Group
Foreword Mrs Melanie Walker Chief Executive Officer Devon Partnership NHS Trust If we are to continue to deliver high quality cost effective care to a growing and ageing population we have to look for new approaches to drive transformation. Historic division in the delivery of acute, mental health, social and primary care and the specialisation of health care more generally has meant increasing difficulty for patients with more than one area of health or social care need. We need to integrate the delivery of health and social care around the needs of the patient. Working closely with my CEO colleagues in Devon we are proposing an integration in our approach to the care of people with physical and psychological symptoms because it will improve the outcome for people with long-term medical conditions, improve the care for people with medically unexplained symptoms and improve the medical care of people with mental illness. This innovation in partnership with the Centre for Mental Health, the University of Exeter Medical School and the Royal College of Psychiatrists aims to find the right model of integration for the people of Devon. Dr Peter Aitken Chair, Faculty of Liaison Psychiatry, Royal College of Psychiatrists Director of Research & Development, Devon Partnership NHS Trust We have come to organise our health care systems around an unfortunate division of symptoms. We have tended to regard symptoms like worry, stress, distress, memory problems or odd behaviour as psychological whilst symptoms like pain, fatigue, breathlessness, altered bowel function and nausea are considered physical. This is unhelpful because the underlying reason for all these symptoms may be medical, psychological or even social. As a result of this unhelpful division we have divided health and social care services into acute, mental health and social care. Once a person is in one service, it has proved difficult for them to access the help of others should the reason for their symptoms be misjudged in the beginning. This integrated psychological medicine service aims to address this. We propose that people presenting with symptoms should meet with the right expertise to determine the underlying reason and a service that can help with combined medical, psychological and social causes. Dr Geraldine Strathdee National Clinical Director for Mental Health, NHS England For patients living with long-term physical conditions, mental illness is a common and disabling occurrence, particularly depression and anxiety. Medically unexplained symptoms are distressing and debilitating. Left untreated, people find it harder to engage with, and feel in control of, their treatment, rehabilitation, and living a healthier lifestyle. They relapse more, need more crisis care, get admitted more often, have more severe illnesses. The clinical and economic impacts are well known and the avoidable costs to the system are large 12-18% of all expenditure on long term conditions is linked to poor mental health and wellbeing. The Five Year Forward View sets out the principles of integration between physical and mental health. This model of integrated care, proposed for Devon, draws on best practice to bring physical, mental and social care around the person, wherever they present and deliver care interventions that work. The rogramme will generate great data on recovery outcome and cost effectiveness to inform service development locally, regionally and nationally for the future. 2 A Vision For An Integrated Psychological Service For Devon
Contents 1. Introduction 4 2. Strategic Context 5 The Vision 5 Integrated Care 5 3. The Case for Change 6 Long Term Conditions and Medically Unexplained/Functional Symptoms 6 Costs of the problem nationally 7 4. Devon Partnership NHS Trust 8 Organisational overview 8 Business strategy and aims 9 SMART Recovery 9 Success Regime 9 5. The Size of the Problem in Devon 10 Long term conditions 10 Medically unexplained symptoms 10 6. Best practice 12 Evidence from research and literature 12 Existing models of best practice 12 Oxford 13 Rapid Assessment Interface and Discharge (RAID) Birmingham 13 Oldham 13 City and Hackney 13 7. Proposed model 14 Approach 14 Structure of the service 14 Training 15 Pathway 15 Structure of the team 17 Demand for the service 17 Phasing of implementation 17 Research 18 Data collection and evaluation systems 18 Risks and mitigations 19 Benefits 19 8. Stakeholder engagement 20 9. Costs 21 Costs of implementation 21 Anticipated savings 21 Impact of Devon Initiatives 21 10. Critical Success Factors 22 References 23 Glossary 24 A Vision For An Integrated Psychological Service For Devon 3
1. Introduction The challenges of managing individuals physical and mental health are complex. There are high rates of mental health conditions among people with longterm physical health problems, increasing numbers live with multiple physical conditions that have psychological impacts, and people with severe mental illness have a reduced life expectancy mainly due to physical health issues. Management of medically unexplained symptoms has historically been poor, with many millions spent on investigations that have limited benefit to patients (Naylor et al, 2016). Integration of physical and mental health care is essential to treating the whole person holistically. Within the context of the success regime in Devon, we propose to design and build an optimal Integrated Psychological Medicine Service (IPMS) within the area covered by the Royal Devon and Exeter Hospital, and Plymouth Hospitals. The service is aimed at managing people with Medically Unexplained Symptoms (MUS), and mental health aspects of long term conditions (LTCs). The service will be connected to Liaison Psychiatry Core24, Clinical Health Psychology and Neuropsychology Services, IAPT (Improving Access to Psychological Therapies) and medical psychotherapy. Currently no comprehensive service exists within this locality to meet this need. The challenge of full integration of physical and mental health services is significant, and therefore it is proposed that the IPMS is developed over three to five years. Year 1 will comprise recruitment and embedding the service in the areas of most need; in Years 2-3 there will be a detailed evaluation of the service, with a view to developing a case in Years 4-5 to expand the service regionally and ideally nationally. Acknowledgements Devon Partnership Trust Dr. Joanna Bromley - Consultant Psychiatrist and Associate Clinical Director, Liaison Psychiatry Team Ralph Hayward - Programme Manager Dr Sue Mizen - Consultant Medical Psychotherapist, Personality Disorder Service Ann Richards - Managing Partner- Specialist Services Dr Phil Yates - Consultant Clinical Psychologist, Head of Clinical Health Psychology & Neuropsychology Services, Mardon Neuro-Rehabilitation Centre Enable East Marianne Rodie, service user Chris Dickens, Professor of Psychological Medicine, University of Exeter Medical School William Lee, Reader in Psychiatric Epidemiology, Plymouth University, Peninsula Schools of Medicine & Dentistry Michael Parsonage, Centre for Mental Health Professor Michael Sharpe, Professor of Psychological Medicine, University of Oxford Northern Devon Healthcare NHS Trust Northern, Eastern & Western Devon Clinical Comissioning Group Royal Devon & Exeter NHS Foundation Trust Plymouth Hospitals NHS Trust 4 A Vision For An Integrated Psychological Service For Devon
