1. Mental health strategic clinical network meeting : Yorkshire and Humber SCN Dr. Geraldine Strathdee, National Clinical director, Mental Health

2. Today’s discussion How common is mental ill health What are we trying to achieve What are the priorities No health without mental health’ national strategy NHS Mandate Emerging SCN priorities across the country Progress update How can we help and what can we learn from Y&H We need your leadership, your expertise and your drive! NHS | Presentation to [XXXX Company] | [Type Date]2

3. 3 How common is mental ill health

4. How common are mental health conditions Our children 1 in 5 under the age of 15 Only 25% can access care 50% bullied, leading to: Depression Low self- esteem Suicide 1: 10 have unrecognised dyslexia, dyspraxia The workforce 1 in 6 adults at any time 1: 10 have depression Suicide is the greatest cause of male deaths < 35 yrs Work related stress affects 1.5 million 5.6 million work days lost a year Senior citizens Dementia effects 5% over 65’s 10- 20% over 80 1 in 6 over 65 suffer from depression Major factors: Social isolation Physical ill- health 30% of >65s in Acute Trust beds have dementia All communities Over 300 spoken languages in UK; many cultural beliefs & mental health issues Over- representation of black people in acute inpatient & forensic care Over 300 spoken languages in UK; many cultural beliefs & mental health issues Over- representation of black people in acute inpatient & forensic care

5. The prevalence of mental health & impact on outcomes PrevalenceICD conditionsOutcome impact Primary care : 30-50% of daily workload Depression & anxiety Substance misuse Children's conditions Premature mortality : 15-25 years Quality of life in LTCs Recovery from illness Patient safety Patient experience Acute care 20%-40% of A/E in 40% acute beds 50% acute LTC outpatient clinics Alcohol & drugs Depression & self harm Depression Dementia Premature Mortality Quality of life for LTCs Recovery from illness Patient safety Patient experience Prisons & offenders 70-80% especially young men ADHD, ASD Depression Substance misuse PD Premature Mortality Specialist mental heath services Psychosis Neurodevelopmental Substance misuse Personality disorders Complex multi axial Premature Mortality : 15-25 years Quality of life in LTCs Recovery from illness Patient safety Patient experience

6. Depression : think about the causes & solutions follow.. opportunities for demand management, prevention & early intervention across Value care pathways Elderly isolated & people with dementia Victims of domestic violence Alcohol and drug addictions Isolated women with small children Victims of school and employment stress and bullying Key life cycle: Divorce Retirement Redundancy Menopause Key life cycle: Divorce Retirement Redundancy Menopause Long term physically ill Dyslexia, Dysprexia ADHD, Autism, Asperger’s and Learning Disabilities Dyslexia, Dysprexia ADHD, Autism, Asperger’s and Learning Disabilities People with schizophrenia and sight and hearing problems

7. 3. The top 10% of Mental health conditions: service redesign for prevention, earlier identification & better access & treatment for young eople The origins and causes of mental ill health The life span health & social determinants of mental health conditions The origins and causes of mental ill health The life span health & social determinants of mental health conditions Genetic & biochemical Organic brain & neurodevelopmental Societal ‘What could we do?’‘What should we do?’‘How should we do it?’ Family history Substance misuse /mental ill health/ chaotic deprivation / abuse: physical, sexual, emotional School difficult Dyslexia, Dyspraxia, ADHD, Autistic spectrum, Bullied Truanting Drug use & dealing Petty crime In Care Mental illness starts Regarded as ‘bad’ or ‘strange’ Institutions career Expensive placements Youth offenders Acute psychiatric wards Forensic units Biochemical ‘causes’ Caffeine, nicotine, alcohol, street drugs Neurotransmitters Endocrine disorders Biochemical ‘causes’ Caffeine, nicotine, alcohol, street drugs Neurotransmitters Endocrine disorders Life span high risk events Long term physical conditions Unemployment Adolescence Pregnancy Bereavement Migration Gang/ veteran trauma Life span high risk events Long term physical conditions Unemployment Adolescence Pregnancy Bereavement Migration Gang/ veteran trauma

