mental health in sussex and east surrey: the case for ...€¦ · 2016/17 the total spend by ccgs...

11

- - Confidentialdraft:workinprogress- -

Sussex&EastSurreySustainability&TransformationPartnership

MentalhealthinSussexandEastSurrey:thecaseforchangeJuly2017(v0.5)

22


ExecutiveSummary(1/2)ThiscaseforchangelaysoutwherethehealthandcaresysteminSussexandEastSurreycanbetterhelpthosewithmentalhealthconditionstoleadmorefulfilledlives.Itcoversaccess,provisionandoutcomechallengesfacedbyouradultandyouthpopulations.IthasbeenproducedinresponsetothenationalcallintheFiveYearForwardViewforMentalHealthandtheCareAct2014.Itaimstoimprovehealthandsocialoutcomesandreducevariationforpeoplewithmentalhealthconditionsby2020/21.

Indevelopingthiscaseforchange,weheldworkshopswithserviceusers,NHSandlocalauthorityprofessionals,voluntarysectorrepresentatives,healthandcarecommissionersandproviders,interviewedsystemleaders,surveyedserviceusersandGPs,andanalyseddataprovidedbycommissionersandprovidersofmentalhealthservicesandothers.

Oncommonmentalhealthdisorders,SussexandEastSurreycurrentlymeetsaccessandwaitingtimestandardsforpsychologicaltherapies,andrecoveryandimprovementratesexceedormatchnationalstandards.Inlinewithnationalrequirements,SussexandEastSurreywillhavetoexpandprovisionsothat25%ofpeoplewhorequirethesetherapiesareabletoaccessthem.ThereisastrongclinicalviewthatpeoplewhoaretoocomplexforIAPT,butnotsevereenoughforsecondarycareassessmentandtreatment,areunderserved.Buildingcapacityinprimarycarecouldmanagesomepatients,especiallythosewithbothphysicalandmentalhealthconditions,closertohomeandtherebyreducepresentationsandreferralstophysicalandmentalhealthsecondarycare.

Turningtosevereandenduringmentalillness(SMI),individualswithSMIdiebetween15and20yearsyoungerthanthosewithout.TheprevalenceofSMIis5%higherthannationally,affecting25,000individuals.Fourinfiveofthoseindividualsrequiringearlyinterventioninpsychosisdoreceiveitwithintwoweeks.InSussex,individualsreferredtoassessmentandtreatmentservicesaretwentytimesmorelikelytoreceivepsychologicaltherapiesiftheyarereferredforcommonmentalhealthconditionsthanpsychosis.A betterofferforserviceusersincommunitysettingswouldallowmoreeffectivesupportforthosewhorequiresecondarycare.Halfofserviceusersreceivesupportformeaningfulemploymentactivitywithlessthan20%receivingfamilyinterventions.

Fordementia,prevalenceis25%higherthannationally,willincreasefurtherasthepopulationages,whiletheproportionof thosewithadiagnosisis5%lower.Dementiaserviceusersalreadyrepresentaquarterofsecondarycarecontactsinmentalhealth.Manypresentinacutecare,achallengerecognisedinplansforimprovedlocalcare.Aquarterofthosefittoleaveacutecarewaitover50daysfordischarge.

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ExecutiveSummary(2/2)

Threequartersoffirstepisodesofmentalillhealthoccurinyoungpeoplebeforetheageof25.Thereisthegreatestmismatchbetweenprevalenceandserviceuseforthisgroup,whichsuggestsSussexandEastSurreyshouldprovidedifferentwaystoaccessservicesthatworkbetterforyoungpeople.Producingservicescollaborativelywithyoungpeopleappearstobethebestwaytoachievethis,withalocalpilotinHastingsachieving100%recommendationrates.

Turningtocrisisservices,oneinseventypeopleincontactwithsecondarymentalhealthservicesreporthavingacrisisplan,andoveraquarterofserviceusersreportthattheydonotknowwhattodoinacrisis.Thismayreflectdifferentroutesintocrisisservices,resultingfromcurrentcommissioningapproaches,anddrivesattendanceatemergencydepartments.

Asmentalillhealthleadstophysicalillhealth,andviceversa,weshouldaddressmentalandphysicalneedstogether.Asthenumberofco-morbidities,andhenceneeds,increasewithage,the17%increaseinourpopulationoverseventyinthenextfouryearswillrequireevercloserintegrationbetweenmentalhealth,physicalhealthandsocialservices.

ThehealthandcaresysteminSussexandEastSurreyfacesasignificantfinancialchallengewithaforecastdeficitof~£750mby2020/21.Localauthoritybudgetshavedeclinedby22%whiletheshareoffundsallocatedbyCCGstomentalhealthhasdeclinedfrom10%to9.9%since2013/14.Thisfundingconstraintwillrequirenewwaysofdeliveringservicestosupportpeopletomaintainthebesthealthandwellbeingpossible.ThereisamismatchbetweentheamountCCGsspendonmentalhealthandthevalueofservicesprovidedfortheirlocalpopulations.

Ourabilitytoimprovecarereliesonourstaffandthebetteruseofinformation.SussexandEastSurreyhashighvacancyratesforacutementalhealthwhichresultsinhighagencyspend.Althoughtherearefundstodevelopnewservices,supplyofstaffforexistingservicesremainsaconstraint.Thecurrentstateofinformationhampersourabilitytoplanandtrackdelivery.

Nowwehaveathoroughunderstandingofthechallengesweneedtoaddress,wewillbeworkingtogether,withourpartnersandouruserstodevelopsustainableopportunitiestoimprovehealthandsocialoutcomesforadultandyoungpeople’smentalhealthserviceusers.Thesewillcometogetherintoa strategicframeworkanddeliveryroadmapformentalhealthinSussexandEastSurrey.

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Contents

Depressionandanxiety

Dementiaandcognitiveimpairment

Youthservices

Psychosis

Resourcesandenablers

Nextsteps

Nationalandlocalcontext

Physicalandmentalhealthintegration

Crisis

55


IntroductionInFebruary2016, theindependentMentalHealthTaskforcebroughttogetherhealthandcareleaders,peoplewhouseservicesandexpertsinthefieldtocreatea FiveYearForwardViewforMentalHealthfortheNHSinEngland.Thissetsoutnationalchallengesandprioritiesforimprovement.InJuly2017,theCQCproduceditsStateofCarereportthathighlightedstaffshortages,poorinformationsystemsandcrisiscommissioningasnationalmentalhealthcareimprovementareas.TheCareAct2014requireslocalauthoritiestopromotewellbeingandmaximiseindependence,particularlyforthosewithestablishedorcomplexhealthconditions,suchasseverementalillnessordementia

ThiscaseforchangebuildsontheForwardView,andlaysoutwherethehealthandcaresysteminSussexandEastSurreycanbetterhelpthosewithmentalhealthconditionstoleadmorefulfilledlives.Itisintendedtoprovidethefocusforthedevelopmentofopportunitiesinastrategicmentalhealthframework.

ThetraditionalwayofdeliveringservicesacrosstheSTPfootprintwillnotmeetdesiredoutcomesandexpectationsofserviceusersinthefuture.Notonlyisfundinginsufficientacrossthewholesystemtomeettheanticipatedincreaseindemandusingthecurrentmodel,butweknowthatbetteroutcomescanbeachievedbydesigningandproducingservicesjointlywithserviceusers.Thismeansweneedafundamentalrethinkofhowweinvolvepeersindesignanddelivery,howweworkacrosscurrentcareboundariesaswellasthenatureandrangeofservicesinthecommunity.

Indevelopingthiscaseforchange,we:

• Heldtwoworkshopswithserviceusers,NHSandlocalauthorityprofessionals,healthandcarecommissionersandproviders;• Interviewed~60systemleaders,GPsandrepresentativesofserviceusers;• Surveyedover400serviceusersandcarersusinganonlinesurvey• SurveyedGPs;• Soughtviewsfromcliniciansandthevoluntarysector;• Analyseddataprovidedbylocalauthorities,commissionersandprovidersofmentalhealthservicesandothers.

Thiscaseforchangearticulatesanumberofstrategicandoperationalchallengesregardingthecurrentprovisionofmentalhealthservices.Thescopeofthisworkcoversadultsofallagesandyouthservicesforthoseaged14-25.Additionalworkfordevelopmentofchildren’smentalhealthservicesisbeingcarriedoutintandem.

SOURCE:Thefiveyearforwardviewformentalhealth,NHSEngland2016

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TheFiveYearForwardViewforMentalHealthsetsoutnationalchallengesandprioritiesforimprovementNHSEnglandhaspublishedtheFiveYearForwardViewformentalhealththatsetsoutnationalimprovementareastobeachievedby2020/21.Thisincludesarequirementtoincreaseaccesstotreatment,commencetreatmentearlier,eliminateoutofareaplacements,provideall-agementalhealthhospitalliaisonteamsandreducesuicideratesandprematuremortality.

Thebasisoftheserequirementsnationallyare:

• Oneinfouradultsnationally experiencesatleastonediagnosablementalhealthprobleminanygivenyear• 75%ofallmentalhealthproblemshavebeenestablishedbytheageof24• Peoplewithsevereandprolongedmentalillnessareatriskofdyingonaverage15to20yearsearlierthanotherpeople–

oneofthegreatesthealthinequalitiesinEngland.Twothirdsofthesedeathsarefromavoidablephysicalillnesses,includingheartdiseaseandcancer

• Peoplewithlongtermphysicalillnessessuffermorecomplicationsiftheyalsodevelopmentalhealthproblems,increasingthecostofcarebyanaverageof45percentintheabsenceofholisticsupport

• Oneinfiveolderpeoplelivinginthecommunityand40percentofolderpeoplelivingincarehomesareaffectedbydepression

• Suicideisrising,aftermanyyearsofdecline.SuicideratesinEnglandhaveincreasedsteadilyinrecentyears,peakingat4,882deathsin2014.Theriseismostmarkedamongstmiddleagedmen.Suicideisnowtheleadingcauseofdeathformenaged15–49

• Nineoutoftenadultswithmentalhealthproblemsaresupportedinprimarycare• Toooften,peopleinmentalhealthcrisisarestillaccessingmentalhealthcareviacontactwiththepolice• Mentalhealthaccountsfor23percentofNHSactivitybutNHSspendingonsecondarymentalhealthservicesisequivalent

tojusthalfofthis• Thecosttotheeconomyofmentalillhealthisestimatedat£105billionayear– roughlythecostoftheentireNHS

SOURCE:Thefiveyearforwardviewformentalhealth,NHSEngland2016

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MentalhealthservicesinourSTPcoverfourplacesforour1.8mresidentpopulation

SOURCE:JSNAs,providerandCCGdatareturns2017;QOF2015/16,ONS2015

• TheresidentpopulationofSussexandEastSurreyis1.8m• 15%ofthepopulationisover70• Nearlyhalfofthepopulationliveinruralcommunities• 170,571peopleareregisteredwithdepressionattheirGPpractice• 17,669peopleareregisteredwithaseriousmentalillness• BrightonandHovehasahigherrateofadmissionformentaland

behavioraldisordersduetoalcohol(134per100,000comparedto87per100,000inEngland)

• Giventheneedtoensurelocalisedcare,fourplacebasedplansarebeingcreatedtoservedistinctgeographiesinourSTP- CoastalCare- NorthCentralSussex andEastSurreyAlliance- SouthCentralSussex andEastSurreyAlliance- EastSussexBetterTogether

Demographics• TheCCGsspent£127monblockcontractadultmentalhealthin

2016/17• ThetotalspendbyCCGsonmentalhealthservicesin2016/17was

£232m,thiswas9.9%oftheCCGs’totalallocatedbudget• Localauthoritieshaveidentifiedaspendof£89monadultmental

health(2016/17)• Themainmentalhealthserviceprovidersinclude:

- SussexPartnershipNHSFoundationTrust(SPFT)- SurreyandBordersPartnershipNHSFoundationTrust(SaBP)- SussexCommunityNHSFoundationTrust(SCFT)

