NHS | Presentation to [XXXX Company] | [Type Date]1

Mental Health Services and the 5 Year

Forward View

This session will focus on the mental health as one of the aspects at

the forefront of delivering the Five Year Forward View Modernisation.

Dr. Geraldine Strathdee, National Clinical Director for Mental Health,

@DrG_NHS

ADSS 2015

What is the definition of Mental health: the basis of a humane and wealthy society

from ‘No health without mental health’, National mental health strategy

The 5 year Forward view & achieving better access to mental health services by 2020 • The NHS Five Year Forward View, published on 23/10/2014 sets out a vision for the future of the NHS.

• It was developed by the partner organisations that deliver and oversee health and care services including • NHS England, • Public Health England, • Monitor & Care Quality Commission • Health Education England,• the NHS Trust Development Authority.

• It sets out how health services need to change & promotes more engagement with patients, carers & citizens & communities Integrated physical & mental health & social care, Integrated primary and specialist care, Integrated health and social care

Where every contact is a kind, enabling, coaching experience

4

5 Year Forward view Lifespan mental health

Being Born well Best early

yearsLiving and working

wellGrowing older

well Dying well

Building Positive

mental health in individuals

and communities

through raising political & public awareness and reduced stigma

Prevention of mental ill health in

communities

through addressing the fundamental causes in each

community

Improving access

standards to

timely, effective care

for the 16 mental

health care pathways

maximizing the potential of the

digital revolution

Transformation of services to

deliver Integrated treatment & care, better outcomes, quality & Value &

personalized

Right Care

Building a sustainable

Future

Of

Leaders, intelligence &

and improvement programmes

At each life stage

Empowering people• Information- Access to information will be improved. Within 5 years all citizens will be able to access their medical care records & share them with carers or others they choose• Provide support to people to manage their own health- There will be investment in evidence-based approaches e.g. group-based education for people with specific conditions & self-management educational courses• Increase patients direct control over the care provided to them- Ensure that patients have choice over where and how they receive care • Integrated Personal Commissioning (IPC)- A voluntary approach to blending health and social care funding for individuals with complex need

• Supporting Carers- New ways will be found to support carers, by working with voluntary organisations and GP practices to identify them and provide better support

• Encouraging community volunteering- Develop new roles for volunteers which could include family and carer liaison workers, educating people in the management of long-term conditions and helping with vaccination programmes

• Stronger partnerships with charitable and voluntary sector organisations- The NHS will try to reduce the time and complexity associated with securing local NHS funding by developing a short national alternative to the standard NHS Contract where grant funding may be more appropriate and encourage funders to commit to multiyear funding wherever possible

• The NHS as a local employer- The NHS is committed to ensuring that boards and the leadership of NHS organisations better reflect the diversity of local communities they serve. As an employer to ensure all staff have support and opportunities to progress and create supported job opportunities to ‘experts by experience’ e.g. people with learning disabilities who can help drive changes in culture and services

Engaging communities

The common causes of common mental ill health conditions Which part of government, wider local government, social care, healthcare, community safety, cultural communities need to act?

Elderly isolated &

people with dementia

Elderly isolated &

people with dementia

Victims of domestic violence

Victims of domestic violence

Alcohol and drug addictionsAlcohol and

drug addictions

Isolated women with

small children

Isolated women with

small children

Victims of school and employment

stress and bullying

Victims of school and employment

stress and bullying

Key life cycle transitions : • Divorce

• Retirement• Redundancy• Menopause

Key life cycle transitions : • Divorce

• Retirement• Redundancy• Menopause

Long term physically ill

Long term physically ill

Dyslexia, DysprexiaADHD, Autism, Asperger’s and

Learning Disabilities

Dyslexia, DysprexiaADHD, Autism, Asperger’s and

Learning Disabilities

People with schizophrenia and sight and

hearing problems

People with schizophrenia and sight and

hearing problems

Human Rights : why are people detained under the MH act in your area: is it illness or unidentified and unaddressed public health needs