8. What Outcomes do our service users ask us to support them achieve

9. From the patient’s perspective Safety “Will I be ok?” Effectiveness “ Will it do me any good?” Experience “ Access, information & treatment experience” Efficiency Was it fast, safe, near home, back to work asap Least restrictive settings What Outcomes do our patients ask us to achieve in partnership with them Professor Bruce Keogh, Medical Director of the NHS

10. Parity : NHS Mandate: what does it mean in practice From a London GP ………………… GPs are trying to do everything for everyone, too much of 21 st Century care is being provided through 19 th century organisational models……… Professor Michael Porter is a world authority on strategy in business, & has spent the past decade working in healthcare systems in dozens of countries. I was struck the other day when I saw a patient - who has been off work for 3 months waiting for CBT. He is depressed and was just told to go on sick leave- no medication, just a referral for CBT in the distant future. When I saw him, what upset me most was that if he had broken his leg, he would have been treated asap, given rehab, told to go to work on crutches and would not have just been abandoned. I want to make it impossible for mental health problems to be treated as second class illnesses - with patients with treatable conditions languishing on waiting lists or worst still with no treatment at all Clare Gerrada

11. The economic impact: 2012

12. Mental health has among the most clinically and cost effective treatments of any sector but access is low and a post code lottery

13. What are the priorities & progress No health without mental health’ national strategy NHS Mandate & Suicide prevention strategy Emerging SCN priorities across the country AHSNs LETBs New funding streams

14. Emerging System priorities..a system based on value, equalities & shared learning 1. CCG: building capacity and capability in mental health leadership 2. Primary care mental health3. Care of people with psychosis : ‘industrializing’ improvement 4. The acute care pathway and suicide prevention 5. Integrated physical & mental health care pathways 6. Mental health intelligence informatics network programme new model of information led commissioning & integrated provision Whole pathway commissioning of Tiers 1-4 Underpinning Value based commissioning and care Outcome measurement Service specifications aligned to PbR and Choice Reducing burden to free up time to care

15. CCG GP Mental health leadership programme Knowledge based leadership for high impact and improving outcomes ….……a new model of leadership Personal leadership developmentMental health Informatics competency Expert ‘what good looks like’ immersion week Commissioning Information and best practice

16. The national care pathways priorities What do we want to commission with partners Prevention & health promotion Early identification & early intervention Timely Access to services offering choice, quality outcome focus Care at home or in the least restrictive settings, Crisis response that is easy to access & expert Parity for people with physical & mental health Integrated physical & mental health & social care Where every contact is a kind enabling, coaching experience Parity for people with physical & mental health Integrated physical & mental health & social care Where every contact is a kind enabling, coaching experience

17. Step 1: Information for Commissioning value based care pathways we have commissioned unique whole care pathway health & social care information for every CCG What are the key high risk prevention & top 10% QIPP opportunities Are standards of services meeting NICE NCB, QOF, COF, CQC, Monitor, Outcomes domains, Operating framework, PbR What evidence based services are available in this borough What funding is spent on mental health in primary care, social care and specialist mental health hospital beds & community services What % age of people with these conditions are GP QOF identified ( and coded) What are the high risk groups to target for risk stratification and prevention How common are mental health conditions in this area In this CCG/ borough, what are the social determinants of mental ill health

18. Clinical and economic best commissioning tools Expert clinical reviewers & implementers CCG MH shared learning & provision network The evaluation and shared learning indicators Economic modelling tools to design and reengineer effective models for local needs Model service specification examples What are the top 4 service ‘Best buys’

19. 2. Primary mental health care in England internationally: they are using systems thinking around the many roles of GPs GP roles Individual clinician Primary care multi disciplinary team Leadership & organization of the practice GP as community leader & prevention GP as Commissioner

20. International learning : Primary care mental health service organization : a ‘ stratification’ approach & federated models e.g. ‘ (Kaeser, Scandanavia, US Vets Primary care service organization Demand management : reduce employment and school and community causes Prevention targeting of High risk groups Self assessment & self management Mild Common conditions Moderate primary care repeat attenders & LTCs Long term severe mental illness