2. Strategic Context The Vision The NHS Five Year Forward View, published in 2014, states that the NHS will take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally but with some services in specialist centres, organised to support people with multiple health conditions, not just single diseases. It states that services need to be integrated around the patient, and that there must be a drive towards an equal response to mental and physical health, and towards the two being treated together We have a much wider ambition to achieve genuine parity of esteem between physical and mental health by 2020. People with mental health problems should have their physical health needs met, and access to psychological therapies should be increased, in particular for those living with LTCs (Mental Health Taskforce, 2016). Delivering the Forward View: NHS planning guidance 2016/17 2020/21 requires every health and care system to come together, to create a Sustainability and Transformation Plan (STP) for accelerating its implementation of the Forward View. STPs will involve a single funding application and approval process, and will be place based rather than organisationally based. STPs will include defined Transformation footprints which should be locally defined, based on natural communities, existing working relationships, patient flows and take account of the scale needed to deliver the services, transformation and public health programmes required, and how it best fits with other footprints In addition in 2016/17 a trial is planned for secondary mental health providers to manage care budgets for tertiary mental health services. The RightCare (2015) programme principles are also relevant here: focusing on value and health outcome, empowering the patient, transforming through systems and networks of care, as opposed to re-structuring, and the need to drive down variation in quality and health outcomes. Thus planning across organisations at all levels of local services will be required to collaboratively develop and deliver all plans going forward. Integrated Care Integrated care involves improving patient care and financial sustainability of health and social care services, and comprises a number of principles: 1. Making best use of resources to improve health and wellbeing outcomes for the whole population 2. Empowering patients to have more control over their care packages, strengthen prevention, selfcare and wellbeing 3. Targeting services focusing integrated services on those patient groups most likely to derive the most benefit 4. Collective leadership and joint working health and social care leaders jointly deliver solutions appropriate to their own communities 5. Incentivising integrated care develop mechanisms to reward organisations and staff to deliver integrated care 6. Ensuring openness and transparency using an open-book approach towards all aspects of integrated care development (NHS Confederation and Royal College of General Practitioners, 2012) 7. Embedding high quality research within the service from the outset will ensure that best methods are used to monitor processes and outcomes of care, and provide the opportunity to improve health outcomes for people with complex physical and psychological needs Better mental health care makes sense. First, it makes sense morally that the major public health problems of our age are addressed. Second, it makes sense because the personal and collective costs, both fiscal and not, of not doing so are so great. IPMS promises better care for patients, fewer harms, and lower costs to the healthcare economy as a whole. It is part of the future of healthcare. William Lee, Reader in Psychiatric Epidemiology, Plymouth University, Peninsula Schools of Medicine & Dentistry A Vision For An Integrated Psychological Service For Devon 5
3. The Case for Change Long Term Conditions and Medically Unexplained/ Functional Symptoms The need to provide improved services for people living with long term physical health conditions (LTC), functional/medically unexplained symptoms (MUS), and mental illness, has been identified in a range of research and in national health policy and practice. LTCs include a wide range of conditions, including cardiovascular disease, diabetes, chronic obstructive pulmonary disease, chronic pain, rheumatoid arthritis, and the effects of stroke (Department of Health, 2008). In England, 15.4 million people have an LTC, with an increasing number having multiple conditions this is expected to reach 2.9 million by 2018. People with LTCs take up 50% of all GP appointments and 70% of hospital bed days; their care absorbs 70% of hospital and primary care budgets in England. Evidence shows that many people with an LTC also have mental health problems. People with one long term condition are 2-3 times more likely to develop depression than the general population (NHS Confederation Mental Health Network, 2015). Such problems can lead to significantly poorer health outcomes and a reduced quality of life (The King s Fund and Centre for Mental Health, 2012), further physical health complications and increased costs of care (Aitken, P, Robens, S and Emmens, T (eds), 2014). Individuals with co-morbid (coexisting) physical and mental health problems are more likely to use hospital services, although their mental health will often not be addressed whilst an inpatient (Aitken, P, Robens, S and Emmens, T (eds), 2014). The King s Fund and the Centre for Mental Health (2012) explored research into long term conditions and mental health and found that whilst treating a co-morbid mental health problem by itself does not always improve physical symptoms, integrating mental health interventions with chronic disease management or rehabilitation provides better outcomes for both conditions. For example, pilot schemes have shown that mental health support for people with diabetes improves health and cut costs by 25% (Mental Health Taskforce, 2016). NICE guidance on depression and chronic physical conditions (NICE Guidance CG91) recommends a collaborative model of care between physical and mental health services, with support for the patient to self manage their conditions, and a stepped approach to more intensive interventions where needed. Costs of the problem nationally At least in every between and 1 8 This means 8 13 that billion billion spent on long-term conditions is linked to poor mental health and wellbeing of NHS spending in England is attributable to mental illnesss co-morbid with long-term conditions. These patients generally use more healthcare resources and contribute to wider costs in the community such as sickness absence, cost of informal care and support from friends and family (NHS Confederation Mental Health Network, 2015). 6 A Vision For An Integrated Psychological Service For Devon