• Around50,000adultsarecurrentlyincontactwithsecondarymentalhealthservicesand37,000incontactwithIAPTservices

• 4%ofadultmentalhealthserviceusersaretreatedinhospitalbeds,themajorityofcareisundertakeninthecommunity

Mentalhealthproviderlandscape

H

+H

Communitysite

Inpatientunit

Placesofsafety

EastSurreybedsfortheresidentsofthewholeofSurrey

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CCGsinSussexandEastSurreyspend£232monmentalhealth,whilelocalauthoritiesidentify£97masadultmentalhealthspend

Source:CCGdatareturns2016/17,providerdatareturns,LocalAuthoritydatareturns;CarnallFarraranalysis

LocalAuthorityadult:mentalhealth£88.8m

PooledbudgetsWSCC£8.8m

Blockcontractoutofscope£22.7m

IAPT:£17.2mCCGblockcontractspendinscope

£127m

Specialistplacements(CCG)£11.5m

CCG:Otherdementia£9.7m

CCG:Othernon-dementia£16.7m

• Inadditiontoidentifiedfunds,

- AboutathirdofGPconsultationshaveamentalhealthcomponent

- Peoplewithmentalhealthconditionsarebigusersofacutephysicalhealthservices

- Localauthoritiesdodeployresourcesfrombudgetsnotidentifiedasmentalhealthbudgets

- Thevoluntarysectorraiseandspendtheirownfundsonmentalhealth

CCGothernon-definedspend£24.0m

B&HCCG£3.4mtoB&HCC

£232m

£97m

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Contents



Youthservices

Psychosis


Nextsteps



Crisis

1010


SussexandEastSurreycanbuildongoodperformancetoexpandaccessandimproveprovisionforcommonmentalhealthdisorders

TheprevalenceofcommonmentalhealthdisordersinSussexandEastSurreyis16%lowerthannationally.Localpsychologicaltherapiesperformwell,exceedingaccesstargetrates(15%target),recoveryrates(50%target),reliableimprovementrates(63%target)andsixweekwaittimes(75%withinsixweeks).Thenationallymandatedtargettoincreaseaccesstopsychologicaltherapiesto25%ofprevalencewillrequiredelivering56%moretherapies,althoughlocalfundingforthishasnotbeensecuredinallareas.Improvingaccesswillalsorequireintegratingpsychologicaltherapieswithphysicalhealthcare.StructuresandpartnershipstobuildcapacityinprimarycareandsupportintegrationarebeingdevelopedacrossSussexandEastSurrey,withTimetoTalkbeinganationalpilotsite.Suchintegrationshouldimproverecovery,andreducereferralstoandpresentationsinphysicalandmentalhealthsecondarycare.

ThereisstrongclinicalconsensusthatthereisagapinserviceprovisionforpeoplewhoseneedsaretooseveretomeetthecriteriaforIAPTservices,butnotsevereenoughtoqualifyforsecondarycareassessmentandtreatmentservices.Furtherworkisrequiredtounderstandthecohortofindividualswhofallintothisgap.Evenforthosewhoareacceptedbysecondarycare,only15%ofpeoplereceiveapsychologicalintervention.

Alocalauditofclinicalstandardshighlightstheneedtoimprove24/7accesstoservices,performmorestafftrainingforinterventionsperNICEguidance,providecleardischargeplansandprovideholisticcarethatincludeshousingandfinancesupport.

Source:CarnallFarraranalysis

1111


ThereareareasofgoodpracticeacrosstheSTPtosupportindividualswithcommonmentalhealthconditionsthatwecanbuildon

SOURCES:Providerdatareturn2016/17;HealthinMind:http://www.sussexpartnership.nhs.uk/service-health-mind,SPFT2017

Workingcollaborativelywithadigitalprovider(IESO)tointegrateadigitaloption(typedCBTtherapy), creatingflexibilityfor additional face-tofaceprovisionforthosepatientswhoneedit (e.g.thoseneedinginterpreters)

• Createdasystematic,digital, alertsystem foridentifyingpatientswhohavenotrecoveredmidtherapy,allowingthecliniciantotargetthosepatientswhoarenotrecoveringwithadditionalresources

• Moreflexibleuseofsteppedcarepathway,toenableadditionalinterventionstobeusedtotargetresidualsymptomsofanxietyanddepressionandsupportpatientsintorecovery

Improved recovery (43%upwardsto52%)andaccess(12.%upwardsto15.%)inCrawley,anareaofhigh socialdeprivation.

What?

How?

Impact?

What?

How?

Impact?

What?

How?

Impact?

Provide coursesandothertypesoftherapiesthathelpwithstress,anxietyandlowmood. Whateverthereasonsareforfeelingdown,relationships,moneyorwork,weofferaservicethatmayhelpyoufeelpositiveagain

• TheserviceisFREEandavailabletoadultsovertheageof18livingintheEastSussexarea

• Theservicesinclude:Telephonesupportandguidedself-help,shortwellbeingcourses,CognitiveBehaviouralTherapy,Eyemovementdesensitisationandreprocessing(EMDR),positivewellbeingcourse,inter-personaltherapy,mindfulness,lowself-esteemworkshop,consultationsandangermanagementcourses

• 98%Agreethattheyfeltwelcomedandlistenedto

• 97%Agreethattheyfoundtheconsultationveryhelpfulandweregivengoodinformation

• 89%Agreethatfollowingthefirstinterventiontheyfeltincreasinglyoptimisticabouttheirfuture

HealthinMIND TimetoTalkGPPersistentSymptomsservice

Providesupportforpatientswithcomplexpersistentphysicalsymptomswherethereisnoobviousunderlyingmedicalexplanation.

• Thepersonbeingreferredwillhavepresentedwithpersistentphysicalsymptomsforatleastsixmonthswhereaclearphysicalcausehasnotbeensufficienttofullyexplainthesymptomsexperienced.

• Assessment&treatmentwillbebasedonabiopsychosocialformulationtounderstandthesedifficulties

• Treatmentplanswillinclude1to1sessions,groupworkorongoingGPinput

• Thisisatwoyearpilotthatyethassufficientdataforevaluation.

• Attheendofyear2,theprojectwillneedtobeabletodemonstrateinanEvaluationReportthatthereareimprovedoutcomesforpatientsaswellasreductionsinsecondarycare,diagnostictestsandmedication.

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16.7%

18.3%

13.7%

15.0%

15.8%

12.8%

16.1%

14.7%

HWLH

EHS

Crawley

HMS

CWS

EastSurrey*

H&R

B&H

12.0% 12.4% 12.7% 12.8% 12.9% 13.3% 13.8%

17.3% 13.4%

15.6%

HWLH

EHS

Crawley

HMS

CWS

EastSurrey

H&R

B&H

STP

England

Theprevalenceofcommonmentalhealthdisordersis16%lowerthannationally,however,accesstorelevanttherapyneedstoincreasesignificantlyby2020/21

EstimatedprevalenceofcommonmentalhealthdisordersPercentageofpopulationaged16-74,204/15

SOURCES:Providerdatareturns2017,PHEFingertips2014/15,2016/17;CarnallFarraranalysis

Currentnationaltarget15%

AccessratesforIAPTentryPercentage,2016/17

16%

Note:EastSurreyisSeptember2016

• In2016/17therewere27,500IAPTfirstassessmentsagainstatargetof25,000• Thementalhealthfiveyearforwardviewrequires25%ofpeoplewithcommonmentalhealthconditionstobeableto

accessIAPT,whichwouldincreasethenumberoffirstassessmentsby15,500(56%)to43,000ayear

1313


AllCCGsexceptBrightonandHovemeetthe6weektargetforreferralstotreatment

1.8

3.4

3.2

4.3

5.5

2.0

1.8

1.7

3.0

2.8

CWS

H&R

EHS

HWLH

B&H

HMS

Crawley

EastSurrey

STP

England

Averagewait- referraltotreatmentWeeks,2016/17

240%

Meeting6weektargetPercentageoffirsttreatmentswithin6weeks,2016/17

98%

89%

89%

83%

68%

98%

98%

96%

89%

89%

CWS

H&R

EHS

HWLH

B&H

HMS

Crawley

EastSurrey

STP

England

Nationaltarget75%

Source:PHEFingertips2016/17;IAPTData2017;CarnallFarraranalysis

1414


WeareperformingwellforIAPToutcomes,reliablerecoveryexceedsthenationaltargetwhilereliableimprovementisrunningaheadofthenationalaverage

SOURCE:IAPTstatisticalrelease2017,PHEFingertips2016/17;CarnallFarraranalysis

52%

50%

54%

54%

41%

54%

46%

50%

50%

49%

CWS

H&R

EHS

HWLH

B&H

HMS

Crawley

EastSurrey

STP

England

ReliablerecoveryPercentage,2016/17

70%

64%

67%

66%

62%

71%

69%

70%

67%

65%

CWS

H&R

EHS

HWLH

B&H

HMS

Crawley

EastSurrey

STP

England

ReliableimprovementPercentage,2016/17

Nationalaverage65%Nationaltarget50%

• Reliablerecovery:Theproportionofpeoplecompletingtreatmentwhohaveshownsignificantimprovementandrecovered• Reliableimprovement:Thisshowsallthepeoplewhosesymptomshaveimprovedoverthecourseoftreatment,includingthoseinwhomtheimprovementfellshortoffullrecovery.

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ThereisaserviceprovisiongapforindividualswhodonotmeetthecriteriaforIAPTorassessmentandtreatmentservicesinsecondarycare

SOURCE:MentalHealthServicesinSussex:the‘Step3Plus’patientgroup2014

• NotallserviceusersreceivetherighttreatmentandcarebecausetheyfallbetweencommunityIAPTandsecondarycareassessmentandtreatmentservicesandwedonotknowhowmanypeoplearecurrentlyaffectedbythis

• Theneedsofthesepatientgroupsareoftenmetbyservicesstretchingtheircriteriaandresources.• Thisinputoftendoesn’tresultinthemosteffective,ormostcostefficientuseofresourcesavailable

• Peoplewhoneedpsychologicaltreatment(particularlypsychologicaltherapy)butwhoseneedsdonotmeetcriteriaforcurrentlycommissionedservices

• PeoplewhohavecomplexpsychologicalneedsthatarebeyondtheskillsandtrainingofIAPTstaffbutwhosedifficultiesarenotsevereordisablingenoughtorequirecoordinatedandhighlyspecialisttreatmentinsecondarycareservices

• Examplepatientsincludepeoplewithpsychosisthathavebeenstableforsometime,butwhomaybesufferingfromanxietyordepressionandcannotaccessto IAPTasitisnotsetuptomeettheneedsofthisgroup.

AbettermodelofcareThisgrouppresentwithneedswherepsychologicaltherapywouldusuallybethefirstchoiceoftreatmentapproachperNICEguidance.Staffdeliveringtheseinterventionsshouldarguablybesittinginaprimarycaresetting(butcloselysupportedbymedicalandpsychologistcolleaguesinsecondarycare)offeringabroaderrangeofinterventions,withstaffwithabroaderskillsbase,withdifferenttargets,fromourIAPTservices.This‘step3pluspsychologicaltherapyservice’couldshareacommontriagerouteintoprimarycarementalhealthserviceswithIAPTbutbedeliveredbyaseparatestaffgroup.Therapistswoulddrawonabroaderapproachtopsychologicalassessmentandtreatment,drawingonarangeofmodels,ratherthanonespecificmodel.

NOTE:1 PatientswithneedsthataretoocomplexforIAPTservicesbutnotsevereenoughtorequirethecoordinatedmulti-disciplinaryinputofsecondarycarementalhealthservices

Whofallsintothisgap?