21. An example of a federated model Hungary Depression & suicide reduction Training, systems redesign, whole team sustainable approach Szanto et al ( 2007 Training for 28 GPs serving 73,000 people.5 year Depression-management educational program for GPs In addition to training individuals, services were reorganised and expertise commissioned to support primary care in a sustainable way. Practice nurses were also trained A Depression Treatment Clinic & psychiatrist telephone consultation service was established. Conclusion: GP-based intervention produced a greater decline in suicide rates cf with the county & national rates.. Key conclusion was that additional service reorganisation such as depression case managers should be tried. The importance of alcoholism in local suicide was unanticipated and not addressed

22. Shared whole pathway learning Oxleas NHS Foundation Trust runs a series of free evening masterclasses on mental health and learning disability issues for primary care professionals. The aim of the series is to: Provide GPs with updates on the current evidence-based treatments for common mental health conditions Share information on new assessment tools Share best practice care pathways Topics have included depression, dementia & child & adolescent mental health issues. GP Master class series

23. AHSNs working with SCNs and LETbs 2. 5 hour Masterclass for practice nurses Masterclass developed by a practice nurse mental health expert with RMNs Train the trainer model : 1 specialist MH nurse trainer per CCG 2.5 hour master classes in each `CCG area for 20 PNs 800/1400 London practice nurses trained in 6 months New modules in depression, suicide prevention, planned NHS | Presentation to [XXXX Company] | [Type Date]23 UCLP practice nurse master classes

24. Emergency Department Mental health liaison team ( dementia, alcohol, psychosis, self harm all ages ) Single Crisis number coordinating tele triage, tele health + 24/7 community Home treatment team & community alcohol detox, Admissions to Acute Care in acute mental health beds Primary Care & self- care Intermediate tier Acute and unplanned care emerging thinking ££££££££££££

25. 5. Integrated physical and mental health care Long term conditions Mental health raises costs in all sectors Chris Naylor, Kings fund Overall, international research finds that co-morbid MH problems are associated with a 45-75% increase in service costs per patient (after controlling for severity of physical illness) Between 12% and 18% of all expenditure on long-term conditions is linked to poor mental health and wellbeing – at least £1 in every £8 spent on long-term conditions.

26. Co-morbidity is the norm Lancet, Barnett, Mercer et al 2012

27. 2012 publication Compendium of examples of cost effective programmes for people with physical illnesses in acute trust, primary care settings

28. The Ian Galton challenge: an integrated dementia, MH and neurological plans Dementi a MHNeurolog y Our integrated support processes: The MH intelligence network will include dementia & neurology CCG commissioning & quality improvements x x x The SCN website: sharing intelligence & updates x x x Mandate : we are working on it as part of a shared governance agenda & the delivery of ICD dementia diagnosis and improved care and IAPT and liaison crisis services x x Particular service models and clinical pathways we are working on in an integrated way The acute and unplanned care programme : inputs to ensure care for people with dementia, self harm, relapsing psychosis & alcohol related d neurological and dementia conditions e.g. Korsakoffs and Wernicke x x x Integrated care pathways for alcohol and young onset dementia & cognitive impairment x x x Dementia DES integrated care pathways for delirium and dementia better diagnosis and assessments? Pt safety: supporting NHS E to implement patient safety for falls and medicines optimisation xxx Integrated physical and Mh care factsheet series between NCDs and MH field experts xx Medically unexplained symptoms common pathway : would love to support neurological MUS & IAPT xx Specialist commissioning group in brain injury are including MH assessment xxx ICD coding in HES and MHMDS: drive up quality in recording diagnosis and better more rapid discharge summaries? xxx Others: PQ what we are doing re ASD and Asbergers services xx

29. Many of the outcomes we achieve for people with schizophrenia and psychosis are unacceptable www.rethink.org Excess mortality – people dying 15-20 years earlier. Poor social outcomes – only 8% in employment. Overrepresentation of people with schizophrenia/psychosis in prison or amongst homeless population. Very high levels of stigma and misunderstanding. Cost to society of £11.8 billion.

