1. Mental Health Learning Workshop – NHS England (Midlands and East)
Joanna Powell
February 4, 2014

2. Plan How did we get here? Why am I here / my hopes for the day?
Introduction to Parity of Esteem Programme (PoE)
Emerging work areas
E.g. Common ‘narrative’
MH CQUIN
Business as usual
Everyone counts – Planning guidance 2014/15 – 18/19
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

3. A few of our drivers
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

4. Health and Social Care Act 2012
The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement –
(a) in the physical and mental health of the people of England, and
(b) in the prevention, diagnosis and treatment of physical and mental illness.
NHS Mandate
By March 2015, we expect measurable progress towards achieving true parity of esteem, where everyone who needs it has timely access to evidence-based services
NHS England’s objective is to put mental health on a par with physical health, and close the health gap between people with mental health problems and the population as a whole
Every community to have plans to ensure no one in crisis will be turned away, based on the principles set in the MH Crisis Concordat
Putting People First
Parity Included in Priority 8 on the NHS England Balanced Score Care
Deliverable 11 against key deliverable: Put mental health on a par with physical health, and close the gap between people with mental health problems and the population as a whole. Extend and ensure more open access to IAPT by March 2015, particularly for children and young people, and for those out of work
Priority 8
Promoting equality and inclusion through NHS services. Highlighting and reducing inequalities in health outcomes across all Outcome domains. This will include parity of esteem for people with mental health issues.
Measured by Progress in reducing identified health inequalities on all indicators for which data are available
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

5. “Person centred, coordinated care”
The vision
What Parity will mean to me:
My family and I all have access to services which enable us to maintain both our mental and physical wellbeing.
If I become unwell I use services which assess and treat mental health disorders or conditions on a par with physical health illnesses.
The patient
“Person centred, coordinated care”
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

6. PoE Programme - key messages
Cultural change is at the heart of the POE Programme
Strategic aim – for POE to be everyone’s business
It cuts across all NHS OF Domains
It is closely aligned to other major transformational programmes – e.g. integration, person centred care planning and personalisation
It does however also have to focus on reducing the many disparities which exist between Mental and physical health
How will the programme be delivered?
Specific improvement / change projects
Business as usual to support POE generally*
Ensure alignment with other organisations and groups
a. Data, Information and Intelligence
b. Development of capability and skills in commissioning – including need to focus on cultural change / behaviour of commissioners change
c. Delivering improvements to clinical services (including IAPT and increasing timely diagnosis and post diagnostic care for dementia)
d. Improving physical health for people with serious mental illnesses – CQUINE – talk about later
e. Addressing and improving crisis Care TOP one for 2014/15
I can provide more details of these specific work streams if required but want to focus on current work
Developing a common narrative – slides taken from CTA event as previously mentioned – but doing more work on this – this will feed into the coms. campaign which will support the cultural change aspects of the programme
Encourage a discussion about business as usual and how it can be used to deliver POE
So some facts and figure
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

7. Emerging PoE narrative
1. What’s the issue?
2. Where are we now?
3. Where do we want to be?
4. How do we get there?
Increasing and more complex care needs
Poor outcomes for people with mental illness
Person centred, coordinated care
‘House of Care’ model
Our mandate from the government requires us to close the gap between mental and physical health services – to achieve parity
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

8. Mental illnesses are very common
1.2m people in England have a learning disability
There will be over a million people with dementia by 2021
In any one year 1 in 4 British adults experience at least one mental disorder
5.4% of men and 3.4% of women have a personality disorder
10% of 5-16 year olds have a mental disorder
Among people under 65, nearly half of all ill health is mental illness
Between 8% and 12% of the population experience depression in any year

9. Among people under 65, nearly half of all ill health is mental illness
% of morbidity in the UK: Physical v Mental illness1
Rates of morbidity in each age group (Equivalent life-years lost per 100 people)2
e.g. mainly depression, anxiety disorders, and child disorders
Morbidity from physical illness rises steadily throughout life, whereas mental illness especially affects people aged 15-44
e.g. heart disease, cancer, diabetes
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014
Source: 1&2: Based on WHO, Further calculations by Mike Parsonage . see: LSE (2012) how mental illness loses out in the NHS