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Buildingcapacityinprimarycarecouldmanagesomepatientsclosertohomeandtherebyreduceactivityinsecondarycare

SOURCE:Jointcommissioningpanelformentalhealthvolumetwo:practicalmentalhealthcommissioning

25

25

12

9

8

8

7

4

1

Commonmentalhealthproblem

Sub-thresholdcommonmentalhealthproblem

Personalitydisorder

Longtermconditionandmentalillhealth

Alcoholdependency

Sub-thresholdpsychosis

Medicallyunexplainedsymptoms

Drugdependency

Psychosis

Mentalhealthneedspresentingingeneralpractice(PercentpatientsonatypicalGPlist)

• Commonmentalhealthproblemsandsomepsychosissupportcanbeseeninprimarycarebutcapacityinprimarycareislimited

• Theseoftenpresentwithphysicalhealthneeds,hencemanagingtheminprimarycarewouldreducepresentationsandreferralstobothphysicalandmentalhealthsecondarycare.

• Closeralignmentofprimarycare,communitycareandsocialworkerfunctionswillbecriticaltocreatecapacitytosupportmentalhealthclosertohome

• Careprovidedclosertohomewillreduceunplannedpresentationsandreferralstophysicalandmentalhealthsecondarycare

• Trainingforgeneralpracticetoincreaseconfidencetoprovidesupportandsignpostappropriatelocalservicesisrequired

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Aclinicalstandardsaudithighlightedriskmanagement,stafftraining,careplanningandinformationsharingindepressionandanxietycareasgaps

SOURCE:ClinicalStandardsauditprovider(SPFTandSaBP)andCCGreturnsJune,2017;CarnallFarraranalysis

Sharinginformation

Providingassessmentandintervention

• Informationaboutcarepathway,treatment,mentalhealthactandcontactdetailsareavailableforpatients,carersandhealthcarepractitioners

• Patientsaresupportedtoaccess housingandfinancesupport• Jointworkingprotocols/carepathwaysinplacetosupportpatientsinaccessingotherhealthcareservices• Jointworkingprotocol/carepathwaywithprimaryhealthcareteamsisinplace

Providingholisticcare

• Healthoutcomesateachappointmentarerecordedandfindingsareusedtoadjustdeliveryofinterventions.• Peoplewithseveredepressionandachronicphysicalhealthproblemreceiveacombinationofantidepressantmedication

andindividualcognitivebehaviouraltherapy.• ThereisactivecollaborationbetweenChildandAdolescentMentalHealthServicesandWorkingAgeAdultServicesfor

transferringpatientsbetweenservices.Thisstartsatleast6monthsbeforethedateoftransfer.• Thereispolicyinplaceforthecareofpatientswithdualdiagnosis• Activitiesareprovided7daysaweekandoutofhours• Cleardischargeplanissenttotheserviceuserandallrelevantpartieswithin10daysofdischarge.

Managingrisk

• Arrangementisinplacetoallowserviceusersandcarerstoaccesshelp,frommentalhealthservices,24hoursaday,7daysaweek

• Riskassessmentsandmanagementplansareupdatedregularly• Teamsfollowprotocoltomanageinformalpatientswhodischargethemselvesagainstmedicaladvice• Proactivelyfollowsupwithreferrersandserviceuserswhohavenotattendedanappointment

Standardsconsideredveryimportantbycommissionersandreportedasnotbeingconsistentlymetbyproviders

Stafftraining • PractitionersreceiveregulartrainingandsupervisionthatensurestheyarecompetentindeliveringinterventionsinaccordancewithNICEguidance,legalframeworkandphysicalhealthassessment

Clinicalstandardsbelowwereself-ratedbythetwomainmentalhealthtrustsasareasthatarenotyetfullymet.ThesearealsothestandardsthatCCGsindependentlyconsidertobethemostimportanttodelivereffectivecare.

1818


Contents



Youthservices

Psychosis


Nextsteps



Crisis

1919


SussexandEastSurreyhasahigherprevalenceofsevereandenduringmentalillnessthannationallyandtherearegapsinserviceprovision

Thereareapproximately25,000peopleinSussexandEastSurreylivingwithseverementalhealthneedsandtheseindividualsareforecasttodie15to20yearssoonerthanthosewithout.Thoseareaswithhigherlevelsofdeprivationalsohaveahigherprevalenceofpsychosis,suggestingscopeforsupportforwiderlifechallengesinthisserviceusergroup.

SMIprevalenceis5%higherthanthenationalaverage.Fourinfivepeoplereferredforearlyinterventioninpsychosisreceiveitwithintwoweeks.Prescribingdatasuggestsvariationfromgoodpracticeinprimarycare,whileinSussex,serviceusersreferredtosecondarycarearetwentytimesmorelikelytoreceivepsychologicaltherapiesiftheyarereferredforcommonmentalhealthdisordersthaniftheyarereferredforpsychosis.

ThosewhohavebeenidentifiedashavinganSMIfinditdifficulttoaccesstherangeofpsychological,social,employmentandphysicalhealthcaresupportthatisrecommendedbyNICE.Evidenceshowsthatemploymentsupportandfamilyinterventionscansupportrecovery,yetSussexandEastSurreysupportslessthan50%intoemploymentandalthoughSPFTperformedattopquartile,lessthanoneinfivereceivefamilyinterventions.Abetterofferforserviceusersincommunitysettingscouldallowmoreeffectivesupportforthoserequiringsecondarycare.

Alocalauditofclinicalstandardshighlightstheneedtoimproveserviceprovisionforriskmanagement,assessmentandintervention,holisticcareandinformationsharing.

2020


82.9

62.2

Non-mentalhealthserviceusers

Mentalhealthserviceusers

MaleswithseverementalillnessinSussexandEastSurreydie20.6yearssoonerthanthosewhodon’t,femalesdie15.7yearssooner

Source:Makingthecaseforintegratingmentalandphysicalhealthcare,SussexandEastSurreySTP,CommissionedbyNHSEngland,2017

86.170.4

Non-mentalhealthserviceusers

Mentalhealthserviceusers

Lifeexpectancyatbirthinyears:MalesYears,2012/13– 2014/15pooled

Lifeexpectancyatbirthinyears:FemalesYears,2012/13– 2014/15pooled

-20.6- 15.7

• Themortalityrateofthementalhealthserviceusersis2.6to26.4timeshigherthantherestofthepopulation• Populationwithseverementalhealthillness1 accumulates454,549lifeyearslost

2121


Higherdeprivationiscorrelatedwithhighersevereandenduringmentalillness(SMI)prevalenceinalmostallareas

Indexofmultipledeprivation(IMD)scoreScore,2015

SOURCES:DepartmentforCommunitiesandLocalGovernment2015;QOF2015/16,

PrevalenceofSMIPercentage,2015/16

• IMDscoresinSussexandEastSurreySTPrangefrom8.3to25.8

• ThehighertheIMDscore,thehighertherateofSMI(withtheexceptionofCrawley)

• HastingsandRother/ BrightonandHovehavethehighestIMDscoresandthehighestnumbersofpopulationdiagnosedwithSMI

• HorshamandMidSussexhasthelowestrateofdeprivationandlowestSMIprevalence

25.8

23.4

18.0

17.8

15.8

12.1

11.2

8.3

H&R

B&H

EHS

Crawley

CWS

HWLH

EastSurrey

HMS

1.32

1.19

1.07

0.73

0.91

0.86

0.78

0.70

H&R

B&H

EHS

Crawley

CWS

HWLH

EastSurrey

HMS

2222


SMIprevalenceis5%higherthanthenationalaveragewithunexplainedvariationintheuseofearlyintervention

0.89

0.94

1.32

1.19

1.07

0.91

0.86

0.78

0.73

0.70

England

STP

H&R

B&H

EHS

CWS

HWLH

EastSurrey

Crawley

HMS

SMIprevalencerate(QOF)PercentageofGPpopulation,2015/16

PatientsincontactwithsecondarymentalhealthservicesclusteredaspsychoticPatientsper1000weightedpopulation,2017

3.6

3.6

15.1

4.4

3.6

3.7

3.8

3.7

4.4

HMS

Crawley

EastSurrey

HWLH

CWS

EHS

B&H

H&R

STP

ReferralstoearlyinterventionsinpsychosisteamNumberofseenreferralsper1000weightedpopulation,2017

Note:referralstoearlyinterventionsteamsareonlycountedifitwasafirstreferral,orsecondifaninternalreferralwasmadeandthepatientwasseen

• TheSussexCCGshaveatargetof194newreferralsperyeartoearlyinterventioninpsychosisteams

• In2016/17158patientswerereferredintotheEIPteamandhadatleastoneappointment

15.1

0.10

0.10

0.10

0.18

0.11

0.04

0.06

0.05

0.08

HMS

Crawley

EastSurrey

HWLH

CWS

EHS

B&H

H&R

STP5%

Source:QOF2015/16,Providerdatareturns2017

2323


Prescribingdataforpsychosisandrelatedconditionsvariesby65%,suggestingvariationfromgoodpracticeinprimarycare

SOURCES:CCGdatareturns2016/17,CarnallFarraranalysis

28 2824 22 20 18 17 17

HWLH B&H H&R EastSurrey CWS EHS HMS Crawley

Scriptsper1000weightedmentalhealthpopulation,2016/17

65%

Scriptsare65%higherinHighWeald

LewesHavens/BrightonandHovethanHorshamandMidSussex/Crawley

2424


Individualsreferredtoassessmentandtreatmentservicesarealmosttwentytimesmorelikelytoreceivepsychologicaltherapiesforcommonmentalhealthneeds

SOURCE:SPFTcluster11stepdowntoprimarycarepaper2014;;HastingsandRotherassessmentandtreatmentservice2016annualservicereport;CarnallFarraranalysis

• Thereisconsiderableinequityastowhogetsaccesstotheexistingresourceinsecondarycare;equivalenttobeingalmosttwentytimesmorelikelytoreceivepsychologicaltherapiesifreferredforcommonmentalhealthdisorders(clusters1-8)thanforpsychosis(clusters11-17)

• Only14%ofpeopleinsecondarycareservicesactuallyreceiveapsychologicaltherapy

• Manycommonmentalhealthproblemscouldbetreatedoutsideofsecondarycaresettingsifcapacitywerecreatedclosertohome

• ApilotinNorthWestSussexrunbySPFThaslookedatimprovingcapacitytoofferpsychologicaltherapytopeoplewithpsychosis

Percentcaseloadforpsychology/psychologicaltherapiesforassessmentandtreatmentservices

23

83

19

6

58

12

ReferralstoATSs Caseload

Psychosis


Commonmentalhealthproblems

2525


WhileallCCGsmeetthewaitingtimetargetforearlyinterventioninpsychosis,firstepisodesaccountfor10%ofpsychosiscontacts

*Target:Morethan50%ofpeopleexperiencingfirstepisodepsychosiswillbetreatedwithaNICE-approvedcarepackagewithintwoweeksofreferral.

Source:NHSEEIPwaitingtimes,2107;SPFT

EarlyinterventioninpsychosiswaitPercentage,2017

8978 70

84 90

6379 77 80

9 1922

16 335

2113 16

1 3 9 8 27 3

1 1 3 1

>0-2weeks >2-6weeks

>6-12weeks 12plus

NationalTarget50%*

8%

13%

6%

11%

11%

8%

10%

11%

10%

92%

87%

94%

89%

89%

92%

90%

89%

90%

CWS

H&R

EHS

HWLH

B&H

HMS

Crawley

EastSurrey

STP Cluster10- firstepisode

Otherpsychosisclusters

PsychosiscontactsbyclusterContacts2016/17

2626


Psychosisaccountsforlessthanafifthofpatients,butmorethanhalfofoccupiedbeddays

*Target:Morethan50%ofpeopleexperiencingfirstepisodepsychosiswillbetreatedwithaNICE-approvedcarepackagewithintwoweeksofreferral.