30. Value based Integrated care pathways design : commissioning for 60% volume, 60% spend; top 10% Depression: is the most common MH condition in PC, acute, MHT, addictions, adolescents, veterans 30-50% of the daily work of GPs is MH related, especially depression Post graduate training for GPs, PNs, HVs, PC has been less available and tailored to PC mental health 78% of people who commit suicides have seen their GP in the month before the suicide Long term conditions: 70-80% of all healthcare & depression is the common comorbidity in 25-40% Untreated depression in COPD, CHD, cancer, stroke, diabetes, means patients die early & cost more 60-90% of those who misuse alcohol and drugs have depression Children and young people can be helped to develop resilience against depression Transport hub suicides are high in London and can be prevented RCGP & AHSCs are keen to develop new population & pathway based approaches to depression in all sectors The young people with psychosis & complex needs in high cost top 10% tier 95% patients are treated in the community, but 60% spend is on beds The Top 10% patients who account for 50-60% spend are not well recognized, helped by caseload zoning and risk stratification Our detention rates are rising year on year despite CTOs 70-80% of those in MSUs and LSUs are young black men with long LOS Substance misuse is a very common comorbidity which triggers 60% high risk events e.g. suicide, homicide, partner impact, but the commissioning & provision are not understood

31. 3. The care of people with psychosis In 2012, the National schizophrenia Commission & National Audit of Schizophrenia found: examples of good practice Wide variation in standard National data shows changes away from demonstrated models of evidence based care The need to ‘industrialise improvement in 5 core areas of care: Physical health Safe optimised medicines Psychological therapy Inpatient care Care plans that are personalized, empowering g

32. Key partners & network members to build synergies ( not inclusive ) Patients and familiesAHSC + LETbsLAs, Social care PHE Care pathway partners,police, ambulance, British Transport system 3 rd sector policy and provision leaders CCG & Commissioning leaders RCGPs, RCN, RCPsych, etc Information transparency programme

33. 2012 publication Compendium of examples of cost effective programmes for people with physical illnesses in acute trust, primary care settings

34. Prevention and Early intervention (Knapp et al, 2011) highly effective treatments: major economic benefit For every one pound spent the savings are: Parenting interventions for families with conduct disorder : £8 Early diagnosis and treatment of depression at work: £5 in year 1 Early intervention of psychosis £18 in year 1 Screening & brief interventions in primary care for alcohol misuse £12 Yr 1 Employment support for those recovering from mental illness: Individual Placement Support for people with severe mental illness results in annual savings of £6,000 per client (Burns et al, 2009) Housing support services for men with enduring mental illness: annual savings: £11,000–£20,000 per client (CSED, 2010).

35. Proportion in UK with mental disorder receiving any intervention (Green et al, 2005; McManus et al, 2009) 28% of parents of children with conduct disorder 24% of adults with common mental disorder 28% of adults screening positive for PTSD 81% of adults with probable psychosis received some form of treatment compared to 85% in 2000. 65% of adults with ‘psychotic disorder’ in past year 14% of adults dependent on alcohol 14% of adults dependent on cannabis only 36% of adults dependent on other drugs Less than 10% of older people with depression receive adequate treatment

36. The prevalence of mental health & impact on outcomes PrevalenceICD conditionsOutcome impact Primary care : 30-50% of daily workload Depression & anxiety Substance misuse Children's conditions Premature mortality : 15-25 years Quality of life in LTCs Recovery from illness Patient safety Patient experience Acute care 20%-40% of A/E in 40% acute beds 50% acute LTC outpatient clinics Alcohol & drugs Depression & self harm Depression Dementia Premature Mortality Quality of life for LTCs Recovery from illness Patient safety Patient experience Prisons & offenders 70-80% especially young men ADHD, ASD Depression Substance misuse PD Premature Mortality Specialist mental heath services Psychosis Neurodevelopmental Substance misuse Personality disorders Complex multi axial Premature Mortality : 15-25 years Quality of life in LTCs Recovery from illness Patient safety Patient experience

37. The route map to delivering the MH strategy