People with MUS present to health services in a range of ways from repeated visits to their GP with minor symptoms, to clinically recognised syndromes such as chronic fatigue or IBS (Department of Health, 2014). Patients with MUS comprise a significant number of attendances at outpatient appointments, including around half of attendances in gastroenterology, neurology and cardiology. They also use rheumatology, orthopaedics, ENT and dental specialties in significant numbers. Within neurology, at least 5,000 people a year in Scotland alone are estimated to be diagnosed with a functional neurological disorder (FND), ie symptoms such as blackouts and paralysis that are not due to a neurological disease. People with FND comprise 30% of new outpatient appointments, and 27% do not work, with resultant impacts on the welfare system. Treatment for common mental disorders such as anxiety and depression can be effective where it specifically focuses on the MUS symptoms, however many people with MUS and their supporting clinicians may not understand their conditions can have a psychological component or how therapy can help (Yon, K et al, 2015). Doctors have reported feelings of incompetence and discomfort in relation to MUS; in such cases patients may feel unheard and re-attend more often for support and answers, and their doctors may commission excessive investigations that could be costly and risk further harm (Yon, K et al, 2015). 20% 50% With regard to MUS, statistics vary but between 20 and 50% of cases seen in primary care can be described as MUS which are not linked to clear diagnoses of organic pathology (Yon, K et al, 2015, and Department of Health, 2014). In outpatient clinics patients with MUS can comprise a significant proportion of attenders: 2% 54% 50% 34% 33% dermatology patients gastroenterology patients neurology patients cardiology patients rheumatology patients (Reid et al, 2001). In relation to MUS, 2008/9 NHS figures shows that people with somatoform disorders (mental illnesses that cause bodily symptoms that cannot be traced back to a physical cause) account for as many as : 20% 7% 25% 8% 5% new consultations in primary care of all prescriptions of outpatient care inpatient bed days A&E attendances The estimated cost to the NHS of MUS is 3.1 billion. About half the cost ( 1.2 billion) was spent on the inpatient care of less than 10 per cent of people with MUS, thus a relatively small number of people receive very expensive and inappropriate care (NHS Confederation Mental Health Network, 2015). There are wider costs to the nation too: losses to national output from sickness absence amount to 5.2 billion per year, and the costs of reduced quality of life are 9.3 billion per year (Bermingham et al 2011). A Vision For An Integrated Psychological Service For Devon 7
4. Devon Partnership NHS Trust Organisational overview Devon Partnership NHS Trust serves a large, mainly rural geographical area. 850,000+ Population served almost 18,000 People supported across Devon and Torbay at any one time 130m Annual budget 2,300 Staff employed It provides a wide range of services for adults and older people including depression and anxiety, dementias, alcohol and substance misuse, psychosis, eating disorders, personality disorder and liaison psychiatry. I have worked across primary, secondary and mental health care systems for 30 years and have seen so many patients fall through the gaps between them. I have also been privileged to see the substantial benefits to patients in services where psychological intervention and formulation has been embedded in medical healthcare. We are now at a stage where the evidence both in terms of clinical outcomes and health economic value is difficult to ignore and potentially offers substantial improvements to all concerned. Dr Phil Yates, Consultant Clinical Psychologist, Head of Clinical Health Psychology & Neuropsychology Services, Mardon Neuro-Rehabilitation Centre The Liaison Psychiatry Service operates an extended day service 7 days a week, with a 24 hour service in Exeter, and offers mental health assessments for patients over the age of 18 to end of life and care plan advice to Consultant-led inpatient teams and the Emergency Department at the Royal Devon and Exeter Hospital (RD&E). The service offers inpatient assessment and limited brief interventions as outpatients. It also offers mental health practice education, training and coaching to managers and clinicians at the RD&E. The Clinical Health & Neuropsychology Services are provided by DPT to serve the RD&E based services in neurology (inpatient neuro-rehabilitation), renal medicine, breast care oncology, cystic fibrosis, respiratory medicine, ENT, general medicine, and the pain service. In neuro-rehabilitation and the pain service the psychologists are embedded within the multi-disciplinary team as an integral part of service delivery. The Community Neuropsychology service works primarily with referrals for complex neuropsychological assessments and interventions for acquired brain injury, functional neurological symptoms and degenerative neurological conditions. Because of the high referral rate and complexity of presentation the Community Neuropsychology service provides a specialist FNS assessment and intervention service utilising triage and short-term interventions plus longerterm but time limited CAT (cognitive analytic therapy), ISTDP (intensive short-term dynamic psychotherapy), CBT (cognitive behaviour therapy) and EMDR (eye movement desensitisation- reprocessing) therapies. The Depression and Anxiety Service is a primary care service and treats individuals and groups, in a range of local GP surgeries and community venues. Psychological wellbeing practitioners and therapists deliver interventions that are proven to work including facilitated self- help, CBT, EMDR and counselling for depression. People receive the least intrusive intervention to meet their needs within a stepped care framework. Medical Psychotherapy provides consultant input to the assessment and management of the most complex of medically unexplained symptoms. Expertise in relational models of therapy, formulation and the dynamics of team practice are a key element in integrating complex packages of care between agencies and optimising use of psychotherapeutic resources. 8 A Vision For An Integrated Psychological Service For Devon
