Northern Region April 1 st 2014 Geraldine.strathdee@nhs

1. Moving to Action to improve mental health outcomes Dr. Geraldine Strathdee, National Clinical Director, mental health Northern Region April 1st 2014 Geraldine.strathdee@nhs.net

2. Northern Region Move to Action for Better Outcomes and Better Value Integrated long term conditions care - Integrated primary care based

3. The Ask… • Can we come and develop a what does good look like top tips • Can you help us help you with information dashboards. Can you give us an analyst with skills • Can you take a regional lead in one of the top 4 programmes • If you have a bit of cash, can you help our capacity to drive a programme of improvement

4. Implementing the national Physical Health CQUIN

5. The physical health CQUIN applies to all inpatient unit types in all NHS and independent sector beds & 3 intensive community teams • NHS funded bed types Costs • 3 intensive community treatment teams • DH commissioned High secure beds • Tier 4 NHS E direct commissioned • CAMHS beds • Perinatal beds • Eating disorder beds • Specialist PD beds • Medium secure beds • Low secure beds • CCG commissioned • Closed rehabilitation beds • Open rehabilitation beds • Psychiatric intensive care • Acute beds for older young adults • Crisis & recovery houses • Provided by NHS, independent & 3rdsector • CCG commissioned • Early Intervention psychosis teams • Assertive outreach teams • Community forensic teams

6. Indicator 1: 65 % 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. 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 ( for those with known substance misuse comorbidities) The results recorded in the patient's notes/care plan/discharge documentation as appropriate, together with a record of associated interventions according to NICE guidelines or onward referral to another clinician for assessment, diagnosis, and treatment eg smoking cessation programme, lifestyle advice and medication review.

7. Indicator 2: 35% funding for completion of a programme of local audit of communication with patients’ GPs, focusing on patients on the CPA, demonstrating by Quarter 4 that, for 90 per cent of patients, an up-to-date care plan has been shared with the GP, including the holistic components set out in the CPA guidance: • ICD codes for all primary and secondary mental and physical health diagnoses. • Medications prescribed and monitoring and adherence support plans. • Physical health condition(s) and ongoing monitoring and treatment needs. • Recovery interventions including lifestyle, social, employment and accommodation plans where necessary for physical health improvement. • The local audit will cover a sample of patients in contact with all specified services for more than 100 days and who are on the CPA.

8. CCG commissioners: to deliver the Physical health inpatient CQUIN, some are commissioning Commissioning guidance of the options to support delivery From primary care local high interest practices • GP practice contracted for wards with practice nurse sessions in diabetes, COPD, CVS for ward staff • CPD for MHT medics and nurses and all MDTs with • SLAs for physical health specialist inputs into MH wards ( like MH liaison services) with acute trusts and community specialists & path labs for sessional provision when needed • Physical health liaison team to emulate a Liaison MH team in acute • LES Enhanced practice schemes : e.g. London, south coast • Integrated community and MH trusts : are developing integrated care • 3rd sector outreach and healthy lifestyle, social inclusion and support for safe medicines community teams that need outreach to bring to appointments • SLAs with diagnostics & Pathology & medical equipment & training

9. What tools are coming to help you? • National psychosis summit April 10thQE, LondonRethink/ NHSE/DH / RCGP/RCPsychetc will showcase best practice and practical implementation supports • Rethink/Rcpsych improvement networks & POMH-UK • National Audit of Schizophrenia 2014 national report • Revised NICE guidelines on schizophrenia Feb 12th 2014 • Domain 1 NHS IQ pilots in 3 areas: adverts soon • Step by step guide to implementation support checklist, posters, tools being developed by SCN clinical leaders • 3 national conferences and Masterclasses • NHSE Domain 1: web resource • Lots more………….