10. Yet, only a quarter of all those with mental illness such as depression are in treatment
% of population with condition
% of people with condition in treatment
Adults
Schizophrenia or bipolar disorder 1%
80%
Depression 8%
25%
Anxiety disorders
Children (5-16)
Conduct disorder or ADHD 6%
28%
Depression & / or anxiety disorders 4%
24%
Autistic Spectrum Disorder
43%
Does this reflect your own clinical experience / practice?
Do you consider this to be a reasonable summary from a patient or service users perspective?
How does this compare to treatment levels for those with long term physical health problems? (in comparable western countries: 94% diabetes, 91% hypertension, 78% heart disease)
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

11. We know significant challenges remain to putting mental health on a par with physical health
People with mental health problems have a significantly different level of contact with physical health services compared with other patients1:
Service users
Non-Mental health
Mental health
1. Accessed hospital services
Is this untreated need in the community?
48%
78%
2. Arrived at A&E by ambulance
…and stayed in hospital around 30% longer
26%
54%
3. Classified as an emergency
Why aren’t we picking up earlier?
40%
71%
Source: 1- HSCIC (2013) HES-MHMDS Data linkage report; additional analysis; England (Experimental statistics). See: T.Fowley (2013) Bridging the Gap – p.9

12. People with poor physical health are at higher risk of experiencing mental health problems…
27%
Diabetes
29%
Hypertension
31%
% of people affected by depression
Stroke
People who experience persistent pain are four times as likely to have an anxiety or depressive order as the general population
33%
Does this reflect your clinical practice ?
Do you think this represents experience from a patient / service user perspective?
Impact – come back to later on - but needless to say impacts on ability to comply with Rx / rehabilitation (motivation)
How many do you recognise – do we do things early enough to prevent more entrenched conditions
Cancer
44%
HIV / AIDS
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

13. Mental health problems impose a total economic and social cost of over £105bn a year
£14bn is already spent on mental health services
Nearly a third of people with long term physical conditions have at least one co-morbid mental health problem. This can exacerbate the person’s physical condition and increase the cost of treatment by between 45% and 75% at a cost to the NHS of an estimated £10bn per year
Medically unexplained symptoms cost the NHS some £3bn per year
Mental illness has a significant impact on public finances: estimated that the costs of depression through lost working days are 23 times higher than the costs to the health service
1 in 4 unemployed people has a common mental health problem
Childhood mental health problems can have a significant economic effect on society. It is estimated that a child with a conduct disorder will, by the age of 28, have generated costs (such as to the health, education, benefits and criminal justice systems) ten times as high as a child without conduct problems
Medical costs
Hidden costs
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

14. Culturally we have started to see attitudes to mental health shift over the past 10 years…
Public attitudes to mental health1:
This shift in attitude is hugely important in the way we think about future service design – rather than see the community as a ‘barrier’ we need to start seeing as an ASSET. How can we enable people to help other people? How do we unlock underutilised resources in our community (i.e. people) to improve the well being of themselves and those around them?
% agreeing with statement
Key question: how do enable new and innovative health (and other public) services so people are seen as ‘active participants’ in their care and individual / community outcomes rather than passive recipients?
Source: 1- The health and social care information centre (2011) Attitudes to mental illness – 2011 survey report

15. …and new service models emerge with huge potential to improve outcomes
Examples:
Improving Access to Psychological Therapies (IAPT) programme had major impact in it’s first 3 years:
treating more than 1 million people in IAPT services
more than 680,000 people completing a course of treatment
recovery rates consistently in excess of 45%
Personalised Health Budgets: the national pilot programme indicated that personal health budgets “had a significant positive impact on care-related quality of life, psychological wellbeing and subjective wellbeing” of the people taking part. People with mental health problems reported improvements in their physical health, and people with physical health problems likewise reported better mental health
Suicide prevention strategy : Findings from three mental health promotion pilot projects to address the raised suicide risk in young men show that:
multi-agency partnership is key to promoting young men’s mental health;
community locations, such as job centres and young people-friendly venues, are more successful in engaging with young men than more formal health settings such as GP surgeries;
front-line staff feel better able to engage with young men if they receive training;
community outreach programmes are seen by young men as more acceptable and approachable than services provided in formal healthcare settings.
Common mental health disorders
Mental illness
New service models that put patients in control
Severe mental illness
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