Source:SPFTandSaBPdatareturns2016/17

Patients,contacts,andOBDsforpatientswithapsychosissuperclusterPercentage,2017

19%

36%

56%

Patients Contacts OBD

• Theaveragelengthofstayin2016/17forpsychosiswas57days(55daysforSPFT;108daysSaBP)

2727


73.6%

76.4%

75.9%

72.7%

72.3%

75.5%

75.3%

75.9%

74.7%

76.0%

CWS

H&R

EHS

HWLH

B&H

HMS

Crawley

EastSurrey

STP

England

78.8%

78.0%

76.9%

77.7%

72.2%

78.5%

80.8%

80.1%

77.8%

81.3%

CWS

H&R

EHS

HWLH

B&H

HMS

Crawley

EastSurrey

STP

England

ThosewhohavebeenidentifiedashavinganSMImaynotreceivethecorrectphysicalhealthandpsychologicalsupport

SOURCES:PHEFingertips2013-2016,CarnallFarraranalysis

PhysicalhealthchecksPercentageofpeoplewithSMI,whohavereceivedtheircompletelistofphysicalchecks2013/14

ComprehensivecareplanPercentageofpeoplewithSMIwhohaveacomprehensivecareplan2015/16

Accesstopsychologicaltherapy (2013/14)Percentageofpsychosiscarespellsreceivingpsychologicaltherapy

6.2

13.0

5.2

11.9

7.6

6.8

7.1

1.7

7.4

7.0

CWS

H&R

EHS

HWLH

B&H

HMS

Crawley

EastSurrey

STP

England

Englandaverage Englandaverage Englandaverage

AlthoughSussexandEastSurreyoutperform,expertopinionisthatuptohalfwouldbenefit

2828


Inthelastnationalaudit,fewerserviceusersatbothSPFTandSaBPreportedhavingsupporttofindajobthanthenationalaverage...

SOURCE:NationalAuditofSchizophrenia,October2014

IdonothaveajobandIamnotgettinghelptofindone

Idonothaveajobbutamgettinghelpfindingone

TheproportionofservicesuserswhowerelookingforworkwhoreportedthattheywereorwerenotgettinghelptofindonePercentageofserviceusers,2014

SaBPSPFT

0

20

40

60

80

100

Totalnationalsample

Topquartile

• AtSaBP andSPFT42%receivedsupporttofindajob

• Nationally50%receivedsupporttofindajob

• Inthetopquartile63%receivedsupporttofindajob

2929


...AndalthoughSPFTperformedattopquartile,fewreceivedafamilyintervention

SOURCE:NationalAuditforSchizophrenia,October2014

Ihavehadoramhavingthistreatment

PatientwhohavereceivedafamilyinterventionPercentageofserviceusers,2014

SaBPSPFT

0

20

40

60

80

100

Totalnationalsample

Idonotwantthistreatment

Ihavenotreceivedthistreatment

Topquartile

• AtSPFT16%haveafamilyintervention

• AtSaBP11%haveafamilyintervention

• Nationally11%haveafamilyintervention

• Inthetopquartile16%haveafamilyintervention

3030


Theclinicalstandardsaudithighlightedriskmanagement,careplanningandinformationsharing inpsychosiscareasgaps

SOURCE:ClinicalStandardsauditproviderandCCGreturns,June,2017;CarnallFarraranalysis

Sharinginformation


• Informationaboutcarepathway,treatment,mentalhealthactandcontactdetailsareavailableforpatients,carersandhealthcarepractitioners



• CBTandfamilyinterventionshouldbedeliveredinaccordanceofNICEguidelines.• Adultswithschizophrenianotrespondingadequatelytotreatmentwithatleast2 antipsychoticdrugsareofferedclozapine• Comprehensivephysicalhealthassessmentsforadultswithpsychosisorschizophreniashouldfocusonphysicalhealth

problemscommoninpeoplewithpsychosisandschizophreniainaccordanceofNICEguidelines.• Interventionsshouldbeconsideredtohelppeoplestopsmoking.• ThereisactivecollaborationbetweenChildandAdolescentMentalHealthServicesandWorkingAgeAdultServicesfor

transferringpatientsbetweenservices.Thisstartsatleast6monthsbeforethedateoftransfer• Thereispolicyinplaceforthecareofpatientswithdualdiagnosis• Activitiesareprovided7daysaweekandoutofhours• Cleardischargeplanissenttotheserviceuserandallrelevantpartieswithin10daysofdischarge

Managingrisk



Standardsconsideredveryimportantbycommissionersandreportedasnotbeingconsistentlymetbyproviders


3131


Contents



Youthservices

Psychosis


Nextsteps



Crisis

3232


Wehavehighprevalenceofdementiawithsignificantsecondarycarecontactsandweneedtoprovidecoordinatedcommunitysupportfordischarge

Theprevalenceofdementiais25%higherinSussexandEastSurreythannationally,itwillincreasesharplyasthepopulationages,andratesofdiagnosiscurrentlylagthenationalrateby4%.Contactswithsecondarycarevarysharply.Dementiaandcognitiveimpairmentalreadyrepresents27%ofmentalhealthcontactsinsecondarycare,andthevolumewillincreaseasthepopulationages.

Clinicalviewsondementiaserviceshighlightalackofsuitableinfrastructure,aneedtoimproveaccesstophysicalhealthsupportandlackofspecialistsupport.Improvingstafftrainingcouldprovidejoinedupsupportacrosscaredisciplines.

Adisproportionatenumberofthosefittoleavetheircurrentsettingofcarehavedementia,withoveraquarterofpatientswithdementiaoracognitiveimpairmentfittoleavewaitingforover50daystoleavetheirsettingsofcare.ThePlace-basedplansinSussexandEastSurreyidentifiedthosewithdementiaasasapriorityforcarecoordination andotherinterventions

Alocalclinicalstandardsauditsuggests24/7serviceaccess,planningforpalliativecare,jointworkingprotocolsforstaffanddischargeplanningcouldbeimproved

3333


Dementiaprevalenceis25%higherthannationallyandthepopulation over70isgoingtogrowby17%by2020/21DementiaprevalenceratePercentageofGPweightedpopulation,2015/16

0.5%

0.8%

0.8%

1.0%

1.1%

1.2%

1.3%

1.2%

1.0%

0.8%

0.3%

0.4%

0.5%

0.5%

0.7%

0.6%

0.6%

0.7%

0.5%

0.4%

B&H

Crawley

H&R

EHS

CWS

HMS

EastSurrey

HWLH

STP

England

Recorded Undiagnosed

SOURCES:Providerdatareturns2017,QOF2015/16,CarnallFarraranalysis

Increaseinpopulationover70yearsoldby2021Percentage,2017

12%

14%

18%

18%

16%

19%

17%

19%

17%

16%

B&H

Crawley

H&R

EHS

CWS

HMS

EastSurrey

HWLH

STP

England

• Byapplyingthesameprevalencerate,includingtheundiagnosedrate(1.5%),thenumberofpopulationaged70+withdementiawillgrowby10.3%withinSussexandEastSurrey

3434


Thedementiadiagnosisrateis4%lowerthannationallyandthenumberofpatientswithdementiaincontactwithsecondaryservicesvariesacrosstheSTP

PatientsincontactwithsecondarymentalhealthservicesclusteredasorganicPatientsper1000weightedpopulation

DementiadiagnosisratePercentofpeoplebeingdiagnosedoverestimatedprevalencelocally

SOURCES:Providerdatareturns2017,NHSDigitalJune2017,CarnallFarraranalysis

• OnlyHorshamandMidSussexisdiagnosingdementiaataratehigherthannationally

• Lowercontactsinsecondarycaremaybeanindicationofmoredevelopedprimarycareandcommunity-baseddementiadiagnosisandpost-diagnosticservices

2.4

7.8

2.6

4.2

10.8

11.9

15.5

5.5

7.2

B&H

Crawley

H&R

EHS

CWS

HMS

EastSurrey

HWLH

STP

64.3%

64.9%

65.0%

67.3%

63.0%

68.5%

68.0%

64.6%

65.2%

68.0%

B&H

Crawley

H&R

EHS

CWS

HMS

EastSurrey

HWLH

STP

England4%

3535


SOURCES:Providerdatareturns2017,Alzheimer’sSociety,QOF2015-16,NHSDigitaldiagnosisrate2016-17

MentalhealthpopulationinSussexandEastSurreyPercentofpeopleincontactwithsecondaryservicesbyCCG

35%

13% 21% 21%

12%

36% 28% 32%

27%

CWS H&R EHS HWLH B&H HMS Crawley EastSurrey

STP

• Thereare18,180individualsinourSTPwhohavebeendiagnosedwithdementia,afurther9,668areestimatedtobeundiagnosed

• Ifcurrenttrendscontinueandnoactionistaken,thenumberofpeoplewithdementiaintheUKisforecasttoincreasetoby40% overthenext12yearsand156%overthenext38years

Dementiaandcognitiveimpairmentalreadyrepresents27%ofmentalhealthcontactsinsecondarycare,andthevolumewillincreaseasthepopulationages

3636


Uncoordinatedcareforthosewithdementiaresultsinpooroutcomesandinappropriatecaresettinguse

SOURCE:ViewsprovidedbyconsultantpsychiatristsatSPFT(2017)

Thereisalotofphysicalandmentalhealthcomorbidityinelderlypatients,especiallythosewithdementiaandnoeasyaccessto

physicalhealthcareforourpatients.

Forourinpatientswithdementia,theyareinvariablyphysicallyfrail,andthewardsatRSCH

fortheelderlylooksimilartothewardsforpatientswithdementiainthatthepatientshave

bothphysicalandmentalillness.

ThemedicationsthatweprescribeforBPSD(behaviouralandpsychologicalsymptomsofdementia)oftencausephysicalhealthissues,andthemostseniorphysicalhealthadviceonthewardscomesfromtheJuniorDrs.We

needformalliaisonwiththeGeriatricianstoadequatelymanagethesepatients.

Ifpeoplewithdementiaaresounwellthattheyareadmittedtothegeneralhospitalthentheylose

theirdementiawardbedandtheirmentalillnessisnotadequatelymanagedonageneralward.Weneedsomejointlymanagedbedsandforour

nursingandmedicalstafftohaveadequateandregulartraininginphysicalhealth.

Difficulttoaccessphysicalhealthcare

Lackofspecialistsupport

Lackofsuitableinfrastructure

Lackofjointupcarewithadequatestafftraining

3737


Adisproportionatenumberofthosefittoleavetheircurrentsettingofcarehavedementia

NOTES: 1 Formallydiagnosedashavingdementia– responserate=97%2 Formallydiagnosedashavingacognitiveimpairment– responserate=96%

SOURCES:SESbedstateaudit2016;CarnallFarrarAnalysis

Patients’fittoleave’ formallydiagnosedwithdementiaPercentage,2016

0%

8%

18%

14%

15%

16%

23%

21%

28%

0%

7%

17%

20%

21%

21%

23%

23%

55%

QVH

ESHT- community

SCT

BSUH

SaSH

ESHT- acute

WSHT

SPFT

FirstCommunity

TotalpatientcohortwithdementiaPatients‘fittoleave’withdementia

3838


NOTES:1 HospitalsincludingFirstCommunity,SPFT,WSHT,ESHT,BSUH,SaSHandSCT.

With27%ofpatientswithdementiaoracognitiveimpairmentwaitingforover50daystoleavetheirsettingsofcare

SOURCE:SESbedstateaudit2016,CarnallFarraranalysis

Timespentas‘fittoleave’fordementiaorcognitiveimpairmentpatientsProportionof‘fittoleave’patients,percentage,2016

8%

15%

27% 23%

26%

1% 1-7days

8-14days

15- 28days

28- 49days

50- 365days

365 +

• 99individualsor26%ofpatientwhohaveaformaldiagnosticofdementiaoracognitiveimpairmentremaininacuteandcommunitybedsacrossforbetween50and365daysoncetheyaremedicallyfittoleave

• 3individualshavewaitedoverayeartobedischargedafterbeingdeclaredmedicallyfit

• Ifwecanimprovethesupportofferforpeopleintheircommunitieswewillbeabletoreducelengthyandunnecessarystaysinsecondarycare

3939


Place-basedplanningworkinSussexandEastSurreyidentifiedthosewithdementiaasasapriorityforcarecoordination

SOURCE:NorthCSESA,SouthCSESAandCostalsegmentationanalyses 2017,CarnallFarraranalysis

• Thereareover4,000elderlyandover600adultsdiagnosedwithdementiainNorthCSESA.

