national perspective - parity of esteem – valuing mental and physical health equally

National Perspective - Parity of Esteem – valuing mental and physical health equally

Joanna Powell

1 April 12014

A few of our drivers

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NHS | Presentation to North Region |1 April 2014

http://www.rcpsych.ac.uk/files/pdfversion/OP88xx.pdf

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Health and Social Care

Act 2012

• The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement –

• (a) in the physical and mental health of the people of England, and• (b) in the prevention, diagnosis and treatment of physical and mental

illness.

NHS Mandate

• By March 2015, we expect measurable progress towards achieving true parity of esteem, where everyone who needs it has timely access to evidence-based services•NHS England’s objective is to put mental health on a par with physical health, and close the health gap between people with mental health problems and the population as a whole•Every community to have plans to ensure no one in crisis will be turned away, based on the principles set in the MH Crisis Concordat

Putting People

First

• Parity Included in Priority 8 on the NHS England Balanced Score Care• Deliverable 11 against key deliverable: Put mental health on a par with

physical health, and close the gap between people with mental health problems and the population as a whole. Extend and ensure more open access to IAPT by March 2015, particularly for children and young people, and for those out of work


What Parity will mean to me:

My family and I all have access to services which enable us to maintain both our mental and physical wellbeing.

If I become unwell I use services which assess and treat mental health disorders or conditions on a par with physical health illnesses.

“Person centred,

coordinated care”

The patient

The Vision


My mental health is not assessed at GP

registration & in annual Health checks

Only 33% of GPs & 1% of practice nurses are trained to assess and make an mental

health diagnosis

I can access treatment if I am one of the lucky 15% & I wait

2 years if I have psychosis

I have a 1: 10 chance only of getting NICE

evidence based psychological

therapies so my life outcomes are poor

I am seldom offered psychological

therapies if I come from a BAME

community or am older

I have a 25% chance of being prescribed

medicines at too high a dose

Only 7% of people with mental illness gain

employment due to stigma & ineffective

treatments

When I am in a mental health crisis I do not know what number to

ring, so I can end up in a police cell

When I go to A/E only 40% of staff know how to assess my needs. so I come back often

and suicidal

I am likely to die 10-20 years early as my

physical health needs are not assessed or

treated

I am not helped to self manage & I am treated

with contempt and stigma

If I am from a BAME community I am much

more likely to be forcibly detained under the Mental Health Act

What is often like now for me?


The NHS England vision of parity

My mental health, as well as my physical

health are assessed at GP registration & in

annual Health checks

My GP and practice nurse are trained to

make an early diagnosis

I can access treatment within weeks & not years, or never, as

happens now

I receive NICE evidence based psychological

therapies as a routine, not just a 1: 10 chance

of getting it

I am offered psychological therapies even if I come from a

BAME community or am older

I am prescribed medicines safely and

helped to take them well

I have a care plan that includes effective

interventions to recover & get employment

When I am in a mental health crisis I dial one

number, and get taken to a healthcare

assessment Centre

When I go to A/E I am assessed by staff trained

in MH awareness & assessment in line with

NICE

My family are well supported in caring for

me

I an supported to self manage and continue to be part of my community

and contribute to it

Every experience is a kind, compassionate,

educating, skilled encounter


• Facilitate NHS England to work to reduce the disparity which currently exists in health outcomes for those with mild, moderate or severe mental health illness

• Support integration and personalisation by promotion of whole person care which values everyone’s mental and physical health needs equally

Parity of Esteem Programme


Cultural change is at the heart of the POE ProgrammeStrategic aim – for POE to be everyone’s business• It cuts across all NHS OF Domains • It is closely aligned to other major transformational programmes

– e.g. integration, person centred care planning and personalisation

• It does however also have to focus on reducing the many disparities which exist between Mental and physical health

How will the programme be delivered?• Specific improvement / change projects • Business as usual to support POE generally*• Ensure alignment with other organisations and groups