With analysis of the use of the Act by LA and CCG, we can now identify the local conditions that can lead to use of the act & high impact & spend

transport hubs, homelessness, no recourse to public funds, cultural mores, link with unemployment & drug and other criminal activities, clinical management & practice variations, service configurations

What are our 5 aims for lifespan mental health?1. Building resilient individuals and communities: To continue to build public and

political support for mental health reform through increasing awareness of the individual and societal

benefits of positive mental health & awareness of the types & causes of mental illness, in order to

transform attitudes to mental health & reduce stigma. The power of social media & digital enablers are key

2. Preventing mental ill-health : To understand and maximize the opportunities for prevention

of mental ill heath, and the promotion of mentally healthy and resilient individuals and communities:

3. Introducing access standards to timely, effective care with outcome measurement When a person develops mental illnesses, they have timely access to personalized ,

integrated, holistic, effective, high quality treatments, that optimizes the health & functional outcomes &

quality of life for individuals, their families, and, as the norm, takes place in the community or in the

persons home, & reduces unnecessary use of healthcare resources.

4. Transformation of services : When a person’s illness is complex and severe, and requires

specialist interventions, that the care provided, is personalized, culturally appropriate, delivered in the

least restrictive settings and 24/7 personalized home care services by trained and supported staff

5. Building a sustainable future :To develop & deliver the transformation needed, though

creation of an expert ‘state of the art’ leadership development, implementation & improvement programme

and promotion of a Learning Organisation model throughout all our commissioned healthcare

organizations

The 5 year Forward view & achieving better access to mental health services by 2020

Why public and political attitudes to mental health are now changing so fast The myths we are busting in England Mental health just happens or not! You can’t learn it!

• No, it’s NOT. Its like physical, academic or creative achievements. It can be taught & learnt. • Mental ill health is a long term condition• No, it’s NOT! Its so often in England an untreated acute condition• Mental health is all too complex!• No it’s NOT! Its the people we all know with depression/anxiety, eating disorders, perinatal depression, OCD, alcohol, psychosis episodes etc.• Mental health has no evidence based treatments • No it’s NOT! We have over 100 NICE guidelines , HTAs, Quality standards etc etc • We have highly powered, robust, cost effective treatments …if given in a timely wayMental health care is only delivered in mental health trusts & should not be funded in healthcare ….. Stigma

• It’s regarded as ‘life’, or ‘social’ , or ‘weak people’, the neurobiology & science & economics & value propositions are not understoodIts leaders are ‘good at financial management’ but ‘its Boards and EMTs cant articulate quality’?..

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5 Year Forward view Lifespan mental health

Being Born well Best early years

Building Positive mental health in individuals and communities

through raising political & public awareness and reduced stigma

Prevention of mental ill health

through addressing the fundamental causes

JSNA basics: In this CCG/ borough, what are

the social determinants of mental ill health & assets

to prevent it?

Prevalence: how common are mental

health care pathways conditions in this area?

Prevention: What are the high risk groups to target

for prevention?

Early Identification: What % age of people

with these conditions are identified ( and coded) e.g. in social care/ GP

QOF?

Access to timely, NICE/SCIE evidence based interventions rates in social care,

primary care, acute care, specialist all sector MH

care

Outcomes achieved that are valued by users, families & services

Least restrictive setting close to home: what

types of beds / teams are people care for in

Spend: on MH in primary care, social care,

specialist mental health hospital beds &

community services?

Quick high impact wins: What are the top 10%

stratification opportunities?

Building collaborative, compassionate , resilient communities What information do we need to deliver whole care pathway health & social care information for every care pathway cluster of conditions by CCG & LA…

We are awash with data on Fingertips for SMI, common mental health conditions, substance misuse, coming soon CYP

The local area risk factors

and assets

Prevalence & high risk

groups

Services in line with

NICE

Quality & Outcomes Spend

• Can you find 15 minutes to go onto the mental health intelligence network Fingertips website: http://fingertips.phe.org.uk/profile-group/mental-health

• Look at the information on that wider community needs, commissioned primary care, social care, CCG and specialists commissioned services, the standards, the quality, the spend

