1. Developing Integrated Mental Health Services Professor Mervyn Morris CCMH BCU 31 st MAY 2013

2. Where are we? UK West Midlands Region SCOTLAND WHERE PRINCE WILLIAM AND KATE LIVE LONDON

3. Birmingham* mental health services Key Facts (2008-9)  Population  Number of staff  Number of beds  Community Teams  Service users seen  1.2 m (including Solihull)  3,924  722  79  48,459 *Birmingham and Solihull NHS Mental Health Foundation Trust

4. Location of City’s 3 Premiership Football teams West Bromwich Albion (Lukaku) Birmingham City ASTON VILLA (Benteke)

5. CONTINUING NEED Rehab / Recovery (SUB) ACUTE Primary Care Liason CONTINUING NEED ASSERTIVE OUTREACH ACUTE HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Houses, PRIMARY CARE Birmingham Model Functional Map

6. Belgium Functional Map of Adult Services

7. CONTINUING NEED F3 Rehab / Recovery (SUB) ACUTE F1/2a Primary Care Liason CONTINUING NEED F2b ASSERTIVE OUTREACH ACUTE F2a HOME TREATMENT Residential based care: F4 Hospital Beds, Day services, Crisis Houses, PRIMARY CARE F1 Birmingham Model Functional Map

9. Total mental health beds per 100 000 population (WHO Mental Health data From Atlas, 2011) 1:700 1:5000

10. What was Birmingham’s message? It is possible to develop a full range of mental health services in the community that replaces the need for current levels of hospital provision. Community services can develop different functions in the same way as hospitals and, like hospitals, can develop an integrated approach. The community creates new opportunities because people and problems are ‘in vivo’. The community creates different challenges because the system has less control than hospital.

11. Three levels of an integrated system Practitioners work in teams, not as individuals = Collaboration = Integrated Care Teams work as part of an organisation of healthcare = Co-operation = Integrated Pathways Health organisations work with other non-healthcare organisations = Co-ordination = Integrated Agencies

12. Integrated Care – Integrated Pathways – integrated Agencies Each team member, both as a person and by professional training, has a different view of the person, their problems and their situation. Diverse thinking is important in making sense and finding solutions, but it is also important that the team works together (collaborate) to identify a common strategy and goal.

13. Integrated Care – Integrated Pathways – integrated Agencies It is important for the person, their family, and people they look to for help to know what service is available and how to access it. Once connected to the service, everyone involved knows what help will be offered, and what continuing mental health service is available next. Teams co-operate to agree who is responsible in what situation to prevent gaps in service, ensuring continuity of care. An integrated pathway has similarities to a stepped care model.

14. Integrated Care – Integrated Pathways – Integrated Agencies Not all support for people with mental health problems is available from mental health services. Access to social care, social support, social housing, welfare payments, all require involvement of other agencies. Co-ordination with other agencies ensures common agreement about longer term support and planning, ensures maximum use of resources, and prevents delay.

15. Integrated Home Treatment Specifically targeted to people who would otherwise go to hospital 24 hours, 7 days a week, frequent, flexible visiting Multi-professional team; doctors and nurses, social worker, occupational therapist, psychologist, community support workers Rapid response, within 2 hours Pathway from and back to community care Gatekeeper to hospital Crisis houses developed as alternative to hospital In-reach to hospital for early discharge

16. COMMUNITY MENTAL HEALTH TEAM Primary CareContinuing Need: Liaison Rehab and Recovery CONTINUING NEED ASSERTIVE OUTREACH TEAM HOME TREATMENT TEAM Residential based care: Hospital Beds, Day services, Crisis Homes ‘Acute’ Care core pathway PRIMARY CARE

17. COMMUNITY MENTAL HEALTH TEAM Primary CareContinuing Need: Liaison Rehab and Recovery CONTINUING NEED ASSERTIVE OUTREACH TEAM HOME TREATMENT TEAM Residential based care: Hospital Beds, Day services, Crisis Homes ‘Acute’ Care core pathway PRIMARY CARE

18. 26%5037Three 48%9650Two 53%9444One Admission Reduction % 1 Year Pre Home Treatment 1 Year Post Home Treatment District Admissions Overall reduction in n. Admissions = 43% Impact on Bed Usage Data on 3 new teams, Birmingham 1995

19. Impact on Bed Usage 30%1,8231,290Three 55%3,6671,662Two 36%3,0361,953One OBD* Reduction % 1 Year Pre Home Treatment 1 Year Post Home Treatment District Occupied Bed Days Average reduction in n. bed days = 40% *OBD = OVERALL BED DAYS Data on 3 new teams, Birmingham 1995

20. What have we learnt from supporting development in other countries? There is existing community innovation and expertise that needs to be recognised and valued, but ultimately to be of value, becomes integrated. Community and hospital psychiatry can have theoretical and ideological and differences, and this can impact on developing integration at all levels. The way funding of services works is a big challenge; usually different services are paid for from different sources. It also means involving different government and local agencies.

21. Developing Community Mental Health You can: Develop a more differentiated community service, that reflects the traditional differentiation found in psychiatric hospitals. Develop evidence to prove the care traditionally provided in hospitals can in many cases be provided in the community, more cost effectively, and with better patient outcomes. Can make community care work for all types of ‘disorder’ and a higher level of ‘severity’.

22. Some possible questions for Brussels.. What is your overall vision for your services? Can you describe your services using functional mapping? What stage are you at? What does a functional map identify that you need to do in a short and long-term plan? Where are the gaps? What is the priority at each level for developing services; teams, pathways, agencies? What is practically possible.. next?