1. Mental Health Needs Assessment and Strategy Review Dr Andrew O’Shaughnessy Consultant in Public Health NHS Airedale, Bradford and Leeds November 2011 Mick James Mental Health Commissioning Lead NHS Airedale, Bradford and Leeds

2. Background Rolling programme of HNAs in Public Health Began 2008 Sexual Health, Children, Smoking, Alcohol, Obesity… Next up Substance Abuse, ASD, Dementia Process focus on commissioning Updated annually Live approach – Observatory Thanks to AL and DC

3. Health Needs Assessment Strategy Partnerships Commissioning JSNA Prioritisation Reorganisation

4. Data Issues Multiple data sources Differing methodologies Differing samples Differing numerator populations Differing denominator populations Data gaps Local improvisation to derive estimates Policy statements Maintains utility NB Observed vs Expected Appendix B

5. Taxonomy Diagnosis Affective disorders Bipolar disorders Psychotic disorders Personality disorders Others e.g. suicide Demographic Gender Age group Young Working age Older people

6. Overall Burden of Illness Source: Estimated from New Horizons and ONS mid 2008 population estimates

7. Children 1 Boys (%)Girls (%)All 5-16 year olds (%) Age5-10 year olds11-16 year olds5-10 year olds11-16 year olds Conduct disorder6.98.12.85.15.8 Hyperkinetic disorder2.72.40.41.41.5 Emotional disorder2.242.56.13.7 Less common disorders2.21.60.41.11.3 Any disorder10.212.65.110.39.6 Source: Mental Health of Children and Young People in Great Britain, ONS 2004

8. Children 2 Age Range Number of ChildrenPrevalenceNumber with a mental health disorder 5-10 yearsFemale21,0575.11,074 Male22,04810.22,249 All 5-1043,1057.73,319 11-15 yearsFemale17,50110.21,785 Male18,19513.12,384 All 11-1535,69611.74,176 5-15 yearsAll78,8019.67,565 Source: CAMHS Needs Analysis Review 2007

9. Older People There are an estimated 4,080 older people with Bipolar I disorder in Bradford District There are an estimated 1,912 older people with Personality Disorder in Bradford District There are an estimated 270 older people with schizophrenia in Bradford District Affective Disorders:

10. Affective Disorders Female ~ 32,000 Male ~29,000

11. Bipolar Disorders Lifetime prevalence (i.e. those who have the disorder for at least part of their lifespan) of Bipolar I disorder is approximately 1.3% Prevalence of Bipolar spectrum disorder (including Bipolar I,II and cyclothymia much less clear but may be between 2.6% and 6.5% Bipolar spectrum disorders often go unrecognized and undiagnosed – hidden and unmet need

12. Psychotic Disorders ~1,700 adults of working age and 270 older people with schizophrenia in Bradford District Larger numbers with schizophrenic disorder NB broad taxonomy of psychosis

13. Personality Disorders Type of personality disorder FemaleMaleAll adults 16-3435-5455-74All16-3435-5455-74All16-3435-5455-74All Obsessive-Compulsive-5271630231215541706124746221524223529116757 Avoidant1369888812456361115-17788312104862845 Schizoid407-9691423565131873160097013118832845 Paranoid204329-53463613788321338311709862489 Borderline340461-7111411574-17784161972-2489 Antisocial3400-3565651115-17789701183-2134 Dependent--440353--356416-0356 Schizotypal686644178-0-013913186356 Histrionic------------ Narcissistic------------ Any personality disorder1154191127756047367338052202960147105785496515648 Source: Psychiatric Morbidity survey 2000 (from clinical interviews). N.B crossover with other types of mental illness e.g. OCD vs. OCPD

14. Hospital Admissions Data were collected from Bradford District Care Trust 60% no diagnosis code so necessary to estimate total admissions by age and disorder type 2008 and 2009 (combined) there were 3,291 admissions (~1,600 pa) Psychotic disorders (n=485 per year) and Affective disorders (371) account for half of all annual admissions to BDCT Significant numbers of admissions for drug (98) and alcohol (129) dependency Older people: Dementia is the largest diagnosis type accounting for over 40% of admissions, with affective disorders comprising a further 30% N.B. admissions elsewhere and “composite” admissions – actual admission burden likely to be higher