10. Primary and community care new style

11. NHS E acute and unplanned care programme & the mental heath Crisis Concordat

12. Depression : the commonest causes in communities & the greatest primary care & LTC demand ….. Elderly isolated & people with dementia • Key life cycle: • Divorce • Retirement • Redundancy • Menopause Victims of domestic violence Dyslexia, Dysprexia ADHD, Autism, Asperger’s and Learning Disabilities Isolated women with small children Long term physically ill Victims of school and employment stress and bullying People with schizophrenia and sight and hearing problems Alcohol and drug addictions

13. Mental health Model Unplanned Tiers of Care Intermediate tier £ £ £ £ £ £ Accessible information to prevent crises and get help early

14. ‘Game changing’ healthcare trends Dementia - common, costly and under-identified Comorbidities- common, costly in current silo models of care, tariff system now inappropriate Comorbidities & mental ill health becoming the norm Dementia Population prevalence (%) by age Growth in nos. of people with dementia 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. Numbers with dementia • 700,000 • In 30 years – doubling to 1.4 m Total cost of dementia in the UK • £17 billion per annum • In 30 years – tripling £51billion pa

16. Sgmentation of needs and patient-centric models are at the heart of efficient service redesign & innovation

17. Service transformation and stratification

18. 6 5 4 3 2 1 Drivers of Change Opportunities Patients of the Future Stratification NHS 6 Strategic Characteristics sustainable system Impact on planning People and carers are active participants in their own care Empowered patients: co-designing the service /managing their condition Citizen Expectations Prevention Agenda Healthy / infrequent user Wider primary care, provided at scale Most care provided outside hospital setting Demographics Low/Moderate single LTC A modern model of integrated care Flexible workforce, trained for people and disease not ‘organs’ or site Technology & Innovation Multiple/ Complex conditions Access to the highest quality urgent and emergency care Year of Care / Pathway Budgets Economic Pressures High expectations of Quality A step-change in the productivity of elective care Community pooled resources – risk/reward sharing commonplace “Units of need and provision” across complex boundaries Outcome Standards Specialised services concentrated in Centres of Clinical Excellence

19. The financial challenge is estimated at £8.4 billion in 2015/16 and £30 billion by 20/21 • Historical Funding pressures on the NHS in England • Real terms freeze through to 2020/21 • Funding£b • £30b • £8.4b • 2013/14 • 14/15 • 15/16 • 16/17 • 17/18 • 18/19 • 19/20 • 20/21 SOURCE: NHS England

20. The recognition of the scale and economic impact of mental ill health and the case for parity of esteem

21. The mental health systemThree segments for our overarching national vision

22. What type of 21st century care do people with, and at risk of mental ill health tell us they want: whole person, contributing citizen, in employment When people use services they ask:

23. NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

24. NHS | Presentation to NHS England (Midlands and East) | 4 February 2014

25. To progress towards parity …..we can provide you with .. • Information care pathway profiles on parity by CCG and LA • Physical health CQUIN to reduce premature mortality • Crisis Concordat • National standard contract • The 5 year commissioning outcomes

26. What are the key Mental health priorities for 2014/2015 In addition to local priorities, the national requirements are set out in the

27. Commissioning for improved outcomes in your community

28. 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, 2008. Further calculations by Mike Parsonage . see: LSE (2012) how mental illness loses out in the NHS

29. What do you need to do to prepare for implementation • Do you know where your services are commissioned that will be this year’s target • Do you know your current premature mortality rates from physical health conditions ( erroneously called natural conditions!) & from mental health conditions • See your new local data from HSCIC…..

30. NHS England & partners: 8 high impact parity programmes

32. What can you buy to avoid admissions

33. National Physical Health CQUIN for all mental health inpatient units and 3 intensive community treatment teams Indicator name Cardio Metabolic Assessment and treatment for Patients with Schizophrenia in all inpatient & 3 intensive community teams Description of indicator To demonstrate, through the National Audit of Schizophrenia, full implementation of appropriate processes for assessing, documenting and acting on cardio metabolic risk factors in patients with schizophrenia The audit sample must cover all relevant services provided by the provider

34. What do you think is needed to implement Commissioners: • agree the implementation model & benefit to new world of commissioning based on outcomes Trust Board & corporate departments Learning & development & audit depts Every MDT in every inpt unit Every individual clinician Every service user and carer What else?

35. What is needed to implement

36. What does every clinical team need to do & what support do they need to do it

37. Clinical • Formulation based shared understanding between service user and team • ICD coding • Template letter to get info from GPs • Information needed for SU, Choice & tariff • Medicines reconciliation. POMH-uk? • Clinical rooms, • Recovery orientated healthy lifestyles: • National audit: focus….