• Elderlywithdementiause5%ofhealthandcareresources(40.0m),despitebeing 1%ofthepopulation.

• Adultswithdementiause1%ofhealthandcareresources(4.8m)andaccountfor0.1%ofthepopulation.

• Elderlywithmoderatefrailtyaccountforthelargestspendperheadofthesetwocohorts.

NorthCSESAadultsandelderlywithdementia

• Over6,750elderlyand700adultshavebeendiagnosedwithdementiainCoastalCare1.

• Elderlywithdementiause7%ofhealthandcareresources(64.5m),despitebeing1%ofthepopulation.

• Adultswithdementiause0.4%ofhealthandcareresources(£3.4m)andaccountfor0.1%ofthepopulation.


CoastalCareadultsandelderlywithdementia

• Thereareover4,800elderlyand780adultsdiagnosedwithdementiainSouthCSESA

• Elderlywithdementiause4%ofhealthandcareresources(46.9m),despitebeing 1%ofthepopulation.

• Adultswithdementiause0.4%ofhealthandcareresources(4.8m)andaccountfor0.1%ofthepopulation.


SouthCSESAadultsandelderlywithdementia

4040


Theclinicalstandardsauditidentifiedriskmanagement,careplanningandinformationsharingindementiacareasgaps

SOURCE:ClinicalStandardsauditproviderandCCGreturns,June,2017;CarnallFarraranalysis

Sharinginformation


• Informationaboutcarepathway,treatmentandcontactdetailsareavailableforpatients,carersandhealthcarepractitioners

• Carersareinformedaboutdischargeplan

• Serviceuserandcarerareinformedregardingtreatmentplanandinvolvedindecisionmakingontheirpreferredcare



Involvingpatientandcarer

• Laterstagesofdementiaareassessedtoidentifyandplanpalliativecareneeds• Activitiesareprovided7daysaweekandoutofhours• Cleardischargeplanissenttotheserviceuserandallrelevantpartieswithin10daysofdischarge.

Managingrisk



Standardsconsideredveryimportantbycommissionersandreportedaspartiallymetornotmetbyproviders


4141


Contents



Youthservices

Psychosis


Nextsteps



Crisis

4242


Youngpeopleaged14-25formahomogenousgroupthatneeddistinctiveandco-producedapproachestomentalhealthcare

SOURCE:CarnallFarraranalysis

Threequartersoffirstepisodesofmentalillhealthoccurinyoungpeoplebeforetheageof25andtheprevalenceofmentalhealthneedsforyoungpeopleishigherthanotheragegroups.Thisiscompoundedbygreateremployment,educationandtrainingproblemsforyoungpeoplethananyotheragegroup.InSussexandEastSurreyweface17%greaterself-harmforyoungpeoplethanthenationalaverageandthisvariessignificantlyacrosstheSTP.

Themismatchbetweenprevalenceofmentalillnessanduseofservicesisgreaterfor16-24yearoldsthananyotheragegroup,whichsuggestsSussexandEastSurreyshouldprovidedifferentwaystoaccessservicesthatworkforyoungpeople.

Producingservicescollaborativelywithyoungpeopleappearstobethebestwaytoachievethis.WehaveanexistingpilotforyouthservicesinHastings(i-Rock)thatprovideslowerthresholdsfor200individualstoaccessservices,actingasaonestopshopincludingemploymentandhousingsupport.Ithasbeenco-producedwithyoungpeoplewitha100%recommendationrate,indicatingthatthisapproachtoservicedesignisrequiredacrossSussexandEastSurrey.

4343


SOURCE:LSEyouthmentalhealth:neweconomicevidenceproject2014;Crawleypathfindermentalhealthproject

Highneeds

Benefitsofyouthservicemodel

Servicegap

• Thetreatmentgapismuchwiderforadolescentsandyoungadultsthanitisforotheragegroups:onlyaboutahalfoftheyoungpeopleaged16-25withmentalhealthproblemswerereceivingmentalhealthservices.

• Ineffectivenessoftraditionalservicestomeettheneedsofyoungpeoplewithemergingmentalhealthneeds.YoungpeopleareleastlikelytoattendtheirGPtogethelpformentalhealthrelatedproblems– thismeansthatthesystemisweakestwhereitneedstobestrongest(McGorry,2010).

• Youngpeopleoftenexperiencementalhealthdifficulties(1in10childrenandyoungpeopleintheUKsufferfromadiagnosablementalhealthdisorder;75%offirstepisodesofmentalillnessoccurbetweentheagesof15&25).

• Youngpeoplewithmentalhealthproblemsweremuchmorelikelynottobeinemployment,educationortrainingcomparedtosimilaryoungpeoplewithoutdisorders

• Thecurrenteconomicclimateandthehighrateofyouthunemploymentiscausingariseinmentalhealthproblemsforyoungpeople.

• TheInternationalYouthMentalHealthDeclaration(2013)requiresustobeprioritisingtheneedsofthisgroupandimprovingservicemodelstobetterfitwiththeirneeds.

• Youngpeople&theirfamiliestellustheywantthem.

• Youthservicemodelscanlocatethemselvesincentrallocationsandmakeiteasierforyoungpeopletoaccessthem.

• Youthservicemodelsdeliverbetteryouthengagementintreatmentandbetteroutcomesthroughimprovedaccessandretention.

• YouthservicemodelsenableustoovercomeproblematicissuesassociatedwiththetransitionbetweenCAMHSandadultservices(SinghTRACKstudy,2010).

• Bycreatingyouthserviceswewillbeabletoofferanearlierinterventionmodelandpreventgreaterproblemsfrombuildingupdownstream.ThisshouldintimeprovetobemorecosteffectiveasevidencedbytheEarlyInterventioninPsychosismodel(Knapp,2014).

• Greatercohesionandcollaborationbetweenthedifferentservices(healthandnon-health)alreadyworkingwithyoungpeoplewillhelpusmakethemostofthelimitedresourcesavailable

Therearenationalgapsinyouthservicesthatneededtobeaddressedlocally

4444


Prevalenceofmentalhealthproblemsisalreadysignificantamongst16-24yearolds

• 75%ofmentalhealthdisordersareestablishedbytheageof24,althoughmanyarenotdiagnoseduntilyearslater• Manyyouthsdonotattendtheirfirstappointment,andfewerreturnforasecondappointment

SOURCE:APMS2014

PrevalenceofmentalhealthproblemsPercentage,2014

4545


MH Prevalence /Service Use Gap

greatest for young people

0

5

10

15

20

25

30

16-24 25-34 35-44 45-54 55-64 65-74 75-85

Pe

rce

nt

Age

Prevalence

Service Use

Youngpeopleaged16-24usementalhealthserviceslessthantheirprevalenceindicatestheyshould

SOURCE:Investinginyouthmentalhealthisabestbuy, PDMcGorry- 2007;CarnallFarraranalysis

• The16-24agegrouphasthehighestprevalenceofmentalhealthissuesamongalltheauditedagegroups

• Thegapbetweenserviceuseandprevalencearegreatestforyoungpeoplecomparedtootheragegroups

• Mentalhealtharethebiggestdiseaseburdenintheage15-25comparedtootheragegroups

DiseaseburdenMentalhealthconditionprevalenceandserviceuse

4646


Youthhospitaladmissionsforselfharmare17%greaterthanthenationalaverageandthereis70%variationacrosstheSTP

Hospitaladmissionsasaresultofself-harmPer100,000population(10-24years),2016

SOURCE:PHEFingertips2016

398.8

465

347.6

362.3

429.8

439.4

471.9

524.8

551.4

590

National

STP

EHS

HMS

B&H

HWLH

Crawley

EastSurrey

CWS

H&R

+70%

4747


Wehaveinnovativeideassuchasthei-RockpilotinHastings thatcanbebuiltontosupportwiderapplication

SOURCE:Businesscaseforyouthmentalhealthservicepilot2016;NHSHastingsandRotherCCG;SussexPartnershipNHSFoundation Trust;EastSussexCountyCouncil

HastingsandRotheri-Rockyouthmentalhealthservicepilot(startedJune2016)

• Aonestopshoptosupportyoungpeopleaged14-25formentalheathissues,wellbeing,education,employmentandhousingsupport

• Over200individualshavebeensupported,neverwaitingformorethan30minutes

• 43%ofyoungpeopleaccessingtheservicearenotineducation,employmentortraining(4timeshigherthanthegeneralpopulation)andtheserviceconsistentlyreachespeopleinthe10%mostdeprivedareas

• Themostcommonageofusersis17,oftenrequiringsupportforanxiety/stress,relationship/employmentissuesorlowmood

• Over70%ofusersweregivensupportedaccesstoservicesand10%transitionedintoaservice

• 100%ofsurveyeduserswouldrecommendi-Rocktoafriendand40%reportedthattheywouldnothaveaccessedotherservices

• Thetraditionalchildandadolescentmentalhealthservice(CAMHS)toadultmentalhealthservicetransitioncanprovetobeproblematicandunsatisfactoryforthemajorityofyoungpeople

• Highthresholdsinstatutoryserviceprovisionandlackofcohesionbetweenstatutoryandnon-statutoryprovisionresultsinseveral“touchpoints”foryoungpeoplebeforeinterventionorsupportisgiven

• Engagementandretentioninservicesaresub-optimalwithhigherDNAratesanddisengagementinadultservicescomparedtothemore“youthfriendly”earlyinterventioninpsychosis(EIP)Services

• Adolescentsandyoungadultspresentwithneedsthatrequiresupportfrommorethanmentalhealthservicesalone(i.e.debtadvice,employmentsupport,anxietymanagement)buttheseareasarenotjoinedup

• Ultimatelythisleadstoincreasedcosts(directandindirect)andpooreroutcomesbothclinicallyandfunctionally

• Theyouthsupportsystemisbasedonservicesthatorganisationsprovideandneedstobebasedonoverallneedsofyoungpeopleandtheirfamilies

4848


Contents



Youthservices

Psychosis


Nextsteps



Crisis

4949


Crisisserviceawarenessandprovisionappearshighlyvariablewithverylowratesofcrisisplanningsupport


AcrossSussexandEastSurrey,1.3%ofpeopleincontactwithstatutoryserviceshavecrisisplans,comparedwithanationalaverageof13.3%.ContactswithcrisisteamswhocansupportplanningarrangementsvariesconsiderablybyCCGarea,whileover25%ofserviceusersinSussexandEastSurreydon’tknowhowtoreceivehelpinacrisis.AlthoughmultiplepointsofaccessforcrisissupportarecommissionedbydifferentCCGs,someserviceusersstruggletoknowwheretoturnforhelp.Thismaycauseemergencycaresettingstobeusedbydefault.

WhenindividualswithmentalhealthneedspresentatemergencydepartmentstheoutcomevariesconsiderablybyTrust.Thisisstrikingforadmissionsandassociatedbeddaycoststhatrangebetween£34kand£1.3mperannumdependingontheTrust.

Almost20%ofreferralstosecondarycarearegeneratedinemergencydepartments,indicatingthatanumberofemergencyattendancescouldbehandledelsewhereifcrisisplanningandresponseweretobeimproved.Thiswouldincludesupportforpeoplewithearlystagesofdementiatopreparecrisisplans.

Forpsychiatricdisorders,attendancesatA&Eforaregenerallyhigherthanthenationalaveragewithover6,000ambulancejourneysmadetoA&Ein2016/17suggestinganeedtoprovideclearsignpostingtoalternativeandmoreeffectivesettingsofcare.