PoE Programme - key messages


PoE Programme

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Current top priorities• Data, Information and Intelligence • Development of capability and skills in commissioning –

including need to focus on cultural change / behaviour of commissioners change

• Delivering improvements to clinical services (including IAPT and increasing timely diagnosis and post diagnostic care for dementia)

• Addressing and improving crisis Care • Improving physical health for people with serious mental

illnesses

Discrete improvement project – Business as usual – Collaboration with system partners


1. What’s the issue?

2. Where are we now?

3. Where do we want to be?

4. How do we get there?

Increasing and more complex

care needs

Poor outcomes for people

with mental illness

Person centred,

coordinated care

‘House of Care’ model

Our mandate from the government requires us to close the gap between mental and physical health services – to achieve parity

An emerging common narrative


Mental illnesses are very common

In any one year 1 in 4 British adults experience at least

one mental disorder

Between 8% and 12% of the population experience depression in any year

10% of 5-16 year olds have a mental disorder

5.4% of men and 3.4% of women have a personality

disorder

Among people under 65, nearly half of all ill health is

mental illness

1.2m people in England have a learning disability

There will be over a million people with dementia by

2021

e.g. heart disease, cancer, diabetes

e.g. mainly depression, anxiety disorders, and child

disorders

% of morbidity in the UK: Physical v Mental illness1 Rates of morbidity in each age group (Equivalent life-years lost per 100 people)2

Morbidity from physical illness rises steadily throughout life,

whereas mental illness especially affects people

aged 15-44

Source: 1&2: Based on WHO, 2008. Further calculations by Mike Parsonage . see: LSE (2012) how mental illness loses out in the NHS

Among people under 65, nearly half of all ill health is mental illness


% of population with condition

% of people with condition in treatment

AdultsSchizophrenia or bipolar disorder

1% 80%

Depression 8% 25%

Anxiety disorders 8% 25%

Children (5-16)Conduct disorder or ADHD 6% 28%

Depression & / or anxiety disorders

4% 24%

Autistic Spectrum Disorder 1% 43%

How does this compare to treatment levels for those with long term physical health problems? (in comparable western countries: 94% diabetes, 91% hypertension, 78% heart disease)

Yet, only a quarter of all those with mental illness such as depression are in treatment


Diabetes

Hypertension

Stroke

Cancer

HIV / AIDS

27%29%31%33%44%

% of people affected by depression

People who experience persistent pain are four

times as likely to have an anxiety or depressive order as the general population

People with poor physical health are at higher risk of experiencing mental health problems…


• £14bn is already spent on mental health services

• Nearly a third of people with long term physical conditions have at least one co-morbid mental health problem. This can exacerbate the person’s physical condition and increase the cost of treatment by between 45% and 75% at a cost to the NHS of an estimated £10bn per year

• Medically unexplained symptoms cost the NHS some £3bn per year

• Mental illness has a significant impact on public finances: estimated that the costs of depression through lost working days are 23 times higher than the costs to the health service

• 1 in 4 unemployed people has a common mental health problem

• Childhood mental health problems can have a significant economic effect on society. It is estimated that a child with a conduct disorder will, by the age of 28, have generated costs (such as to the health, education, benefits and criminal justice systems) ten times as high as a child without conduct problems

Medical costs

Hidden costs

Mental health problems impose a total economic and social cost of over £105bn a year


• Improving Access to Psychological Therapies (IAPT) programme had major impact in it’s first 3 years:

• treating more than 1 million people in IAPT services • more than 680,000 people completing a course of treatment • recovery rates consistently in excess of 45%

• Personalised Health Budgets: the national pilot programme indicated that personal health budgets “had a significant positive impact on care-related quality of life, psychological wellbeing and subjective wellbeing” of the people taking part. People with mental health problems reported improvements in their physical health, and people with physical health problems likewise reported better mental health

• Suicide prevention strategy : Findings from three mental health promotion pilot projects to address the raised suicide risk in young men show that:

• multi-agency partnership is key to promoting young men’s mental health;• community locations, such as job centres and young people-friendly venues,

are more successful in engaging with young men than more formal health settings such as GP surgeries;

• front-line staff feel better able to engage with young men if they receive training;

• community outreach programmes are seen by young men as more acceptable and approachable than services provided in formal healthcare settings.