• Primary care MH In England has not been a focus so: • OECD countries indicates that our primary care mental health services development is one of the least

advanced & this lack of support is a major cause of our poor employment • Mental ill health accounts for 1/3rd of the daily work of GPs but• 2/3rds GPs & less than 99% practice nurses do not get post graduate training • Brilliant innovations are developing across England, but we need to be more systematic in supporting and

evaluating• Pathfinder programmes & some PC MH experts in NHS leadership roles• CQC primary care regulation includes SMI and CMD MH o

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5 Year Forward view Lifespan mental health

Best early years Living and working well

Improving access to

timely, effective services for the 16 mental health care pathways maximizing the potential

of the digital revolution

Transformation

of services to deliver value, better outcomes, quality & personalized Right Care

Perinatal mental health : why invest?The cost of NOT providing perinatal MH care results in major impacts on: • Maternity & perinatal services • Criminal justice system• Education system • Employment system • Mental health in NHS• 2nd greatest cause of maternal deaths • Social care

Tackling causesBuilding heath literacy Prevention

Employment Family friendly employment practice is a ‘win win’

Better productivity, happy staff & families, less GP visits

What can HWWBs, JSNAs, CCGs do?

Schools: 4 RsReading, writing, ‘arithmetic, Resilience Incorporating resilience into all the curricula Building resilience, addressing dyslexia Training school nurses & form tutors, Engaging school governorsUsing the pupil premium

College students @transition Building resilience & healthy lifestyles at transition

Physical & mental health literacy in future leaders

Parenting programmes; ‘the statin of mental health’

Transport related :Preventing isolation in older people Reducing avoidable suicides and Reducing S 136 detentions

Fire chiefs70% of avoidable fires, domestic accidents, & RTAs in England & Sweden

Police commissioners Commissioning parentingSafer neighborhoodsGangs and abuse in scope Alcohol : serious strategy needed

Taxpayers ask: is it 20% or 40% of unemployment, fires, domestic accidents, school exclusions, imprisonment alcohol related illness that are preventable

‘Thinking’ Communities are acting and calculating the cost of NOT addressing mental health

The way london calculated the cost : www.london.gov.uk/mentalhealth

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5 Year Forward view Lifespan mental health

Improving access to

timely, effective services for the 16 mental care pathways

maximizing digital potential in

Communities

primary care

acute A/E, wards, OPCs

Specialist mental heath community & hospital services

In research and genomics programmes

The integrated care vision for physical & mental health & social care, primary and specialist care

& health and social care

Where every contact is a kind enabling, coaching experience

The 15/16 Access & Waiting Time Standards

19

New access standards

• Access to psychological therapies: Depression & anxiety

• 75% of people referred to the Improved Access to Psychological Therapies programme will be treated within 6 weeks of referral, and 95% will be treated within 18 weeks of referral.

• Access to early intervention for psychosis:

• More than 50% of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral.

• Access to eating disorder services for CYA

• Access to perinatal care

• Liaison mental health in acute hospitals

• £30m targeted investment on effective models of liaison psychiatry in a greater number of acute hospitals. Availability of liaison psychiatry will inform CQC inspection and therefore contribute to ratings.

20

5 Year Forward view Lifespan mental health

Transformation

of services to deliver value,

better outcomes, quality &

personalized Right Care

Building a sustainable

future of

Leaders, intelligence &

and improvement programmes in

Learning Organisations

Transforming Mental health care in England 2020to achieve parity of access, effective care, quality & value across the Lifespan: 5YFV

Communities:• Building informed, collaborative resilient communities • Maximizing prevention

Introduction of access & integrated, effective care standards & measured outcomes for • the 16 mental health conditions /pathways from primary care to specialized commissioned provision

Integration of clinical practice and pathways through transformation of • Primary care: Integrated assessment, treatment, skillmix, federations, digital, stratification approaches • Acute care: Liaison services to Acute care: A/E &• Integrated care pathways in LTC clinics in acute trusts & community provider services• Vanguards, and new models of commissioning & payments

Crisis Care transformation: Inverting the triangle & achieving fidelity models• No more CYP in police cells, stratification