Business strategy and aims Our vision An inclusive society where the importance of mental health and wellbeing is universally understood and valued. Our aims To deliver consistently high quality care and treatment To ensure our services are driven by the voices of people who use them To build a reputation as a recognised centre of excellence and expertise To attract and retain talented people and to create a great place to work, with a shared sense of pride and ambition To challenge discrimination and stigma and to champion recovery, inclusion and wellbeing To be an efficient, thriving and successful organisation with a sustainable future. DPT s stated major service priorities this year include: Expanding its liaison psychiatry services in Barnstaple, Exeter and Torquay supporting people with physical health needs in general hospitals who may also have mental health and learning disability needs Reducing waiting times for psychological therapies to a maximum of 18 weeks (Quality Account 2014/15) DPT s Summary of its Business Plans 2012-16 includes the aim to Invest in mental health to support physical health care pathways and improve the overall cost effectiveness of the local NHS. To achieve this DPT has committed to expand psychology and other liaison services for people with physical health problems and to meet the needs of people with medically unexplained symptoms. The outcome will be measured by Improved outcomes for people measured by number of contacts with services and feedback from surveys and other sources. DPT has also agreed a number of targets with commissioners for 2015/16 under the CQUIN programme, including: To improve the experience of everyone using our services, including staff. Improving diagnosis and re-attendance rates of people with mental health needs at A&E. (Annual Report 2014/15) SMART Recovery SMART Recovery is DPT s service improvement strategy that has three underpinning aims: the Right Pathways of care for people from assessment to recovery/discharge, the Right Practice to provide the best possible support to people, and the Right Place to achieve flexible services that support more people without compromising quality and safety of care. Integration and collaborative care are key elements of this strategy, to ensure collective ownership within and across teams, and overall a cohesive strategy to planning and delivering healthcare. Success Regime Devon is part of the Success Regime, which aims to help create the conditions for success in this area by providing increased support and direction and aims to secure improvement in three main areas: Short-term improvement against agreed quality, performance and financial metrics; Medium and longer-term transformation, including the application of new care models where appropriate; Developing leadership capacity and capability across the health system, ensuring collaborative working. This project will aim to achieve the second of these areas, by developing a new care model locally that will improve services in line with the NHS s objectives for physical and mental health. A Vision For An Integrated Psychological Service For Devon 9
5. The Size of the Problem in Devon Long term conditions A number of factors affect the likelihood of acquiring an LTC and the difficulties of managing it. Risky lifestyle behaviours such as smoking, excess alcohol, diet, high blood pressure, being overweight and physically inactive are preventable but contribute disproportionately to deaths from LTCs including cardiovascular and circulatory disease, chronic respiratory disease and diabetes. Deprivation has the biggest impact: rates of people treated with LTCs are up to 70% higher, and hospital admission rates are over 50% higher, in the most deprived areas compared to the least deprived (Public Health Devon, 2015). A proportion of hospital admissions could be avoided through personalised care planning and selfmanagement in primary care. Integration of care would also improve communication between mental health and physical health services, a difficulty identified by a Healthwatch Devon survey (2014). Long term conditions are a significant cost to health and social care services in Devon. The table below illustrates the estimated numbers of people with a variety of LTCs and their associated costs. Many people with LTC will still need to access local health and social care services, so an IPMS would be targeted at reducing these continuing costs, rather than preventing them being incurred. Long term condition No. of people in Devon Annual costs (millions) affected (estimated) Coronary Heart Disease 43,759 64.7 Stroke 19,154 52.4 Diabetes 53,733 45.9 Asthma 71, 853 43.6 Chronic Obstructive 21,405 23.3 Pulmonary Disease c.1,200,000 Devon and Torbay population Medically unexplained symptoms 18+ Data from Scotland found that neurologists are diagnosing Functional Neurological Syndromes (FNS) in around 1% of the population (NHS, 2015), and based on this information we would expect around 10,000 people to be diagnosed with MUS in Devon and Torbay in the main neuro/gastro/rheumatology medical specialties. Most MUS patients will have mild to moderate symptoms, and respond well to brief and short term interventions. However we estimate that in Devon at least 2,000 have complex severe difficulties, which can cost an average of 5,500 per year mainly through attendance at Accident and Emergency and with about 80% being over the age of 18yrs Source: Devon County Council, Devon Health and Wellbeing 1% Severe MUS patients account for approximately 1% of each GP s population (Commissioning Support for London, 2011) - almost 10,000 patients with severe MUS in Devon. inpatient stays, though some cost as much as 52,000 a year. These figures do not include the costs of GP time, social care, out of hours and ambulance services. Based on data from the Commissioning Support for London project (2011), using the GP database to find frequent attenders (over 10 in 2 years) it is estimated that 17 patients at one Devon surgery cost 81,494 in secondary care, or 2396 per patient. The lack of an effective care pathway means that these patients experience little benefit in health outcomes and are caught in an unhelpful cycle of referrals and investigations. A joint research project between DPT and Royal Devon and Exeter Hospitals NHS Trust studied over 250 neurology patients with MUS. 10 A Vision For An Integrated Psychological Service For Devon
