Integration of physical and mental

health services for young people

Dr Lesley FrenchClinical DirectorChildren & Young People’s DirectorateManchester Conference 08 December 2016

Challenges to integrated health care for young people

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From The Winter’s Tale by William Shakespeare

I would that there were no age between ten and twenty-three

That youth would sleep out the rest

For there is nothing in between but getting wenches with child,

wronging the ancientry

stealing and fighting.

What we know

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• Around 80% of those patients with chronic medical conditions, often starting in childhood have associated mental health co-morbidity.

• 75% of adults with MH problems age of onset <24 years

• Some estimates 1:8 adult physical health patients receive evidence-based mental health treatment

• Extensive evidence that mental health plays a key role in pain management, recovery and quality of life

• Extensive evidence that physical health strategies improve outcomes for mental health conditions such as depression

Why is it so difficult

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• Biggest barrier is service organisation

• Current commissioning structures in the NHS

• Financial pressures more acute than ever

• Health economic arguments of life-time savings in services do not bring immediate solutions to cash-strapped NHS and Local Authority providers

• In children’s services multiple agencies can be involved with children with complex needs, each providing good care but multiple contacts for the family to manage

What good looks like

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• For real integration of physical and mental health services?

• An unrelenting focus on outcome changing care

• A champion –led culture shift to holistic care

• Cross-disciplinary training (more diversity per professional)

• Use of care managers/care co-ordinators as specialists

• Co-ordinated records and systems

• A total population focus at commissioning level

• A respectful co-ordination of co-located interdisciplinary clinical services (Kathol et al, 2010)

Triangulation of Outcomes

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“Are CYP receiving

our services improving?”

Service User Satisfaction & QoL

(CHI-ESQ, Friends & Family Test)

Goals Based Outcome Measure

Physical/Mental Health Measure

(RCADS, CGAS)

Integration of Physical and Mental Health in Practice

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• Three boroughs, three sets of commissioning arrangements and a range of local priorities for one health provider

• A re-furbishment of one building has prompted a re-think about co-location of physical and mental health services for children across two boroughs

• Health visiting, school nursing, children with complex disabilities and child with mental health needs (CAMHS)

• Existing practice should be transformed by proximity of teams

• Culture change embedded

Local examples

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• Integrated neuro-developmental service

- psychiatry, psychology paediatrics and SaLT

• Dietetics and CAMHS – working with obesity

• Sickle cell physical health and emotional care

• Physiotherapy joint clinics with orthopaedic hospital surgeons

• Community health & well-being services in schools

• Physical health clinics for adolescents with complex MH needs

• Working with LA to ensure disabled access in local parks

• Diabetes community nursing and clinical psychology provision

Why integration matters

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• Broad agreement in the literature that for children & young people co-ordinated and integrated care the best offer

• All our efforts at whatever point of contact for the young person should be to enhance the social and emotional competence of young people

• Schools can be seen as a de facto mental and physical health system

• A single point of access for children which is non-stigmatising

• Secondary school age children should be a key focus for public health programmes given the evidence of vulnerability

The developmental arguments

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• Young people ( 12 – 24) are developmentally emerging adults

• The stage in which most mental health disorders emerge

• A high rate of self-harm – and suicide a leading cause of death

• A strong relationship between poor mental health and other health and developmental concerns & educational outcomes

• Global estimates 1 :4 YP will suffer one mental disorder

• Poverty and social disadvantage strongly associated

• Protective factors include a sense of connection and social support, parents and friends who model health behaviours

Mind the Gap

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• Most MH care for YP delivered in outpatient community settings

• Sometimes housed within adult services

• Access to mental health poor especially for late adolescence early adulthood – the most at risk period

• If physical health good unlikely to have relationship with GP or any other health worker able to connect to a wider system

• Often diagnostically confusing and need multi-disciplinary cross-service support along with excellent engagement skills

• A substantial gap still exists for rapid and effective service responses at the time of greatest mental health need for YP

Implications for policy and practice

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• Disseminate health-based interventions for young people through co-located health sites and schools

• Stigma of mental health limits access to the traditional offer

• Integrate MH intervention into general health interventions

• Physical health practitioners trained to deliver treatments such as CBT and evidence-based counselling when treating children with chronic health disorders

• A single young people-friendly site under one clinical management structure -primary and tertiary care

Thank youlesley.french1@nhs.net