Transforming specialist mental health services through transformation of • Psychosis care: 60% spend & needs: improving access, Right Care, reducing major efficiency variation,

stratification• MH needs help to better understand and improve our pathways

Enablers: Leadership, Workforce, Networks, digital, scientific revolution, payment systems

22

New Care Delivery Options with MH impact

• Multispecialty Community Provider- Groups of GPs to combine with nurses, other community health services, hospital specialists and mental health and social care to create integrated out-of-hospital care

• Primary and Acute Care Systems- integrated hospital primary care provider- general practice and hospital services working together

• Redesigning of Urgent and emergency care- These services will be redesigned to enable A&E departments, GP out-of-hours services, urgent care centres, NHS 111 and ambulance services

• Enhanced health in Care Homes- NHS England will work with the local NHS and the care home sector to develop shared models of in-reach support, including medical reviews, medication reviews and rehabilitation services

• Specialised Care- NHS England will work with local partners to create specialists providers to develop network of services over an area; integrating different organisations and services

• Digital revolution –– To support care delivery & therapies

The most frequent complaint about mental health professionals was that they were too pessimistic about the likely outcome

Schizophrenia Commission, 2014

Why set a standard?

In 2011, No Health Without Mental Health, highlighted the effectiveness of EIP services. When delivered in accordance with NICE standards they help people to recover from a first episode of psychosis and gain a good quality of life.

Elective care system in mental health 2015-2020: clinicans want to we are building personalized, recovery orientated, high quality care, home based 24/7 care & reduction of suicide at every level

High secure beds

Medium secure beds

Low secure beds

Intensive rehabilitation closed unit

for complex dual diagnosis

Open rehabilitation units

Locally authority Residential rehabilitation

Supported accommodation with care package

Own tenancy plus personalized budget

24/7 Assertive outreach/ community forensic team multi agency teams

24/7 Assertive outreach /rehabilitation & recovery, multiagency teams

24/7 Assertive outreach /rehabilitation & recovery multi agency teams

Rehabilitation / recovery team: multi agency

Rehabilitation / recovery team

CMHT/ Enhanced primary care SMI with 3rd sector outreach

CMHT/ Enhanced primary care SMI with 3rd sector outreach

Design Principle :It is vital to understand that in mental health our ‘technology’ and ‘care model design principle’ is that in order to provide safe, NICE concordant , efficient services, we need proven effective care teams to link with beds In mental health we are expert at using case managers to triage all admissions & work early on the discharge plans

The beds The teams

The MH crisis concordat / UEA care model

8. Adequate beds when needed

7. Alternatives to Hospital beds e.g. day treatments and crisis

houses

6. 24/7 Liaison mental health teams in A/E & acute trusts all

ages

5. 24/7 Crisis Home Treatment Teams

4. Places of safety for S 135/136

3. Trained tele triage & tele health

2. Single number access ? 111

1. CCGs & HWWBs tackle causes

1. Identify Causes & Prevent by all agencies :• Identify the causes of MH crises & prevent• Public health, Health & Wellbeing Boards, CCGs, transport

systems, police, housing, social care, primary care

2. Single coordinated access number & system

• single access number to ring ? 111• all agency response, GPs, social care, NHS

3. Tele triage and tele health well trained staff• Reduce suicide & face to face need by 40% • Respond to police & other referrers

4. S 136 places of safety/ street triage

5. Crisis Home treatment teams with fidelity• reduce admissions and LOS by 50%• ? Could coordinate street triage etc

6. Liaison mental health teams • in A/E & acute trusts reduce admissions to acute

beds and care homes by 50% & reduced LOS

7. Crisis houses & day care for as alternatives 8. Adequate acute beds when needed

What do the mental health NICE guidelines say There are 7 core effective care interventions

1. Right information

2. Right Physical health care

3. Right Medication

4. Right Psychological therapies

5. Right Rehabilitation/ training for employment

6. Right Care plan addressing housing, healthcare, self management

7. Right crisis careIn the Right least restrictive setting by the Right trained, supervised team

27

Mental health : Is the problem that we have no evidence or value based guidance? Mental health has over 100 NICE Health Technology appraisals, NICE

guidelines, Public health related guidelines and Quality standards….. The problem is not lack of guidance The problem is that we have not focused on how we learn and disseminate from

those that can and have implemented We have not communicated this to our Boards The standard of Care has unacceptable major variation across England

The standards in your area

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

Have you ever been offered Cognitive Behavioural Therapy (CBT)?