They found that 28% of patients accessed acute and specialist medicine, 26% accessed orthopaedic and critical care, and 24% accessed professional services eg physiotherapy. 3,600,000 and 8,250,000 We estimate that Devon and Torbay spend between 3,600,000 and 8,250,000 on diagnostic, outpatient and inpatient stays for people presenting with functional symptoms with no organic pathology. 16% of patients attended Accident and Emergency with symptoms such as non-epileptic seizures and pain, and over half of these were then admitted. Just 26 patients with non-epileptic seizures cost 26,360 in outpatient, and 47,534 in inpatient costs. Recognition of these syndromes is increasing, but what is needed is the right treatment after the right diagnosis. The evidence base for treatment overwhelmingly supports a multi-disciplinary approach incorporating medication and psychological therapy from self guided help to intensive individual and group therapy to admission to a dedicated functional assessment inpatient bed. DPT has conducted a number of research projects to identify the impact of MUS and to support development of innovative services. A study in Devon five years ago of 55 young people receiving psychotherapy services for severely debilitating symptoms, identified the following costs. The severe MUS patient group used approximately 12 times the resources of a person with solely three LTC per year. No. Outpatient Inpatient Cost Outcome of patients Per Annum Non MUS 1 14,720 22,500 1378.2 Multiple severe solely 3 LTCs health problems Moderate 14 121,900 180,150 1260 Frustrating lack of MUS Mean: Mean: 12,867 access to a service Patients 8707 Range 0-47,250 which addresses Total 302,050 their difficulties Severe 41 447,120 5,502,030 16,547.5 Clinical deterioration MUS Mean: Mean: 134,195 outside therapeutic Patients 10,905 Range 3750-682,500 settings. Total 5,949,150 Specialist services include: The Health and Neuro-Psychology Service provides intensive support to inpatients with Functional Neurological Syndromes (FNS) at the RD&E. There is currently only one allocated inpatient bed for FNS in Devon at the Mardon Neuro-rehabilitation Unit. These patients are on a 4-week turnaround for inpatient functional multidisciplinary assessment and so 12 patients a year can be accommodated. There are currently 10 patients waiting for this service at any one time (approx. 10 month waiting list) and more awaiting community neuropsychology team FNS services currently a 6 month (24 weeks waiting list). The service has seen 55 patients in one year, providing brief and longer term complex therapies, resulting in significant symptom remission, with improvements also seen in reductions in GP and consultant appointments. Current data show that the value of triage assessment by experienced senior clinicians as a risk stratification system identifies those requiring short-term intervention (approximately 40%) with quick gain clinical outcomes achieved within an average of 4 sessions. Once triaged the 60% of patients requiring long-term therapy are seen without further waiting time. There is no equivalent service for non-neurological functional disorders in an accessible, timely, acceptable or targeted way. DPT s Liaison Psychiatry and Clinical Health Psychology has piloted a symptom management clinic approach in four clinics in Devon and Torbay between 2010-2012. Tracking of a small cohort of patients who accessed the service to identify their use of secondary care services following the intervention, has identified: savings of 52% in secondary care costs included reduced outpatient diagnostics, GP time, inpatient stays and iatrogenic complications (caused by medical interventions) A Vision For An Integrated Psychological Service For Devon 11
6. Best practice Evidence from research and literature The King s Fund and Centre for Mental Health s report (2012) on the cost of long term conditions and mental health co-morbidities found growing evidence that supporting psychological and mental health needs of people with LTCs can lead to improvements in physical and mental health and reduce the excess costs associated with co-morbidity. However the separation of physical and mental health services institutionally, financially and professionally, means co-morbid mental health in LTC is often undetected or poorly supported. They recommend a series of strategies: Prevention research shows we can reduce the number of people with LTC developing mental illness, for example by supporting with workplace stress, debt and isolation. Detection - Physical illness can make detecting mental illness more difficult, so active case finding is needed to improve detection. Collaboration integrating mental health into chronic disease management or rehabilitation programmes can improve outcomes for both physical and mental health. In practice however this is not consistently achieved: The British Heart Foundation (2014) found that co-morbidities are increasing in cardiac rehabilitation services but the provision for psychological therapies is lacking - of 260 programmes only 25 included a psychologist, and 4 included a counsellor in the staff team. Risks of social isolation and deprivation mean collaboration is also needed with social and welfare agencies. Training integrated care provides opportunities to inform and train the wider workforce in mental health and co-morbidities. People with LTCs should receive support for the psychological aspects of their condition as a standard part of their care (Naylor et al 2016). A stepped approach can support people with MUS. Those with mild symptoms may be supported by a watchful GP, those with moderate symptoms will have psychological interventions as needed, and those with complex needs should access a specialist service (Naylor et al, 2016). The IAPT Medically Unexplained Symptoms/Functional Symptoms Positive Practice Guide (Department of Health 2008) suggests a variety of possible models for IAPT services including addressing wellbeing in primary care settings; being part of a multi-disciplinary team as part of a treatment package in acute care or pain clinics; training and supervision of clinicians