Common mental health disorders

Severe mental illness

Mental illness

Examples:

New service models that put patients in control

…and new service models emerge with huge potential to improve outcomes


Most people with Serious Mental illness don’t receive physical health

checks

National audit of schizophrenia – only 29% of service users getting

proper metabolic monitoring

There are significant delays in diagnostic treatment for people

with learning disabilities

We run a national programme of health checks within school, but we

only check physical health

The current design of our health system doesn’t ensure ‘whole-care’ packages


My goals/outcomes e.g.• All my needs as a person were

assessed and taken into account.

The House of Care - The House supports National Voices ‘I’ statements

Communication e.g.• I always knew who was the

main person in charge of my care.

Information e.g.• I could see my health and

care records at any time to check what was going on

Decision-making e.g.• I was as involved in

discussions and decisions about my care and treatment as I wanted to be. Care planning e.g.

• I had regular reviews of my care and treatment, and of my care plan.

Transitions e.g.• When I went to a new

service, they knew who I was, and about my own views, preferences and circumstances.

Emergencies e.g.• I had systems in place

so that I could get help at an early stage to avoid a crisis.

Planning Guidance 2014/15 -18/19 Headlines

• Outcomes drive everything we do• Significant financial challenge: no change is not

an option• 2014/15 – transformation year in preparation for

2015/16 (Better Care Fund)What’s new?

• Support available to support commissioners• Operational (2 years) strategic (5 years) plans• Integration / collaborative working a key feature

• Monitor / NHS TDA (providers and commissioners)• Local authorities (Better Care funding)

• Unit of planning to support Health and Social Care planning NHS | Presentation to North Region |1 April 2014

The 6 Characteristics of sustainable services (emerging from Call to Action)

• Citizens included in all aspects of service design and change and patients fully empowered in their own care

• Expanded primary care• A modern model of integrated care• Access to the highest quality urgent and emergency care• A step-change in the productivity of elective care• Specialised services concentrated in centres of

excellence.


Planning Guidance 2014/15 -18/19

Level Summary Relevance to POEAmbition for NHS

• 7 measureable ambitions

• 6 service characteristics AND

• 3 key measures

QOL / LTC ambition - IAPT and dementia referenced Trajectory for Dementia diagnosis and Trajectory for IAPT coverage and recoveryPOE expected to be reflected in CCG plans for delivery of 6 characteristics AND is a key measureable

Steps CCGs are expected to undertake in order to deliver these ambitions

Local ambitions linked to the 7 measureable ambitions Planning fundamentals National conditionsIntegration /holistic care

POE is a planning fundamentalAcute Care -Plans not to have a negative impact on the level and quality of mental health services. Integration / holistic care - Dementia services particularly important Assurance process – POE to be included see above

Underpinned by CQUINS for Dementia and Mental Health - DES for dementia and learning disability - Quality Premium for IAPT Standard contract sanctions– MH MDS focus Informed by baseline data provided in State of the Nation Report NHS OF – IAPT indicator


High quality care for all, now and for future generations

• High Quality – ‘Driven by quality in all we do – our patients rightly expect the best possible service’

• For all – ‘…whether need is for mental or physical help and support. We must put the greatest effort in providing care for the most vulnerable and excluded in society’

• For now – ‘Need to get better at sharing good practice rapidly across the NHS’

• For future generations – ‘Strategic plans developed in partnership working between commissioners, providers and local government to deliver models of care that will be sustainable in the longer term’


Previous events - objectives

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South (January) Midlands and East (February)