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

41

42

39

21

24

50

65

09

20

17

25

33

49

45

48

06

08

44

02

07

67

12

27

31

59

51

60

05

04

36

01

16

TN

S69

54

61

29

72

71

10

03

13

19

56

53

11

28

46

15

52

74

73

47

64

43

70

66

38

35

37

30

34

63

26

68

Source: Audit of practice

Yes No, but was available No, as CBT was not available Not known Yes, was taken up

Human Rights : why are people detained under the MH act in your area: is it illness or unidentified and unaddressed public health needs

With analysis of the use of the Act by LA and CCG, we can now identify the local conditions that can lead to use of the act & high impact & spend

transport hubs, homelessness, no recourse to public funds, cultural mores, link with unemployment & drug and other criminal activities, clinical management & practice variations, service configurations

Primary care MH: transformations learning from the best of international primary care MH leaders & role modeling collaborative partnerships

Registration & annual checks: making every contact count

• Include 1 min self completion MH & behavioural health assessment

Primary care team skillmix needs to include MH workers

• Mental health is 30% of the daily work of primary care, so now we have a new focus on increased

staff training & access to psychological therapists

Supporting primary care clinicians with useful tools like they have for diabetes

• Clinicians decision support templates, especially for annual physical QOF SMI check e.g. Bradford

genius one

• Family and 3rd sector outreach to support people attend for health checks

Primary care ‘at scale’ integrated care groups e.g. Oxford, Swindon LIFT

• ‘Living well’ with stroke, diabetes, pain, COPD, bariatric surgery,

• Enhanced SMI care, Enhanced MUS care, Alliance commissioning models

• Named worker for SMI, depression case managers etc etc

What good looks like

London Strategic clinical network & London CCG MH leaders

• 70+ case studies of primary care mental health integrated physical and MH

recovery care, integrated public health approaches , all securing evaluation support now

Ref : Commissioning primary care MH guide: http://bit.ly/mhpricare

2a. Primary care transformation

• There are very obvious quick wins

• Primary care transformation fund to develop changes skillmix of staff e.g. as per hackney, sand well, etc

• Federated practices

• Enhanced SMI care / LES

• Digital access to therapies

• MUS LES

• Skillmix in primary care team to include trained, supervised mental health professionals in all larger practices

• All will pay for themselves with reductions in avoidable repeat crisis attendances, admissions and A/E and LTC clinic attendances

• In England, we are arguably, the least advanced in the OECD countries in our primary care mental health services development, potentially one cause of our poor employment ……….

• Mental ill health accounts for 1/3rd of the daily work of GPs but• 2/3rds GPs do not get post graduate training & less than 1% practice nurses • Brilliant innovations are developing across England, but do we need to be more systematic in

supporting and evaluating innovations • Do we have a pathfinder programme & some PC MH experts in NHS leadership roles• Do we need a quick primary care MH task force?

18%

23%

46%

Mental Health and Employment

Source: Data & figures from the Annual Report of the Chief Medical Officer, 2013 – Chapter 10, ‘Mental health and work’, (Max Henderson, Ira Madan); Labour Force Survey, 2013; and OECD, 2014, ‘Mental Health and Work, UK’.

• Mental illness costs the UK economy £70 - £100bn per year – 4.5% of GDP (OECD estimat)

• Since 2009, the number of working days lost to ‘stress, depression and anxiety’ has increased by 23%• Since 2009, the number of working days lost to ‘severe mental illness’ has doubled

• 60-70% of people with common mental disorders (such as depression and anxiety) are in work but this can be seen as a risk factor for future employment difficulties

• Co-morbidity of mental disorder and physical disorder is common; of the 15 million people in England with a long-term (physical) condition, 30% also have mental illness.