in low intensity techniques in LTC and MUS. Possible therapies include: CBT and graded exercise therapy this has the strongest evidence of effectiveness Interpersonal therapy Acceptance and commitment therapy (ACT) Mindfulness therapy there is some evidence this is effective Eye movement desensitisation ie reprocessing (EMD-R) and Trauma focussed CBT this has the strongest evidence of effectiveness for trauma related presentations Intensive short-term psychodynamic therapy (ISTDP) there is emerging efficacy for somatoform / FNS disorders and compelling health economic value. A US study (Abbess et al, 2011) found ISTDP reduced hospital costs by average 3203 per patient compared to increased costs of 974 for patients who did not receive ISTDP Existing models of best practice There are a number of examples of best practice around the UK, here are just a few. Common features include psychiatric and psychological services fully embedded into physical care services, which can be situated in hospitals, intermediate care, primary care or community settings; multi-disciplinary mental health teams collaborating directly with other specialisms; assessment and provision of a wide range of treatments tailored to a huge diversity of patients with long term difficulties; and training of the wider workforce to enable better identification and support of mental health needs. Our proposal draws primarily on the Oxford model where psychiatry and psychology are fully embedded into a range of specialties where MUS and LTC occur, to be able to rapidly identify, assess and treat mental illness as part of a holistic package. The RAID model is the preferred model for urgent care and would form part of the comprehensive IPMS service. The other models described here provide a service covering parts of the primary or secondary services in their areas, but show how effective even these levels of provision can be, and the savings and health outcomes that can be achieved. 12 A Vision For An Integrated Psychological Service For Devon
Oxford Approach Oxford University Hospitals has integrated psychological medicine systemically: (1) integration with medical services; (2) integration of disciplines (psychiatry and psychology); (3) integration with Oxford University. Service - Clinical services include an assessment, advice and support service available for acute hospital inpatients; specialist services for appearance related issues eg craniofacial or plastic surgery; psychological treatments to patients with long term issues eg chronic pain, chronic fatigue and cystic fibrosis; and mental illness associated with cancer or diabetes. Training is provided to professionals in these and other services such as gynaecology, maternity and palliative care. Evaluation - Data on savings is not yet available, however significant improvements are reported in clinician and patient satisfaction, as well as earlier discharge and reduced readmissions, since the service commenced. Oldham Approach The Psychological Medicine Service uses a biopsychosocial approach to improve quality of life for people with physical illness. The service can include liaison psychiatry, CBT therapy, clinical psychology, speciality doctors, physiotherapy, specialist nursing and talking therapy. Service The team carries out multidisciplinary assessments (psychological and psychiatric). Through the hospital, treatments include psychosocial distress and psychiatric disorders, common mental disorders, trauma, sleep disorders, somatoform disorders and MUS. Patients commonly have cardiovascular and respiratory disease, neurological and gastrointestinal problems, diabetes, cancer and chronic pain. In the community, psychological and psychiatric support focuses on pain management for musculoskeletal conditions including arthritis and fibromyalgia. In primary care a persistent pain service provides psychological support using self care and shared decision-making. The team also trains professionals in the acute trust, musculoskeletal care, mental health and IAPT, primary care and higher education. Evaluation - Outcomes are assessed using clinician and patient rated outcome measures. 2/3 of those patients offered an intervention are rated much improved or very much improved. There are significant reductions in scores on the hospital anxiety and depression scale. Over 90% rate of patients rate the quality of care as good or excellent. Birmingham Approach - The Rapid Asssessment service is for people aged over 16 years with mental health or substance misuse needs who access A&E departments in Birmingham and Solihull hospitals. Service Referrals are through a single point of access, patients are seen in one hour in A&E, and in 24 hours elsewhere in the hospital. Early detection of mental illness enables rapid interventions to be arranged. Assessment is made of the care needs of older people with mental illness, and continuity of care is provided for those known to mental health services. Advice is given on alcohol and substance misuse, and the team provides a morning after clinic for those misusing alcohol. The team also supports discharge planning for patients. The team comprises of nurses, psychiatrists, psychologists and physicians assistants. Evaluation in the first year the average length of inpatient stay reduced from eight days to five, with 14,600 bed days been saved over eight months, and the length of stay for dementia patients in City Hospital reduced by at least by 7.5 days per admission. LSE carried out an evaluation in 2011 showing a service benefit to cost ratio of 4:1. City and Hackney Approach - City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS), is an outreach service supporting local GPs in managing patients with complex mental health and other needs that result in frequent use of health services. They may fall through gaps or be difficult to manage due to complexity, eg MUS, personality disorders or chronic mental illness, plus poor physical health and social issues. Service - Support is medical psychotherapy led, provided through case discussions, training and direct clinical interventions. 40-50 referrals a month are received, over 60% from BAME groups. Evaluation - Following treatment 75% of patients show improvement in mental health, wellbeing and functioning, and 55% show recovery ie drop to below a clinical threshold. GPs expressed satisfaction with the service of 8.5-9 on a scale of 1-10. A Vision For An Integrated Psychological Service For Devon 13
