Cathy Riley Director of Pharmacy & Medicines Optimisation

1. Integrated Care in Severe Mental Illness: Local Examples of Pathway Development, Joint Working & Adherence Cathy Riley Director of Pharmacy & Medicines Optimisation South Staffordshire & Shropshire Healthcare NHS Foundation Trust

2. What is an Integrated Care Pathway? • ‘structured multidisciplinary care plans which detail essential steps in the care of patients with a specific clinical problem’ • Sometimes called: ‘clinical pathways’, ‘critical pathways’, ‘care plans’, ‘care paths’ and ‘care maps’ • However, there is no single definition of integrated care

3. Why should we want develop Pathways for SMI? • The NHS has restructured many of its services based around the use of integrated care pathways (ICPs)- easier to understand skill mix and resource required, useful to review evidence-based interventions and current practice (what brings value?) • Its easier to cost care if there is a consistent pathway used (important for tariff approach) • Its transparent to commissioners, service users and carers about what can be expected • In other settings, ICPs have been shown to reduce hospital costs

4. Why are few ICPs established in SMI (in West Midlands)? National Institute for Health Research (Sep. 2011)1: • Found no systematic reviews of the effectiveness of ICPs specifically in mental healthcare. • Two well-conducted systematic reviews provide evidence that ICPs can improve some outcomes compared with usual care in some hospital settings. Very little of the evidence included in these reviews comes from mental healthcare or UK settings • Studies that have looked at the implementation of ICPs in mental health settings in the UK NHS have generally reported on the experience of particular services. The findings are of limited value for decision-making because of their lack of methodological rigour and reporting of process outcomes and expert opinion rather than patient outcomes. • While there is some evidence suggesting that ICPs can reduce hospital costs, their relevance to MHTs is uncertain as most studies were not conducted in either the UK NHS or mental health settings. • Given the uncertainties around the generalisability of the evidence and the best ways to implement ICPs, it will be important to plan carefully for implementation of any change to services and to monitor resource use, costs and clinical outcomes during and after any change. • 1http://www.york.ac.uk/inst/crd/pdf/Integrated%20care%20pathways%20evidence%20briefing.pdf

5. What are the Challenges in ICP Development in SMI? Crossing Boundaries: Improving integrated care for people with mental health problems Final Inquiry Report September 2013 (Mental Health Foundation) “Good integrated care for people with mental health needs remains the exception rather than the rule”

6. Mental healthcare provision- based on a flawed paradigm? • Physical and mental health are fundamentally different (albeit each having some impact on the other), requiring different specialist approaches, and ignores the common factors in the global determination of health and illness, which have biological, psychological and, in particular, social components

7. How can we better integrate?- 2 underpinning essentials: • cross-boundary inter-professional training and education • having the right people in the organisation – both leaders who will drive forward integration at a strategic level and staff who understand and respect the roles and responsibilities of other professions and are willing to work with patients and across organisational and professional boundaries

8. Factors that facilitate good integration: • Information sharing systems • Shared protocols • Joint funding & commissioning • Co-located services • Multidisciplinary teams • Liaison services • Navigators • Research • Reduction of stigma

9. Successful integrated care “The future of effective integrated care therefore lies primarily in recruiting, maintaining and developing a workforce, both in health and social care, and in other organisations who have contact with people with mental health needs, that is passionate and committed to the principles and practice of holistic care and partnership working”

10. What does the Royal College of Psychiatrists say? Whole-person care: from rhetoric to reality Achieving parity between mental and physical health

11. Why bother? The facts (Schizophrenia Commission 2012) • Prevalence of diabetes is 2-3 times higher for people with schizophrenia • 61 % of people with schizophrenia smoke, compared to 33% of the general population • People with SMI are twice as likely to die from heart disease, 3 x as likely to die of respiratory disease and 4x as likely to die of infections than the general population • People with schizophrenia who develop cancer are 3 times more likely to die than those in the general population.

12. Some more facts • People with schizophrenia and bipolar disorder die an average 25 years earlier than the general population, largely because of physical health problems. • 11% of adult health care costs in the UK are attributable to physical symptoms caused or exacerbated by mental health problems.

13. Schizophrenia Commission

14. How far are we away from this? Integrated care might also be considered to simplify the delivery of “shared care”, Lester (2005) giving a GP’s perspective on health care for people with a mental illness: “Shared care enables a ‘best of both worlds’ scenario, with the opportunity to provide good-quality holistic care. Shared care should lead to pooling of expertise and enhanced creativity in problem-solving. It should also lessen the possibility that vulnerable patients are ‘left in limbo’, with patients and carers feeling that they are failing to make progress through the mental health system….. Shared care also offers opportunities for addressing long-standing issues regarding the morbidity and mortality of people with serious mental illness”.

15. Focussing on Medicines • New Dawn: Medicines Optimisation • Medicines Optimisation must be a feature of all ICPs

16. Medicines Optimisation • Medicines Safety - Avoiding harm from medicines - Ensuring good medicines governance and the safe and secure use of medicines - Learning from errors and incidents

17. Medicines Optimisation • Effective Outcomes - Ensuring optimal outcomes from medicines by implementing NICE guidance, evidence based practice and the rapid adoption of appropriate innovatory treatments - Delivering value for money from medicines and reducing pharmaceutical waste - Helping all staff understand their own responsibilities in optimising medicines use

18. Medicines Optimisation • Patient experience - Ensuring decisions are made jointly and that patients and their carers are knowledgeable about their medicines. - Providing support for patients at all points and across all interfaces of healthcare. - Local decisions about medicines are robust, transparent and in accordance with NHS Constitution - Care is integrated and personalised around the individual patient

19. Medicines optimisation is a more patient-focused approach to getting the best from medicines "Medicines optimisation is a vital agenda, not an agenda added on to something else we are trying to do, this is absolutely central to it." Sir David Nicholson, Chief Executive, NHS

20. Workforce Development Prescribing Medicines Administration & Care Co-ordination Pharmacy Shared Decision Making

21. Realising the Benefits of Technology E-prescribing & administration Assistive Technology (adherence) Technology to support non-pharmacological approaches Choice & Medication (good quality information)

22. Improving Medicines Safety Currently, where there is a gap between best practice and current practice, this most commonly occurs around the monitoring of medicines. Lack of buy in to: Informed patient choice Therapeutic trial to avoid side effects “Medical Model”…..caused historical lack of infrastructure and negative association with medicines

23. Monitoring of Medicines • Monitoring Effectiveness • Monitoring Side effects • Monitoring Adherence • Monitoring Physical Health at Initiation and • during Continuation • Education and resources required so to • provide individual & effective management • & support

24. Partnership Working Oversight while under the care of the GP GP provision of prescriptions and physical testing Confidence of community pharmacists to review mental health medicines

25. Innovation, Research, Spreading and Maintaining Best Practice • Developing a Centre of Excellence for • Medicines Optimisation in Mental • Healthcare: Bringing Medication to Life • – A Partnership Approach.

26. Integrated Care Pathways- Don’t Forget: • Physical health • Supporting Medicines Better