• In 2013, almost 41% of Employment and Support Allowance recipients had a ‘mental or behavioural disorder’ as their primary condition :

2b Acute & community provider long term conditions & integrated care Comorbidities- common, costly in current silo models of care and commissioning and tariff system incentives inappropriate

Heart Failure Stroke Heart diseaseDiabetes Hypertension Arthritis COPD Cancer Asthma0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

Depression

Anxiety

% in

cre

as

e in

an

nu

al p

er

pa

tie

nt

co

sts

(

ex

clu

din

g c

os

ts o

f M

H c

are

)Comorbidities & mental ill health becoming the norm

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.

March 2015 v3

2014 baseline: The “I’ statements in 2014 for people who use mental health services – what they experience now and what they want

‘I cannot find good information on how to build my resilience for

whatever life throws at me

I look on NHS choices and i can’t see what services I can access

locally or on line

I am not sure if its safe to speak to peers on line in digital support

I have to tell my story over and over again in

every settings.

I am not sure my clinicians know what

each other has recommended

I don’t get any text reminders for

appointment or for my blood tests like I do

from the dentist & my physio

I don’t know what treatments will help me or how to judge

them

One of my psychiatrists uses an app to help me to do

mindfulness exercises as part of my therapy and its really helpful

I use crisis service often because i can’t

seem to get them all to work together to share

my crisis care plan

I can’t have my treatment at home although it is a struggle for me to get out because my CPN’s trust will not let her use

video-calls or skype

I wish I could have my physical health monitored at home, so I don’t have to travel to be told my blood pressure is normal

and to carry on with the same treatment

My mother has dementia and she is not safe as she wanders at night and we dont have technology to

keep her safe at home

March 2015 v3

Admission/Attendance

Referral

Assessment

Care Planning

Investigations Treatments

Discharge

I can only receive information by fax or over the phone and then have to transcribe this into an electronic record system

I have to write duplicate entries in the medical records, often still paper based, and the mental health records system

I cannot use technology based interventions and monitoring routinely in

care planning

I have to rely on colleagues in acute trusts to access pathology results otherwise I have to call the pathology lab and receive the results manually over the phone

I have to rely on paper systems to transfer results of investigations between acute settings and mental health outpatient and community clinics

I cannot routinely contributed to an integrated discharge summary that is electronically distributed.

I can only use technology in a limited way to keep patients up-to-date with follow-up arrangements

There is no place for an collaborative shared care plan between the medical team, mental health team and the patient/their carers

Information about attendance or admission is not automatically sent to mental health trusts systems

The current use of technology in Mental Health Care is far from what it could or needs to be to meet the vision of the #5YFVLiaison Services – example “I statements” for professionals now

Transparency and transforming the Quality of care : Board to Floor clinical quality dashboards

See Devon dashboards : Social demographics: age, gender, ethnicityICD codes: physical and mental health & formulation Right NICE effective interventions: trained, supervised staff • Right Information• Physical health • Medicines optimisation • Psychological therapies • Training for employment• Sable accommodation & crisis relapse plan

Outcomes measured by patient and clinician

5 safe, efficiency factors: access std, no delayed discharge, empowered April 2015 v5

Who are the patients

What are their physical &

mental ICD conditions

Right Care Are they getting NICE/SCIE

effective interventions

Outcomes How good are the

outcomes

Fast, safe & close to homeAccess std, fast discharge

Every clinical team wants its electronic caseload zoning dashboard in vivo information on

Quality dashboards project Wessex AHSN MHIL Intelligence & leadership

programme Health Foundation Monitor

Next steps : What are the enablers

• The voice of the people & communities & government

• Leadership development

• Information, data, intelligence, improvement programme

• Identifying what good looks like & leading edge 5YFV

• Communication strategy

• Workforce strategy

• Development of economic modeling tools

• Pricing & Value based commissioning models

• Reducing waste & bureaucracy

• Digital to fast track improvement & access

38

Great new references

NHS | Presentation to [XXXX Company] | [Type Date]39