7. Proposed model The proposal is for a cutting edge service based on our service in Oxford. We know that if properly resourced it will transform the quality and efficiency of medical care in the region. Professor Michael Sharpe, Trust Lead for Psychological Medicine, Oxford University Hospitals NHS Foundation Trust Approach A biopsychosocial model is accepted to be the most effective intervention to address the patient s holistic needs. This model, founded by Engel, incorporates three levels, biological, psychological, and social, into all health care tasks. Liaison psychiatry and clinical health psychology and neuropsychology services operate outside mental health settings, and instead are part of multi-disciplinary services within acute care settings. They are ideally placed to use its biopsychosocial model to deliver brief interventions to those with physical long-term conditions, unexplained symptoms, and psychological difficulties. The team will be able to provide expert biopsychosocial assessment, formulation, diagnosis, triage and brief interventions for people presenting in medical or surgical care pathways with depression, anxiety or complex unexplained functional symptoms. Medical psychotherapy would offer assessment formulation and supervision to the most complex high-cost cases. The IPMS will be a consultant delivered service drawing from psychiatry, psychological therapies and medicine integral to the multidisciplinary teams working on medical and surgical care pathways. The team will have the expertise to understand: Biomedical care and the creation of an evidencebased medicine management plan. Psychological care and set a psychological therapies intervention plan to evidence based outcome. Social care and set a social care intervention plan to evidence based outcome. Skilled to offer brief intervention in all areas. Experienced in working with young people in a preventative way. The IPMS will offer longer term specialist treatment to the small number of those with complex needs. Structure of the service Referral For those with LTC, the potential need for a mental health service could be identified where the individual, GP, hospital or clinical staff recognise a patient s mental distress or suspect mental disorder, or the patients themselves may disclose mental distress. For those with functional symptoms, the potential need for the service can arise where the following features are identified: Presence of multiple symptoms. Care in multiple pathways. Many investigations. Non-response to treatment. Priority will be given to those patients with greatest complexity and greatest chronicity in the most costly care settings. Assessment and planning treatment On receipt of a referral the IPMS will carry out an expert consultant-level biopsychosocial assessment, and will create with the referring team a formulation, diagnosis and intervention plan The patient should experience the IPMS element of the service as integral to the referring hospital or clinic team, so the IPMS will be fully integrated into the acute hospital setting. Interventions A range of interventions and links to partner services will be available, depending on the outcome of the assessment. A brief intervention can be delivered by the IPMS, limited to four or eight sessions, using models of intervention ranging across pharmaceutical, psychological therapy and social change. This is expected to be offered to approximately 25% of the patient group. 14 A Vision For An Integrated Psychological Service For Devon
The majority of patients with lower complexity of needs can be referred to IAPT, which has a significant success rate - data from April 2012-March 2015 shows that across Devon, of around 24,000 patients seen: 60% experienced a reliable 40% most positively, just improvement in their under 40% were deemed mental health to have recovered. The remaining 40% experienced no reliable improvement The remaining 60% were not deemed to have recovered Support can be provided to patients to self manage their conditions, and to GPs to manage their patients effectively within primary care after specialist intervention. A specialist service for planned elective medical and surgical care, will operate equivalent hours, taking referrals from consultant led medical and surgical teams from wards and outpatient clinics, and in time from general practice according to the principles of priority agreed for the service. The IPMS will run alongside the 24/7 seven day liaison psychiatry service to the urgent and emergency care pathway to be responsive to patient needs. The IPMS will connect to an appropriately resourced IAPT service, which will need to be expanded to anticipate the new work revealed by engaging with the anticipated 30% of people on wards and in outpatients hitherto undiagnosed, and enabled to take high-volume, low-complexity patients into stepped interventions. The IPMS will connect to an appropriately resourced Medical Psychotherapy Service expanded to anticipate the new work revealed that is low-volume, highcomplexity and high-cost and requires expert practitioner interventions over a longer time frame, which could include the highest intensity IAPT. It is planned that the IPMS will include all age, and women s health and midwifery linking to perinatal services including mental health. Training The IPMS will support the training end education of clinicians treating the target patient groups and supporting patients self care management. Pathway The aims of the patient pathway are to break the cycle of repeated investigations and consultations, and to create a simple pathway to shorten the patient journey and provide access to the right treatment and the right time. Referral for those in hospital or using outpatient clinics could be by a hospital consultant, those receiving solely primary care services can be referred by the GP or Devon Referral Service. All referrals will be screened and prioritised appropriately. The initial contact with the referrer will also help the referrer through discussion, reflection, and support with a range of issues e.g, child protection. The IPMS will work closely with other local services that also provide psychological and psychiatric services, who will be able to refer in to the IPMS: The clinical health psychology service works with people recovering or rehabilitating people from stroke, heart disease, cancer treatment etc. Specialist areas include neuropsychology assessment and therapy services. The new Core24 liaison psychiatry service within the urgent and emergency care pathway. The pathways for treatment will include access to: 1. IAPT primarily for the high volume of low complexity interventions in LTC, typically where anxiety/depression is discovered, the patient recognises their need for psychological support, and this level of support is appropriate. Levels of support: (i) Psychological Wellbeing Practitioners IAPT - for mild to moderate symptoms and functional disability, no history of multiple treatment A Vision For An Integrated Psychological Service For Devon 15