5050


FewermentalhealthserviceusershaveacrisisplanthannationallyandcontactswithcrisisteamsarehighlyvariableacrossCCGs

13.3

1.3

0.4

0.2

0.6

10.9

0.2

0.9

0.2

0.1

England

STP

B&H

CWS

Crawley

EastSurrey

EHS

H&R

HWLH

HMS

MentalHealthServiceuserswithcrisisplansAsapercentageofpeopleincontactwithservices(endofquartersnapshot),2015/16

SOURCE:PHEFingertips2015/16

ContactswithacrisisteamPer1,000population,2015/16

44.8

7.2

31.1

18.2

26.2

36.4

64.0

37.7

HMS

HWLH

H&R

EHS

EastSurrey

Crawley

CWS

B&H

5151


Yes,IwouldgototheAccidentandEmergencyDepartment

Althoughsimilartothenationalaverage,morecanbedonetosupportserviceuserswhoneedhelpincrisis

Doyouknowhowtogethelpinacrisis?Percentageofserviceusers,2014

Yes,IhaveanumberformentalhealthservicesIcanringinanemergency

No,IdonotknowhowIcangethelpinanemergency

0

20

40

60

80

100

SPFT SaBPTotalnational

sample

SOURCE:ReportofthesecondroundoftheNationalAuditofSchizophrenia2014

Topquartile

• AtSaBPandSPFT72.6%and72.7%knowhowtoseekhelpincrisis,respectively

• Nationally72.8%knowhowtoseekhelpincrisis

• Inthetopquartile81.8%knowhowtoseekhelpincrisis

5252


AlthoughmultiplepointsofaccessforcrisissupportarecommissionedbydifferentCCGs,someserviceusersstruggletoknowwheretoturnforhelp

SOURCE:PHEFingertips2015/16;CCGservicemapping;CarnallFarraranalysis

• Thirdsectormentalhealthhelpline• Rapidresponseopenaccessphonelineservice

• AssessmentandTreatmentService• CrisisResolutionandHomeTreatment (CRHT;throughSPFT)

• SPFTreferralcoordinator(8amto6.30pmthroughGP)

• Crisishouses• GP-ledurgentcarecentres• Rapidassessmentandinterventionteam

• Mentalhealthcrisisline• SafeHavens(5-11pm)• HomeTreatmentteams(throughtheCommunityMentalHealthRecoveryServices/PsychiatricLiaisonatA&E)

• Thirdsectormentalhealthhelpline• Rapidresponseopenaccessphonelineservice

• A&E(throughMHLiaisonservices)• S136pathway(throughStreettriage)• Hastingssanctuary• Nightsittingservice

“Itcanattimesbedifficulttopersuadethecrisisteamtotakeonapatientthatneedshelp”

“Thereisnorealalternativetobeingsectionedbypoliceifyougettocrisispoint”

“Weneedproperemergencyhelptobeavailablewhenacrisisoccurs.Thehelplinewasinadequateandleftme

feelingcompletelyisolatedandvulnerable,especiallyatnightand

weekends.”

“Morefunding,andincreasedaccessforcrisisteamsoutside

officehourswillstoppeoplegoingtoA&E”

• DifferentCCGscommissiondifferentcrisisservices• MentalhealthliaisonservicescommissionedbyCCGsarenotyetoffered24/7• StrategiccommissioningofcrisissupportacrossSussexandEastSurreymaycreateamore

coordinatedandroundtheclockserviceoffer,basedonsharedbestpractice• CCGsarealreadycollaboratingtoimprovecrisissupportthroughajointservice

developmentandimprovementplanwithSPFTforCRHTs

Examplesofcrisisservicesofferedduringworkinghours

Examplesofcrisisservicesofferedoutsideworkinghours

5353


AttendanceatacuteemergencydepartmentswithaprimarymentalhealthneedresultsinmixedoutcomesforserviceusersandcostsbyTrust

1080

1570

55 2989 72 17

194

973

918

246

303 854

984

599

84403

555

812

12096 252

160121

29 399

SaSH WSHFT ESHT BSUH

Unknown

Other

Referred

GPfollowup

Discharged

Admitted-assessmentunit

Admitted-psychiatricunit

Admitted

Outcomeafteremergencydepartmentattendance(2016/17)Patientnumbers

Totalbeddaysandcosts(2016/17)Beddays

2000 1836

542 96

SaSH WSHFT EHST BSUH

1.3m 1.5m 189k

• Costdataonlyincludesreferencecostdata,theactualcostislikelytobehigherduetotheintensivenursingrequired

1902 3925 2856Total Costs(£)

Note:Admittedreferstothesametrust;referredincludestootherhealthcareproviderorGP;bedsdaysandcostsareonlyforadmittedpatientsSource:Providerdatareturns2016/17,CarnallFarraranalysis

• Asignificantproportionadmissionsarefor0or1daylengthofstays(SaSH73%,WSHT84%,ESHT75%,BSUH69%)suggestingtheyarerapidlyreferredonordischarged.

34k2034

5454


PrimaryCare54%

ED

18% Self-Referral8%

SecondaryCare6%

Otherhealthcareteams2%

LocalAuthority1%

Other11%

Note:PrimarycaredoesnotincludeIAPTSource:Providerdatareturns2016/17,CarnallFarraranalysis;1Makingthecaseforintegratingmentalandphysicalhealthcare,NHSE2017

ReferralsintosecondarycareoriginatefromseveralpointsofdeliveryPercentage,2016/17

*95%ofselfreferralsweretoIAPTservicesatSussexCommunity4%ofreferralsfromanemergencydepartmentteamaretoanA&Eliaisonteam

1902

3925

20342856

SaSH WSHFT ESHT BSUH

TotalattendancesatemergencydepartmentsandcostsAttendances,2016/17

282 384 311

Attendancesatemergencydepartmentsforpatientswhoseprimarydiagnosisdescriptionisamentalhealthneedi.e.overdose,depression,anxietypersonalitydisorder

Costs(£000s) 177

2.0% 2.8% 2.6%Percentage

oftotalattendances

1.9%

18%ofmentalhealthpatientsarereferredtosecondarycareservicesafterattendanceatemergencydepartments

5555


AttendancesatA&Evariesconsiderablyforpsychiatricdisordersandover6,000ambulancejourneysformentalhealtharemadeperyear

Source:PHEFingertips2012/13,Providerdatareturns,2016/17

AttendancesatA&EforapsychiatricdisorderPer100,000population(10-24years),2012/13

19

22

196

203

359

422

449

569

244

EastSurrey

Crawley

HMS

HWLH

CWS

B&H

EHS

H&R

England 6110

186

MentalHealth Section136

AmbulancejourneysmadeforSection136ormentalhealthneedsPatients,2016/17

5656


Contents



Youthservices

Psychosis


Nextsteps



Crisis

5757


Integratingphysicalandmentalhealthisneededtoimproveoutcomesandprovideaconsistentservicetoourpopulation

Source:CarnallFarraranalysis

Mentalandphysicalhealthshouldbeaddressedtogetheraspoormentalhealthleadstopoorphysicalhealthandviceversa.169,000peopleinSussexandEastSurreyhavebothamentalhealthconditionandaphysicalcondition.Thisisequalto45%ofpeoplewithamentalhealthconditionhavingaphysicalcondition.

Notaddressingtheemotionalandmentalhealthchallengesofpeoplewithoneormorelongtermphysicalconditionsresultsinsignificantnegativehealthoutcomes.Italsoleadstosignificantadditionalcostsforservices.

Asthepopulationages,thechallengewillincrease.Thechancesofhavingdementiaincreasestwelvefoldintheover70s.Physicallongtermconditionsincreasewithageanddiabetesandcardiovasculardiseaseincreasetheriskofdementia.SussexandEastSurreywillhave34,000morepeopleovertheageof70by2020/21,reinforcingtheneedtotreatpeople,ratherthandiseases.

Wecanimprovehowmentalandphysicalhealthcometogether.Atpresent,thebedsweprovideformentalhealthneedsareoftenlocatedinsmallunitsawayfromservicesforphysicalconditions.

79%ofmentalhealthserviceusersandcarershaveexperiencedstigmaandthisoftencomesfromNHSprofessionals.Ifmentalandphysicalhealthcareandsupportisofferedbydefaultbystafftrainedinholisticcare,thiswillbeimproved.Over50%ofserviceusersand75%ofGPsstronglybelievethatcoordinationbetweenservicesisfragmentedandshouldbeovercometoimprovementalhealthcareincludingphysicalaspects.

5858


•Mentalhealthimpactoflivingwithachroniccondition• Psychiatricsideeffectsofmedication,e.g.,steroids• Directeffectsofhormonalimbalancesonmentalhealth• Increasedriskofdementiaamongpeoplewithdiabetes/cardiovasculardisease

• Physicalhealthsideeffectsofpsychotropicmedication,e.g.raisedriskofobesity• Directeffectsofchronicstressonthecardiovascular,nervousandimmunesystems• Directeffectsofeatingdisordersoself-harm,e.g.electrolyteimbalances• Higherrateofunhealthybehaviours,e.g.smokingorexcessivealcoholuse• Reducedabilityormotivationtomanagephysicalhealthconditions• Lesseffectivehelp–seeking• Barrierstoaccessingphysicalhealthcare,e.g.asaconsequenceofstigmaor‘diagnosticovershadowing’

Goodmentalhealthoutcomesrequireholisticmanagementandsupportforphysicalandmentalhealthconditions

SOURCE:TheKing’sFund– mentalhealthandnewmodelsofcareMay2017

SocialdeterminantsE.g.,poverty,socialisolation,discrimination,abuse,neglect,trauma,drugdependencies

Physicalhealth

Mentalhealth

5959


169,000people(45%)withamentalhealthconditionalsohaveaphysicalhealthconditioninSussexandEastSurrey

SOURCES:Peerintegrateddataset2016,CarnallFarraranalysis;Bringingtogetherphysicalandmentalhealth ,Kind’sFund2016NOTE:Databasedonnationalestimate

Mentalhealthconditions:16%ofpopulationofSussexandEastSurrey(371,000)

Longtermconditions:26%ofpopulationofSussexandEastSurrey(556,000)

27%ofpeoplewithlongtermphysicalconditionhaveamentalhealthproblem(169,000)

45%ofpeoplewithmentalhealthproblemhavealongtermphysicalcondition(169,000)

6060


Aspeopleage,theriskofdevelopingmultiplelongtermconditionsincreases

SOURCES:Peerintegrateddataset2016,CarnallFarraranalysis;Bringingtogetherphysicalandmentalhealth ,Kind’sFund2016

NumberofchroniccomorbiditiesbyagestratumPatientspercentage,2016

6161


TheSTPhasavariedbedbaseandsomesmallerunitswhicharenotco-locatedwithphysicalhealthservices

SOURCE:Providerdatareturns2016/17;CarnallFarraranalysis

STPbedbasebytypeNumberofbedsbyhospitallocation,2016/17

12

10

10

12

15

20

10

16

23

34

36

47

40

15

12

18

18

19

12

10

15

15

28

9

RutlandGarderns

Burrowes

CrawleyHospital*

HorshamHospital**

StAnnes

ShephardHouse

Lindridge

Connolly House

Oaklands

UckfieldHospital**

HKU

AmberstoneHospital

ConquestHospital*

Meadowfield

DoP(Eastbourne)*

LangleyGreen

MillView

PICU

InpatientOrganic

AcuteInpatient

InpatientFunctional

Acuteinpatient- SPFTrun

RehabilitationInpatient

*AcuteSite**CommunitySite(non-mentalhealth)

• Thereare17inpatientsitesinrunbySussexPartnershipinSussex

• Sevenofthesehavelessthan20bedsandarearenotlocatedwithphysicalhealthcareservices

6262


79%ofmentalhealthserviceusersandcarershaveexperiencedstigma,oftenfromNHSprofessionals...