38. Mental health crisis causes and care in hospital

39. SMI CMHT Primary care Community Stratification : target the top 10% of patients who used 50% of spend The top 10% are expensive because • Hospital Capital costs • Repeated admissions • Mental health Act detentions • Comorbidities • Psychosis • Substance misuse • Personality development • Organic brain problems • Physical LTCs • Stigma and social exclusion • Offender patterns

40. Economic crisis ……..what will deliver value

41. MH treatments • £600 million in primary care • £2.31 billion in secondary and tertiary care • £2.63 billion in physical health treatments • £550 million social care spend • Informal carers £1.2 billion

42. Mental ill health affects 1 in 4 Londoners each year and results in £26 billion annually in total social and economic costs to the city. • A crippling £7.5 billion spent each year by London’s public sector to directly address mental ill health in the capital. • A further £10.4 billion lost to London businesses through such costs as sickness absence and reduced productivity. • £960 million spent each year on benefits to support people with mental ill health. • ·         £220 million spent each year on crime related to mental health.  • The wider impacts result in around £2?6? ?b?i?l?l?i?o?n? ?each year in total economic and social costs to London. • The public sector spends £7?.?5? ?b?i?l?l?i?o?n? ?a year to combat it. • Another £2? ?b?i?l?l?i?o?n? ?is lost through lost taxes • M?e?n?t?a?l? ?h?e?a?l?t?h? ?t?r?e?a?t?m?e?n?t?s? ? • £6?0?0? ?m?i?l?l?i?o?n? ?in primary care • £2?.?3?1? ?b?i?l?l?i?o?n? ?in secondary and tertiary care • £2?.?6?3? ?b?i?l?l?i?o?n? ?in physical health treatments • £5?5?0? ?m?i?l?l?i?o?n? ?s?p?e?n?t? ?t?h?i?s? ?y?e?a?r? ?b?y? ?s?o?c?i?a?l? ?c?a?r?e? ?t?o? ?t?r?e?a?t? ?m?e?n?t?a?l? ?i?l?l? ?h?e?a?l?t?h? ? • I?n?f?o?r?m?a?l? ?c?a?r?e?r?s? ?c?o?n?t?r?i?b?u?t?e? ?£1?.?2? ?b?i?l?l?i?o?n? ?i?n? ?s?u?p?p?o?r?t? ?

43. What Outcomes do our patients ask us to achieve in partnership with them Professor Bruce Keogh, Medical Director of the NHS

44. SMI CMHT Primary care Community Stratification : target the top 10% of patients who used 50% of spend The top 10% are expensive because • Hospital Capital costs • Repeated admissions • Mental health Act detentions • Comorbidities • Psychosis • Substance misuse • Personality development • Organic brain problems • Physical LTCs • Stigma and social exclusion • Offender patterns

47. OxleasQIPP through use of technology Where innovation and new technology can help Pathway points • Identification • Assessment • Evidence based NICE pathways • Recovery & social inclusion • Evidence based service design & delivery • Risk alert awareness technology • Self assessment tools • Clinician assessment tools • e.g. Tele triage • Clinician decision support tools • Information in all languages • eRecords, eCare, ePrescribing, eInvestigation results, efMRI • Assistive technology for : • home based care for dementia, LD • safety & support for all MH • Technology to reduce beauracy & duplication

48. … Primary care mental health: oxleas style, we support 1 2 3 4 5 • Working with Communities to reduce primary care demand • Employers, schools, safer community initiatives • Enhanced roles for pharmacists e.g. smoking cessation • Library & education centres to provide information • Creating work and volunteering opportunities • Re-engineering spend to create money for increased capacity • Decrease referral for medically unexplained symptoms Increase Primary care IAPT • Prescribing benzos, antidepressants, painkillers • Increase capacity through affordable skillmix workforce initiatives • Telecare nurses/ workers, IAPT, counsellors, • Enhanced practice nurses, health visitors, district nurses, GPwSI • Depression case managers, user experts • Increase capacity by treating causes, not just symptoms through protocols, creation of expert patients for long term care • self help manuals • Information & green prescriptions, new intranet design • Use of more standardised assessment & outcome tools • Improve the interfaces through agreed NICE stepped care & SLAs

49. The key quality and safety issues

50. Primary care mental health service organization (Kaeser, Scandanavia, US Vets