failure, no significant risk of self harm, patient amenable to self management (ii) High-intensity IAPT for moderate physical symptoms and functional impairment, minimal past multiple treatment failure, co-morbid depression and anxiety 2. Medical Psychotherapy primarily for the smaller number of high-complexity patients, often with MUS, who perhaps may be exhibiting abnormal illness behaviours or where there is some other specific concern eg high level of disability, multiple treatment failures significant comorbid medical condition or psychopathology, complex social issues, difficulty engaging with therapy. (Department of Health 2008) 3. Community Neuropsychology service patients with complex neuropsychological co-morbidity associated with neurological disorder and those with FNS will be seen by this service. The service will also link to and collaborate with: Drug & Alcohol Services for those presenting with these issues Mental Health Services for patients diagnosed with Psychosis Dementia Services for all age groups Specialist mental health services for eating disorder, neuropsychiatry, etc Below is a chart showing the proposed pathway. Patient experience Referral and treatment pathways Assessment Treatment LTC plus possible Anxiety/ Depression GP Self referral IAPT service: Low / high intensity Psychological therapy MUS / FNS physical symptoms underpinned by possible Anxiety/ Depression or other comorbidity Health & Neuro -psychology service Core 24 in urgent & emergency care Acute hospital consultant IPMS MDT triage and assessment If patient reluctant to accept treatment further intervention required re health beliefs and relevance of therapy Inpatient MDT neuro-rehab / Neuropsychology FNS services Support for patients to self manage conditions Medical psychotherapy service: high complexity Link into specialist services: dementia substance misuse, eating disorders, neuro-psychiatry etc Draft pathway for IPMS 16 A Vision For An Integrated Psychological Service For Devon
Structure of the team The IPMS requires high-level expertise able to assess, formulate, diagnose, triage, briefly intervene and when necessary move patients onto treatment pathways in IAPT or Medical Psychotherapy. The team should comprise consultant psychiatrists, consultant clinical psychologists and very experienced liaison mental health nurses. They must be able to work in the biopsychosocial model and be fluent in the language of medicine and surgery as well as psychology and sociology. Trainees in all disciplines should work across all three pathways. Time should be allowed for the team to carry out assessments, attend multi-disciplinary team meetings, develop and deliver therapies, support ward and primary care professionals, and provide supervision. The management of the three components of urgent emergency care, LTC and MUS should be common and have leadership in common. The IPMS will achieve this through being co-located, in a single management structure with integrated learning environment. Demand for the service Taking the statistic that patients with severe MUS account for approximately 1% of each general practice s population, DPT estimates that there may be an average potential MUS group of 85 patients per practice across Devon. The most costly of these will be 20% of this group, or 17 patients, and thus it is estimated that an IPMS service could offer 20 patient slots per practice, or around 2000 referrals per year. Demand for a service for patients with LTC would be in addition to this. Demand will be controlled carefully using clear threshold criteria. It is expected that patients will lie somewhere on a continuum between two points. At one point there are a large number of patients, with LTC, who identify with the clinicians involved in their care that they would benefit from talking therapies. For such patients a referral is made by patients selfreferral to IAPT, or through primary care to IAPT or the IPMS. At the other end of the continuum are a small number of patients, often with MUS, who are difficult to treat due to the complexity of their conditions and circumstances, and who use a considerable amount of inpatient, outpatient and primary care resources. For these patients assessment by the IPMS would lead to development of a personalised pathway of care, involving inpatient and community services combining physical health, mental health, and social care services who have been trained and supported by the IPMS to break the cycle of investigations and diagnoses that risk significant iatrogenic harm. It is also anticipated that there will be up to a 30% increase in demand for IAPT due to the new service. Such an increase could cost up to 2 million, and therefore demand and the consequent increase of resources will need to be carefully managed. The demand for IAPT will be carefully monitored during implementation in Years 1-3 to ensure that resources are targeted effectively and that they can meet demand. Phasing of implementation It is possible to manage significant challenges of securing resources and service development by phasing the implementation of the IPMS. Priority should be given to those patients already consuming significant non-ipms secondary care resources, both in terms of the type of services they use, and the specialisms in which they are situated. Year 1 Year 2 Year 3 Year 4 Year 5 Development of IPMS for hospital inpatients, initially focusing on gastroenterology conditions, respiratory conditions and diabetes, and acute neurology. Extension of IPMS to outpatients and paediatrics, and commencement of formal evaluation of the service. Extension of IPMS to general practice/ primary care and perinatal, and completion of evaluation of the service. Implementing learning from evaluation and continual service improvement. Development of a case to extend the model regionally and nationally. The IPMS describes a collaborative and visionary aim to deliver whole person healthcare at an early point of contact with the patient and not after they have suffered more distress, waited longer for assessments and slipped further back in their recovery. We live our lives joined up physically and mentally, we should expect our healthcare to be joined up too. Dr. Joanna Bromley, Consultant Psychiatrist and Associate Clinical Director, Liaison Psychiatry Team, DPT A Vision For An Integrated Psychological Service For Devon 17