16. The current design of our health system doesn’t ensure ‘whole-care’ packages
Most people with Serious Mental illness don’t receive physical health checks
We run a national programme of health checks within school, but we only check physical health
There are significant delays in diagnostic treatment for people with learning disabilities
National audit of schizophrenia – only 29% of service users getting proper metabolic monitoring
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

17. To realise the vision we are developing a ‘House of Care’ framework to support delivery…
Patients, carers and professionals will have the right information needed to provide the right care at the right time (e.g. medical care in hospital and social care at home)
Services will be available as and when needed by people without undue difficulty in transferring between agencies and settings.
People will know where and to whom to turn for assistance in managing their conditions.
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

18. Mental Health CQUIN for 2014/15
Improving physical healthcare to reduce premature mortality in people with severe mental illness (SMI)
Indicator 1: 65 per cent of funding for demonstrating, through the National Audit of Schizophrenia, full implementation of appropriate processes for assessing, documenting and acting on cardio metabolic risk factors in patients with psychoses, including schizophrenia.
Indicator 2: 35 per cent of funding for completion of a programme of local audit of communication with patients’ GPs, focusing on patients on the Care Programme Approach (CPA), demonstrating by Quarter 4 that, for 90 per cent of patients, an up-to-date care plan has been shared with the GP
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

19. Mental Health CQUIN for 2014/15
The following cardio metabolic parameters (as per the 'Lester tool' and the cardiovascular outcome framework) are assessed;
Smoking status
Lifestyle (inc. exercise, diet, alcohol and drugs)
Body Mass Index
Blood pressure
Glucose regulation (HbA1c or fasting glucose or random glucose as appropriate)
Blood lipids
Hepatitis C
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

20. Current top priorities
PoE Programme
Current top priorities
Addressing and improving crisis Care TOP one for 2014/15
Data, Information and Intelligence
Development of capability and skills in commissioning – including need to focus on cultural change / behaviour of commissioners change
Delivering improvements to clinical services (including IAPT and increasing timely diagnosis and post diagnostic care for dementia)
Improving physical health for people with serious mental illnesses – CQUIN – talk about later
Discrete improvement project – Business as usual – Collaboration with system partners
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

21. Planning Guidance 2014/15 -18/19 Headlines
Outcomes drive everything we do
Significant financial challenge: no change is not an option
2014/15 – transformation year in preparation for 2015/16 (Better Care Fund)
What’s new?
Support available to support commissioners
Operational (2 years) strategic (5 years) plans
Integration / collaborative working a key feature
Monitor / NHS TDA (providers and commissioners)
Local authorities (Better Care funding)
Unit of planning to support Health and Social Care planning
Strategic and operational planning guidance for NHS commissioners (CCGs and NHS England)
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

22. Outcomes – NHS OF – linked to 7 ambitions
Key measures (3)
Service characteristics (6) - to drive transformation
Essential elements (4) for service delivery
Part 1
Strategic, operational and financial plans – process and overview (including direct commissioning)
Bold, developed in partnership and locally led (unit of planning)
Better Care Funding Health & Wellbeing Board level
Planning support
Part 2
This document builds on the great work done last year in response to Everyone Counts: Planning for Patients 2013/14 2. Part 1 focuses on the outcomes we want for patients and describes our bold ambitions to deliver them. It describes the emerging findings from our strategy, which lead us to six new models of care which together will deliver the transformational change needed if the NHS is to deliver improving outcome at a time of increasing need, unprecedented new treatment options and economic restraint. In our role as leaders of the commissioning system we emphasise where our focus will lie – delivering the government’s mandate to us and going beyond that to secure even better care. It concludes by reaffirming our commitment to a clinically led commissioning system with CCGs as local leaders. NHS England is also a local commissioner and throughout we recognise our dual role – a local commissioning partner as well as the coordinator and leader of a commissioning system on which better health and better care depend.
Part 2 of this document outlines the planning process and details of the plan which needs to be produced. The first chapter provides an overview of the fundamental planning considerations for all plans, outlines the strategic enablers, describes how plans will be submitted and assured and provides an overview of the support available for the process.
CCGs, as the local leaders of the NHS supported by Commissioning Support Units, NHS England, and all NHS providers, will need to work closely with all the key partners on the Health and Wellbeing Boards. It will be vital that NHS commissioners work closely with Local Authorities, who have such an important part to play in securing the broader determinants of health as well as delivering high quality social care services, and Healthwatch who will ensure the patient perspective is paramount.
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