15. Hospital Admissions

16. Ethnicity People from minority ethnic groups living in the UK are more likely to –Be diagnosed with mental health problems –Be admitted to hospital with mental health problems –Experience a poor mental health treatment outcome. There may also be low levels of reported and diagnosed mental health disorders due to negative stigma. This results in low engagement with services Rates of affective disorders 15-20% higher within the S. Asian pop. of England Black groups have lower prevalence for affective disorders than the general pop African Caribbean people are 3 to 5 times more likely to be diagnosed and admitted to hospital for schizophrenia than other groups. Evidence is inconclusive as to whether South Asian groups have higher rates of schizophrenia than whites, although they have better rates of recovery No relationship between any of the QoF MH indicators and South Asian ethnicity in B&A Those from South-Asian ethnic groups in B&A have higher levels of satisfaction with their financial situation than those from the White group

17. Prescribing 587,000 prescribed items per year in Bradford District Cost of £5.9 million per year Antidepressants comprise more than half Substantial variation in prescribing across the District

18. Benchmarking 1 Bradford’s relatively deprived population,compared nationally, may be expected, at the population level, to generally suffer higher levels of bipolar and psychotic disorders Almost two thirds of those in need receive either enhanced or standard CPA in Bradford, compared to one third in our peers and England as whole In Bradford District 10,440 people claim mental health incapacity benefit. This is 3.5% of the working age population, compared to 1.7% nationally In 2008/2009 there were 32,111 patients with diagnosed depression on GP depression registers. This is 6.1% of total patients on lists compared to 7.7% in Yorkshire and Humber and 8.1% in England

19. Benchmarking 2 The rate of access to mental health services for adults is below our PCT peers and England for older people but above the England average for adults of working age Bradford has a lower proportion of contacts with psychiatrist / psychologist / psychotherapists, at 14% compared with our PCT Peers at 24% In Bradford patients are more likely to be admitted than those in contact with services in similar PCTs or in England as a whole Approximately 1,400 people were detained under the Mental Health Act 1983. The proportion formally detained for at least one day is similar to our PCT peers but above the national average

20. Local Geographic Variation Residents from City and South and West Alliance areas were slightly more likely to report feeling downhearted and depressed Levels of life satisfaction are lowest in the South and West Alliance area Substantial variation in QoF prevalence between practices, with greatest variation between practices in the City Care and South and West Alliance Of the 13 practices achieving less than 90% of mental health reviews for patient, 9 are in City Care Alliance. Patients within these practices are also less likely to have a comprehensive mental health care plan or be followed up for non-attendance of 15 months reviews Antipsychotics drug prescribing rates and cost per head of population are similar across the 4 alliances. South and West alliance has the highest prescribing rate (0.16 items per head) with Airedale alliance the highest cost per head (£5.19) However, there is a huge range in prescribing of antipsychotic drugs between practices ranging from 0.02 items per head (£0.41) to 0.6 items per head (£11.40). City Care Alliance has the lowest number of items and cost per patient for antidepressants (£2.14 per head of population) and hypnotics and anxiolytics (£0.86). For hypnotics and anxiolytics, prescribing rates and cost are broadly similar across other alliances S&W alliance has the highest number of items per patient for anti-depressants, although Airedale and YPCA/BANCA alliances have higher costs per patient, suggesting variation in the type and quantity of drugs prescribed by GPs

21. Strategy Review Need to review local strategy Changing Commissioning landscape Public Health changes Health and WellBeing Boards Integration Personalisation Joint Commissioning Alcohol, Substance Abuse

22. CCG Context Strategic planning Commissioning plans Partnership working Prevention and Management Focused workstreams –IAPT Need/Capacity planning –Antipsychotic prescribing in Primary Care –Antipsychotics in Dementia –Guidance Taxonomy –Autism HNA –Dementia HNA

23. Next Steps Complete the HNA triangle In tandem with commissioners as part of MH strategy development: –Analysis of need and service provision with gap analysis –Use of evidence and guidance to identify approaches to address these –Assessment and application of published clinical and strategic guidance on mental health and well- being. –Focused review of published research literature as required –Engagement with partners including clinicians in Primary and Secondary Care