21%

21%

21%

37%

Note:1ParticipantscanselectasmanyresponsesastheyhaveexperiencedSOURCE:ServiceuserandcarersurveyJune2017

Haveyouexperiencedstigmaand/ordiscriminationasaresultofamentalhealthproblem?Percentageofrespondents,2017

44%

36%

35%

33%

17%

5%

2%

2%

2%

Familymembers

NHSprofessionals

Friends

Workcolleagues

Neighbours

Public

Employer

Police

School

21%

79%

Never Yes

Ifyes,fromwho?Percentageofrespondentsselecting’yes’,2017

6363


69%

55%

44%

43%

39%

19%

9%

Treatmentisdelayedornotgivenearlyenough

Servicesdonotcommunicatewitheachotherwhendeliveringcaretothesameperson

Staffarenotalwaysavailablewhenweneedthem

PeopledonotthinkMentalHealthisimportant

PeopledonotknowenoughaboutMentalHealth

Informationisnotreadilyavailable

Servicearetoofarfromme/thefamily

“Weworkinsilosanddon’tknowwhatelseis

beingoffered”“Socialcareisvery

fragmentedandneedstoworkwithprimary

care”

“Fragmentedservicesisoneofourbiggest

roadblocks”

“Weneedtocommissionmoreservicesjointlyacrossdifferent

providers”

“Weuselotsofseparatesystemsthatdon’ttalk

toeachother”

Treatmentisdelayedornotgivenearlyenough

Servicesdonotcommunicatewitheachother

Staffarenotalwaysavailablewhenweneedthem

PeopledonotthinkMentalHealthisimportant

PeopledonotknowenoughaboutMentalHealth

Informationisnotreadilyavailable

Servicearetoofarfromme/thefamily

ServiceusersandcarerswantcommunicationbetweenservicesandstaffavailabilitytoimprovePercentageofrespondents,2017

76%

64%

62%

52%

14%

Fragmentedservices

Undercapacity

Lackoffunding

Delayedtreatments

Availabilityofinformation

Fragmentedservices

Undercapacity

Lackoffunding

Delayedtreatments

Availabilityofinformation

GPsviewfragmentedservicesasoneofthebiggestroadblockstodeliveringmentalhealthservicesPercentageofrespondents,2017

SOURCES:SussexandEastSurreyserviceuser/carerandGPsurveysJune2017;stakeholderinterview2017

...Whileabouthalfofserviceusers,carersandthreequartersofGPsbelievethatfragmentedservicespreventscoordinatedsupportbeingoffered

6464


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Psychosis


Nextsteps



Crisis

6565


SussexandEastSurreyfacesanongoingfinancial,workforceanddatarecordingchallenge


SussexandEastSurreyfacesasignificantfinancialproblemwithaforecasthealthandsocialcarechallengeestimatedat~£750mby2020/21.Localauthoritybudgetshavedeclinedbyanaverageof22% whiletheshareoffundsallocatedbyCCGstomentalhealthhasdecreasedfrom10%to9.9%since2013/14.Thisfundingconstraintwillrequirenewwaysofdeliveringservicestosupportpeopletomaintainthebesthealthandwellbeingpossible.

SpendperweightedheadvariesamongtheCCGsby60%andamonglocalauthoritiesby252%andamismatchexistsbetweenwhatCCGspayforversusthevalueofservicesreceivedbytheirpopulation.Weareincurringgreatcosttosendpeopleoutofareawiththemajorityofcasesduetolocalprovidersnotofferingservices(£9mofactivity).ThevarietyofcommissionedservicesoutsideofmainblockcontractswithSPFT,SaBPandIAPTpresentsanopportunitytoexplorestrategicorjointcommissioning.

InSussexalone,wefacethesecondhighestvacancyrateforacutementalhealthservicesthathasledtoasustainedincreaseinagencyspendfrom£2.6min2012/13to£9.8min2015/16.Carersformanimportantpartofourworkforcebutover60%donotfeeladequatelysupported.

Althoughweknowthatservicesneedtobemoreholistic,wedonotrecordinformationonlifeoutcomeswellwithforhousing(74%unknown)oremployment(84%unknown).

6666


SussexandEastSurreyfacesasignificantfinancialproblem

Source:SESSTPFinanceSubgroup

• ThefinanceenvelopehealthandcareinSussexandEastSurreyis£3.7bnfor2017/18

• SPFTrecordeda£1.1mdeficitin2016/17,SaBPa£0.5msurplus(althoughunderlyingmovementsdiffer)

• TheNovemberSTPprojectedtheNHSgapwouldgrowto£653mthesocialcaregapto£212mby2020/21ifnothingisdone.However,giventhedeterioratingfinancialposition,thisislikelytobehigher

• Thefundingconstraintwillrequirenewwaysofdeliveringservicestosupportpeopletomaintainthebesthealthandwellbeingpossible

6767


ThetotalmentalhealthspendforCCGsin2016/17was£222m with£12monjointbudgetsand£89mofidentifiedlocalauthorityadultmentalhealthspend

Source:Provider/localauthoritydatareturns2016/17

130

13

12

9

14

8912

45

BlockcontractCCGs

IAPT

SpealistPlacements- CCG

Other-dementia

Other- non-dementia

LAspend

LAjointbugets

Other- outofscope

MentalhealthspendacrosstheSTP£m

• ThetotalspendonmentalhealthbyCCGsis£222m

• TheCCGsspend£177monadultsmentalhealth

• Thelocalauthoritieshaveidentifiedaspendof£89monadultmentalhealth

• WestSussexcountycouncilhaveapoolbudgetandcontributed£8.8m(13.5%)tothis

• BrightonandHoveCCGmakeanannualcontributiontowardsSection117andspecialistplacements of£3.4m

• Itmaybenecessarytoshiftthecurrentbalanceoffundingbetweenserviceareasandspecificelementsofcarepathwaystosupportgreaterinvestmentinpreventativeservicesandimproveoutcomes

6868


Source:CCGdatareturns,CCGannualaccounts(2013/14to2016/17),CCGBreakdownofProgrammeCosts2015/16Plans(£'000),NHSEngland- CCGAllocations2016-17to2020-21,CalculationofWeightedPopulation(MentalHealth),CarnallFarrarAnalysis

CCGspendonmentalhealthserviceshasdecreasedslightlyasashareoftotalallocationfrom10%in2013/14to9.9%in2016/17

10.0%

9.6%

8.6%

8.0%

12.6%

12.2%

7.1%

9.1%

9.9%

10.1%

9.8%

7.9%

8.7%

12.6%

12.2%

7.3%

9.6%

10.0%

CWS

H&R

EHS

HWLH

B&H

HMS

Crawley

EastSurrey

STP

2013/14 2016/17

ChangeinproportionofallocationspentonmentalhealthPercentage,2013/14– 2016/17 • Mentalhealthspendin2013/14acrossSussex

andEastSurreywas£206m;in2016/17itwas£232m

• CCGspendonmentalhealthhasincreasedby£26.2m.Thisisacompoundannualgrowthrate(CAGR)of4.1%

• Inrealtermsthisinanincreaseinmentalhealthspend

• However,theCCGallocationsacrosstheSTPgrewby4.5%inbetween2013/14and2016/17

• ThereforeCCGmentalhealthspendinghasdecreasedfrom10.0%ofthetotalallocationsto9.9%.

• Eastbourne,HailshamandSeafordistheonlyCCGthathasincreasedthepercentageoftheirallocationspentonmentalhealth

Note:CoastalWestSussex,HastingandRother,Eastbourne,HailshamandSeafordandHighWealdLewisHavenshaveaprimaryCareNHSEco-commissioningarrangementwhichhasincreasedtheirtotalallocation,thishasbeenremovedfromthetotalCCGallocation.CCGpeergroupingsbasedoncomplexityofpopulationmentalhealthneeds.

21%

10%

-2%

15%

2%

-57%

-24%

-20%

-3%

ComparisonofspendperheadtoCCGpeersPercentage,2015/16

6969


IncomeandcostperCCG£/standardisedunitactivity,2016/17

445

703

397

600642

415

558

440

749

466 450

622

496

725

0

100

200

300

400

500

600

700

800

CWS H&R EHS HWLH B&H HMS Crawley

Income Cost

Note:Dataincludesnon-psychotic,psychotic,organicandunclusteredincomeandcostSource:Providerdatareturns2016/17,CarnallFarraranalysis

ThereisamismatchbetweenwhatCCGspayin,andthevalueofservicesreceivedbytheirpopulation

7070


Localauthorityadultsocialcareservicesexpenditurehasreducedbyanaverageof3%againstbudgetsthathavefallenbyanaverageof22%

-8%

-3%

-2%

-5%

-3%

Brighton&Hove

EastSussex

Surrey

WestSussex

Weightedaverage

-28%

-25%

-20%

-19%

-22%

Realchangeinadultsocialcareexpenditure2013/14– 2017/18

Realchangeintotalserviceexpenditure2013/14– 2017/18

Source:Departmentforcommunitiesandlocalgovernment;HMTreasury;CarnallFarraranalysis

7171


120

75

10385

74 77 73 63

10

8

11

138 9 8

8

7

5

9

8 5 48

29

4915

16

19 18 2315

EastSurrey

CWS HWLH B&H H&R Crawley HMS EHS

MHTrustBlockContract

IAPT

SpecalistPlacements

OtherProviders

165 128

BrightonandHoveCCG’sincludes£3.4mannualcontributiontothecitycouncil,theirIAPTserviceincludesemploymentsupportandwellbeingservices

137 123 109 109 108 94

Source:CCGdatareturns2016/17,providerdatareturns,LocalAuthoritydatareturns;CarnallFarraranalysis

ThereishighvariationinspendperheadonmentalhealthforbothCCGs(60%)andlocalauthorities(252%)

MentalhealthCCGweightedspendperhead(2016/17)£,allspend

66

4132

19

WestSussex

Brighton&Hove

EastSussex Surrey

66 3241 19

Mentalhealthweightedlocalauthorityspendperhead(2016/17)£,adultspend

+60%

+252%

Thisisspendidentifiedasadultmentalhealthspend;therewillbespendonmentalhealthfromotherbudgets.Itdoesnotincludejointbudgets(WSCC)orBrightonandHoveCCGannualcontributiontowardsSection117andspecialistplacements,WSCCincludes£1mtobettercarecontributiontomentalhealth

7272


Inpatientcapacityisconstrainedbybedoccupancyrangingbetween91%and103%acrossSussex

Source:CarnalFarrarbedaudit,March2017,providerdatareturns,CarnallFarraranalysis

94% 91%

103% 103%

92%

Rehabilitation Dementiaandcognitive

impairment

Functional Acute PICU

OccupancyratebybedtypeforNHSprovidersinSussex(2016/17)Percent

Bedtype No.of beds

Rehabilitation 77 (SPFT)12(SaBP)


67

Functional-olderpeople

82

Acute-working ages 196

PICU 22

EastSurreyuses14bedsatLangleyGreenlocatedinSussex(Crawley)

Thereare45bedsacrossSPFTwhicharenotfitforpurpose:• RutlandGardens’inHovea10bedrehabilitationunit• StRaphaelWardinHastingsandRotherisinadequatelysizedandconfigured,itis isa15bedacuteworkingageward• Beechwood,a20beddementiaandcognitiveimpairmentwardatUckfield hospitalbedswillbereprovisioned attheSt

Anne’sCentreinHastingssubjecttoinvestmentapproval

7373


1

33

118

58

10 4

1

4

3 8

ASD Complex/Refractory Neuropsychiatry PD

OutsideofSPFTblockcontract

SPFTdoesnotprovidethisservice

Otherreason

SussexCCGsspent£9monspecialistplacementsin2016/17andsecondarycarecapacityandcapabilitywouldberequiredlocallytoavoidthese

Source:Provider/CCGdatareturn

Reasonsforoutofareaspecialistplacements(SPFT)Numberofplacements,2016/17

Costofoutofareaspecialistplacements£m,2016/17

SPFToutofblock

SPFTdoesnotprovidethis

servie

Otherreason EastSurrey

£9.0m£1.7m £1.0m

Note:otherreasonincludes,specialistservicerequired,ASC/CHCfundingrefused.DataincludedallplacementsthatSPFTmanage thatarenotNHSfunded;EastSurreyhasspecialistplacementsincludedintheirblockcontract

£0.8m

7474


AgencyspendatSPFTandSaBPasaproportionofthewagebillhasincreasedsince2012/13

Source:MentalhealthtrustannualreportsforSPFTandSaBP,SPFTproviderreturns

Agencyspendasapercentageoftotalwagebill(Percent)