23. Level of ambition NHS Outcome framework Outcome ambitions (7)
Domain 1: Preventing people from dying prematurely
1: Securing additional years of life for the people of England with treatable mental and physical health conditions
Domain 2: Enhancing quality of life for people with long-term conditions
2: Improving the health related quality of life of the 15 million+ people with one or more long-term condition, including mental health conditions
3: Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital.
Domain 3: Helping people to recover from episodes of ill health or following injury
4: Increasing the proportion of older people living independently at home following discharge from hospital.
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

24. Level of ambition (cont.)
NHS Outcome Framework
Outcome ambitions (7)
Domain 4: Ensuring that people have a positive experience of care
5: Increasing the number of people having a positive experience of hospital care
6: Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community
Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm
7: Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care
Guide developed by Commissioning Assembly Quality Working Group
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

25. Key measures (3)
Improving health, Health and Wellbeing Boards, Commissioning for Prevention. Every contact really does count
Reducing health inequalities. Ensure the most vulnerable in our society get better care and better (integrated) services to improve health outcomes
Parity of esteem focus on improving mental and physical health and ensuring that patients with mental health problems don’t suffer inequalities, either because of the mental health problem itself or because they then don’t get the best care for their physical health problems
Everyone must make sure they work with all partners so that all those things which affect the broader determinants of health are addressed.
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

26. Support available Universal support can be found here
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

27. Example of support available
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

28. NHS | Presentation to [XXXX Company] | [Type Date]

29. Planning Guidance 2014/15 -18/19 Level Summary Relevance to POE
Ambition for NHS
Outcomes NHS OF 5 Domains
7 measureable ambitions AND
3 key measures is
QOL / LTC ambition - IAPT and dementia referenced Trajectory for Dementia diagnosis and Trajectory for IAPT coverage and recovery
POE is a key measureable
Steps CCGs are expected to undertake in order to deliver these ambitions
Local ambitions linked to the 7 measureable ambitions
Planning fundamentals
National conditions
Integration /holistic care
POE is a planning fundamental
Acute Care -Plans not to have a negative impact on the level and quality of mental health services.
Integration / holistic care - Dementia services particularly important
Assurance process – POE to be included
Underpinned by CQUINS for Dementia and Mental Health - DES for dementia and learning disability - Quality Premium for IAPT Standard contract sanctions – MH MDS focus NHS OF – IAPT indicator
We have been established as an independent organisation, at arms-length from government. Each year the government gives us a mandate1 setting out its ambitions for the NHS. This details the outcomes that the government wants us to achieve for patients, but gives us the flexibility to determine how to deliver the mandate through our own direct commissioning and through Clinical Commissioning Groups. Delivering the mandate is central to our work but we also are determined to go further.
Service transformation
FFT expanding to MH services
Choice for MH services
Personal health budgets
Digital revolution
Personalised care plans
Health literacy (to use technology)
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

30. High quality care for all, now and for future generations
High Quality – ‘Driven by quality in all we do – our patients rightly expect the best possible service’
For all – ‘…whether need is for mental or physical help and support. We must put the greatest effort in providing care for the most vulnerable and excluded in society’
For now – ‘Need to get better at sharing good practice rapidly across the NHS’
For future generations – ‘Strategic plans developed in partnership working between commissioners, providers and local government to deliver models of care that will be sustainable in the longer term’
Everyone to have greater control over their health and wellbeing, supported to live longer, healthier lives by high quality health and care services that are compassionate, inclusive and constantly improving
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

31. In summary The NHS Mandate clearly sets out priorities for the system
We all need to collaborate in order to deliver the mandate
NHS England National Support is there to support you and your local CCGs to deliver the NHS mandate
What do you and your local CCGs need us to do to help you to deliver the mandate?
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

32. Any questions and thank you
Joanna Powell, Domain Team Lead NHS England
NHS | Presentation to NHS England (Midlands and East) | 4 February 2014