Sectorised mental health services in England Alan Yates – Director, Unique health solutions

Introduction Previously Chief Executive of three Trusts in England with mental health services Latterly, the Chief Executive of Mersey Care NHS Trust for 13 years: Treatment to 34,000 patient pa 672 In-Patient beds 520,000 out patient contacts per year 33 buildings €250m pa 4,600 staff Retired in September 2012 and with four colleagues established UHS – a healthcare management consultancy Advise clients about integration, finance, quality and service redesign

History and Reasons Long tradition of the asylum – hospitals which withdrew people from society if they showed mental health or social “maladjustment” In England In-Patient beds peaked in 1954 at 148,000 These beds have reduced to 19,000 in 2011/12 as a result of psychotropic drugs, the development of community services and scandals of abuse and neglect in large out of town hospitals. Before 1980 about less than 20% of English mental health services were sectorised and community based After 1990 80% of English mental health services were sectorised and community based In 1999 the UK Government produced the National Service Framework for Mental Health describing a good service and over 6 years it was implemented

National Service Framework for MH (1999) A strategy based on evidence rather than political preference for the first time, Prof Francis Creed (1997) and others demonstrated that IP care was mostly no better than day care and more expensive, Assertive outreach was effective in keeping people out of hospital at no increased risk Early intervention in Psychosis significantly increases the number of patients who have only one episode of psychotic illness. NSF supported Community Mental Health Teams (CMHTs) as the basis of diagnosis, treatment and care NSF created Crisis and intensive home care teams, Early intervention teams, Assertive outreach teams and Criminal Justice Liaison teams as well as CMHTs

Model In Patient Beds Crisis and intensive home treatment team Assertive outreach team Early intervention in psychosis team Community metal health team

General context in england - 2012 Adult acute beds Median beds per 100,000 popl. 22 Median bed occupancy 90% Median admissions per 100,000 popl. 240 Median length of stay 29 days Community Referrals to CMHTs per 100,000 4000 CMHTs caseload per 100,000 1700 CMHT contacts per 100,000 33,000 Crisis caseload per 100,000 25 Crisis contacts per 100,000 4000

The range is great For Beds

And for community services

A sectorised service In england Typical organisation in England and Wales which I have supported has: Population of 500,000 with 8 sectors Each sector will typically have: Average population per sector of 75,000-100,000 Multi-disciplinary team with Psychiatrists, Nurses, Psychologists, Occupational Therapists, Social workers, Care assistants and Administration – a team of perhaps 30 In-patient beds of 20 – 25 per sector 3000-4000 referrals per year A caseload of 1500 patients 28,000 appointments per year

The future Two problems: Difficulty of managing the community and the in-patient service Challenge of integrating the work of the generalist mental health teams (CMHT) and the specialist teams (assertive outreach, early intervention, crisis, criminal justice liaison etc) Solutions “Acute care model” which provide separate In-patient teams Merge specialist teams and CMHTs

Conclusion The French had “La politique du secteur” before the English in the 1960s However UK Government policy in the 1980s and 1990s enabled the establishment of well resourced community based services UK spend as a % of total health spend is 14% - in France it is 8% Sectorisation is very dependent on the use of other community resources such as housing, employment, social care and these have been reduced by 25% in England in the last 3 years – very difficult circumstances The English mental health services are moving into increased social and educational approaches to recovery. This is a challenge for Community Mental Health Teams. Sectorisation has worked well in England but is now coming under strain.

So onwards and ever upwards! alanyates@uhsltd.co.uk