1.6%

4.4% 4.4% 5.2%

6.5% 8.2% 8.9%

12.5% 12.1%

9.7%

2012/13 2013/14 2014/15 2015/16 2016/17

SPFT

SaBP

Spendonagency(£m)8.9 9.7 13.7 10.52.6 7.9 8.1 13.6 12.910.7

• Asthefiveyearforwardviewformentalhealthisimplemented,serviceareasthatarenovelorexcitingforstafftoworkinwillincrease

• Thiscreatesariskthatstaffshortagesintraditionalserviceareaswillincreaseasstaffmoveintonewservices

• SussexandEastSurreyneedstoensurethatworkforceplanningmitigatesagainstthisoutcome

7575


Themajorityofthebankandagencyworkforceishospitalnursingstaff,whereapproximatelyonethirdofpostsarevacant

8.4%

15.1%

32.7%

16.8%

5.7%

13.3%

5.2%

2.4%

33.8%

20.3%

1.3%

0.4%

Consultants

Othermedicalstaff

Nursing:Hospital

Nursing:Community

Psychology&Psychotherapy

AHPsSaBP

SPFT

VacancyratePercentage,2016/17

Source:Providerdatareturn,2016/17CarnallFarraranalysisNote:Hospitalnursingincludesoutpatient,daycare,inpatients,othermedicalstaffnotenteredforSPFTasWTEnotenteredforsecondedoragencystaff

AgencyandbankusebystafftypeWTEMarch17

8.4

0.0

217.2

80.7

4.0

5.2

6.8

4.0

36.3

19.9

0.0

0.0

Consultants

Othermedicalstaff

Nursing:Hospital

Nursing:Community

Psychology&Psychotherapy

AHPsSaBP

SPFT

7676


Althoughtherearefundstodevelopnewservices,thesupplyofprofessionalsisstillconstrained

6%

13%

14%

12%

Transformationareas

Coreacute

Corecommunity

Overall

Medical staff%vacancies,2016

10%

12%

12%

11%

12%

6%

7%

8%

Nursing&midwiferystaff%vacancies,2016

AHP&technical staff%vacancies,2016

Source:Steppingforwardto2020/21:ThementalhealthworkforceplanforEnglandJuly2017- HealthEducationEngland

7777


21%

21%

21%

37%

Howwellarecarerssupported?


38%

24%

22%

12%

3%

NotsupportedatallInadequatelysupportedNeithersupportednorunsupportedAdequatelysupportedVerywellsupported

Howcouldcarersbebettersupported?

• Timelyaccesstoservices:especiallyduringoutofhoursandwhencrisiscareisrequired

• Morepeersupport:recognisecarers’valueandexperienceandofferopportunitiesforthemtosharetheirexperienceandsupporteachother

• Betterunderstandingandcommunication:listentocarersabouttheirconcernsandexperienceandinvolvethemincareplanning

• Improvetransparencyofinformation:tohelpcarerstonavigatethesystemandgetinformationandadvicewhenrequired

• Provisionofrespitecare: toallowcarerstotakebreak

• Improveconsistency:both intypesofservicesandqualityofcare

Carersareanimportantpartoftheinformalworkforcebutover60%donotfeelsupportedbystatutoryorganisations

7878


Thereisasignificantrelationshipbetweenemploymentandmentalhealthand84%ofcontactsinsecondarycarehavenorecordedemploymentstatus

SOURCE:Mentalhealthandwork,RoyalCollegeofPsychiatrist2008,Providerdatareturns2017,NHSDigital2017,CarnallFarrar analysis

1710

96

55

43

HWLHEHS

EastSurreyH&R

CrawleyCWSHMSB&H

ProportionofpeopleonCareProgrammeApproachaged18-69recordedasinemploymentinSussexandEastSurreyPercent

ProportionofpeopleincontactwithsecondarymentalhealthservicesinemploymentPercent

’Workgivestheworkerasocialidentityandstatus;socialcontactsandsupport;ameansofstructuringandoccupyingtime;activityandinvolvement;andasenseofpersonalachievement’(Warr,1987).

‘Thesocialexclusionthatserviceusersexperienceasaresultofmentalillhealthisreducedbyworkandaggravatedbyunemployment’(SocialExclusionUnit,2004).

‘…thatasmanyas90%ofworklesspeoplewhousementalhealthserviceswishtowork’(Grove,1999;Seckeretal.,2001).

84%

UnknownRetiredUnemployedEmployedStudentOther

7979


SOURCE:Quantitativeresearchwith3,509Englishadults,Shelter2017,Providerdatareturns2017,NHSDigital2017,CarnallFarraranalysis

1in5Englishadults(21%)saidahousingissuehadnegativelyimpactedupontheirmentalhealthinthelast5years

Housingaffordabilitywasthemostfrequentlyreferencedissuebythosewhosawhousingpressureshavinghadanegativeimpactupontheirmentalhealth

3in10ofthosewhohavehadahousingproblemorworryinthelastfiveyears,notonlysaidthatithadhadanegativementalimpact,butthattheyhadnoissuewiththeirmentalhealthpreviously

ProportionofpeopleonCareProgrammeApproachrecordedasinsettledaccommodation inSussexandEastSurreyPercent

ProportionofpeopleincontactwithsecondarymentalhealthservicesinstableaccommodationPercent

74%

UnknownCareHomeTemporaryAccommodationMainstreamHousingSupportedAccommodationShelteredHousingHomelessOther

7941

2523

1716

119

EastSurreyHWLH

CrawleyEHSH&RHMSB&HCWS

Housingpressureisanimportantfactorcontributingtomentalhealthissuesandnotwellmonitoredas74%ofsecondarycarecontactshaveanunknownstatus

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Contents



Youthservices

Psychosis


Nextsteps



Crisis

8181


SOURCE:TheCareAct2014

TotransformthedeliveryofmentalhealthcareforthewholeofSussexandEastSurrey,oursolutionsneedtoreachacrosstraditionalhealthandsocialcareboundariesandrecognisetheimportanceoftheCareAct,aswellascontributionsandchallengesfacedinthesocialcaresystem.

ChallengesandprincipleshighlightedintheCareActthatweneedtoaddressformentalhealthinclude:

• Pressuresonadultsocialcare/localauthorityfunding

• Capacityandqualityissuesinthesocialcareprovidermarket

• Thesocialimpactofdementiaoncarers,familiesandcommunitieswillgrowmorewiththedemographicpressuresandwillrequiretargetedinvestmenttomanage

• TherewillneedtobeaHousingstrategyformentalhealthserviceusersatbothSTPandCountyCouncillevel

• TherewillneedtobeadementiastrategyatbothSTPandCountyCouncillevel

• Personalisation/choiceandcontrol/greaterresilienceisasignificantculturalshiftawayfromtheprofessionalexpertmodel

• SafeguardingcitizensandpatientsthroughtheCareActisacoreprincipleofthiscaseforchange

• OurentirehealthandcaresystemneedstodevelopaclearandconsistentunderstandingofstatutoryrolesandresponsibilitiesinrespectoftheCareAct.

TheCareActprovidesastrongcasefortransformationofwholecaresystemsandwillbeusedtoinformourmentalhealthstrategicframework

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• 75%ofpeopleareabletoaccesstreatmentwithin6weeks,95%within18weeks;andatleast50%achieverecoveryacrosstheadultagegroup

• 25%ofpeoplewithcommonmentalhealthconditionsareabletoaccesspsychologicaltherapies

• Atleast60%ofpeoplewithfirstepisodepsychosisstartingtreatmentwithaNICE-recommendedpackageofcarewithaspecialistearlyinterventioninpsychosis(EIP)servicewithin2weeksofreferral

• Adoublinginaccesstoindividualplacementandsupport(IPS),enablingSMIpatientstofindandretainemployment

• Accesstoliaisonanddiversionservicesreached100%ofthepopulation;closealignmentwithpolicecustodyhealthcareservices.

• Outofareaplacementswillbeeliminatedforacutementalhealthcare

• Savings fromdecreasedoverallbedusagewillbereinvestedincommunity-basedcare

• ArmedforceschampionsandaspecificnamedclinicianwithanexpertiseinmilitarytraumainMentalhealthproviders

• Allacutehospitalswillhaveall-agementalhealthliaisonteamsinplace,andatleast50%ofthesewillmeetthe‘Core24’servicestandardasaminimum

• Allareaswillprovidecrisisresolutionandhometreatmentteams(CRHTTs)deliveringa24/7service

• Newmentalhealththerapistswillbeco-locatedinprimarycare

• Morepeoplewithaseverementalillnessreceivingafullannualphysicalhealthcheck

• Reductioninprematuremortalityofpeoplelivingwithseverementalillness(SMI)

• Reducedsuicidalrateby10%supportedbylocalmulti-agencysuicidepreventionplans

SOURCES:Thefiveyearforwardviewformentalhealth,NHSEngland2016

Thefiveyearforwardviewformentalhealthoutlinesseveralimprovementareasthatneedtobemetnationallythatrequirenewwaysofdeliveringservices

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ThiscaseforchangehasdeterminedchallengestomeetforadultandyouthmentalhealthcareinSussexandEastSurrey:

• IncreaseaccesstotherapiesforcommonmentalhealthdisorderswithanofferforpeoplewhoseneedsaretoocomplexforIAPTservices

• Providegreatercommunitysupportforpsychosisandallowthoserequiringsecondarycareinpsychosistoaccessitmoreeasily

• Coordinatehealthandcareorganisationplanningfordementiatoreducedelayedtransfersofcareandprepareforanageingpopulation

• Co-produceayouthserviceofferwithyoungpeople,coveringholisticsupportthatgoesbeyondtraditionalhealthandcaresupport

• ImprovecrisisplanningandcrisisservicecommissioningtoreduceconfusingentrypointsintoservicesandunnecessaryattendancesatA&Edepartments

• Addressphysicalandmentalhealthtogethertomeetholisticcareneedsofthepopulationandreducestigmabetweencurrentcareboundaries

• RebalancespendandcoststodelivermentalhealthservicestohelpreducetheSTPfinancialdeficit

• Createaworkforceplantoreducerelianceontemporarystaffbyattractingandretainingthebesttalent

SOURCES:Thefiveyearforwardviewformentalhealth,NHSEngland2016

Conclusions

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Nextsteps

SOURCE:[includeJSNAs,ONS,providerandCCGdatareturns]

Futureworkwillfocusonthreeareas:developopportunitiesagainstchallengesinthisdocument;produceastrategicframeworkformentalhealthinformedbythoseopportunities;createahighleveldeliveryroadmapthatwillsupportfutureplanningactivities.

1. Developopportunitiestoaddresschallengesinthiscaseforchange

Opportunitiestoimproveadultandyouthmentalhealthserviceswillbediscussedanddevelopedinanumberofforums.TheclinicalandprofessionalworkinggroupwillactasasourceofideasanddrawonexistinggoodpracticefromwithintheSTPandtheneedsofthementalhealth5YFV.Theworkshopon24Julywilldevelopopportunitiesbysegmentsidentifiedinthisreport.Thefinanceandmodellingworkinggroupwilldeterminethefinanceandactivityimpactofeachopportunity.

2. Createthementalhealthstrategicframeworkforadultandyouthservices

Thestrategicframeworkwillincludetheevidencebaseforopportunitiesdeveloped,includingthequalityandfinanceimpact.Whereactivityislikelytobereduced,reinvestmentoptionswillbeproduced.Investmenttodeliverthementalhealth5YFVwillbeestimated.Itwillincludeoptionsforfuturecommissioningandproviderarrangements.

3. Produceahighleveldeliveryroadmap

Futureplanninganddeliverywillbebasedonadeliveryroadmapwithprioritisedopportunities.Thiswillallowsubsequentplanstostartwithopportunitiesthatwillhavethemostimpactonqualityandspend.ItwilltakeaccountoftheNHSE2017/18mentalhealthimplementationplan.

mental health in sussex and east surrey: the case for ...€¦ · 2016/17 the total spend by ccgs...

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