Understand the National priorities SCNs, Regional and Area Teams to work together to support ongoing CCG engagement

Foster good working relationships within SCN communities

Secure regional and local focus and leadership for IAPT, Dementia and the MCA

SCNs to identify work priorities Better equip local teams to offer targeted support to those localities or commissioners who have significant distance to travel in the delivery of the above priority work streams

Identify and share good practice Share and disseminate learning


Outcomes from the South event

NHS | Presentation to [XXXX Company] | [Type Date]24 NHS | Presentation to North Region |1 April 2014

• The NHS Mandate clearly sets out priorities for the system

• We all need to collaborate in order to deliver the mandate

• NHS England National Support is there to support you and your local CCGs to deliver the NHS mandate

• What do you and your local CCGs need us to do to help you to deliver the mandate?

In summary


Thank you

?

Joanna Powell, Domain Team Lead [email protected]

mailto:[email protected]

Improving physical healthcare to reduce premature mortality in people with severe mental illness (SMI)

Indicator 1: 65 per cent of funding for demonstrating, through a national audit process, full implementation of appropriate processes for assessing, documenting and acting on cardio metabolic risk factors in patients with psychoses, including schizophrenia.

Indicator 2: 35 per cent of funding for completion of a programme of local audit of communication with patients’ GPs, focusing on patients on the Care Programme Approach (CPA), demonstrating by Quarter 4 that, for 90 per cent of patients, an up-to-date care plan has been shared with the GP

Mental Health CQUIN

The CQUIN guidance for 2014/15 was reissued in February on NHS England website


The following cardio metabolic parameters are assessed and actively managed;

• Smoking status• Lifestyle (incl. exercise, diet, alcohol and drugs)• Body Mass Index• Blood pressure• Glucose regulation (HbA1c or fasting glucose or random

glucose as appropriate)• Blood lipids

Mental Health CQUIN


Discrete improvement project – Business as usual – Collaboration with system partners

NHS England Parity of Esteem Work-packages


Data, Information and Intelligence

Product Purpose Update and next stepsNational Mental Health Intelligence Network

To bring together key users and holders of mental health data and intelligence, to oversee improvements in data availability and flow The aim of which is to put mental health and wellbeing intelligence into the public domain to enable local decision makers to improve mental health and wellbeing across England.

A steering group and governance structure has been established. The network is being developed using Expert Reference Groups. The network will be formally launched in May 2014.

Parity of Esteem Dashboard The dashboard will present a range of information on outcomes, experience and access to mental health services. It will be available to the public and NHS organisations.

The potential contents of the Dashboard were discussed at the PoE programme launch in December 2013. Dashboard will be available from November 2014.

Improving the quality of MH data in the national reporting and learning system (NRLS)

To improve reporting of patient safety from providers to the NRLS to support evidence based change in patient safety.

All 12 trusts with data reporting issues) to have developed and agreed action plan by September 2014. Guidance on how restraint should be reported produced by April 2014, implemented by October 2014.

Implementation of the Friends and Family test in mental health

The FFT is important measure of how people feel about the care they receive. As per our mandate objective, we will roll out the test in mental health by December 2014.

The specific questions are currently being tested for appropriateness across MH settings and pathways having established pathways. Guidance will be complete by June 14, with a view to going live by December 2014.

Improving data flow and linkages To improve data and intelligence infrastructure to improve the timeliness, coverage and linkage of data on mental health.

Working with the HSCIC, significant improvements have already been made to IAPT data quality and availability. Work will continue on other areas throughout 14-15.

State of the Nation Report (Parity of Esteem)

To provide a baseline of prevalence and service information to inform future progress of the Parity of Esteem Programme

We have used existing nationally available data to build this report. This work has highlighted gaps as well as providing a baseline from which the Parity of Esteem Programme can build from. The report will be published early in 2014/15 and it is anticipated that this tool will be of use to commissioners, providers and the public.

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Commissioning skills and capabilities (progress and deliverables)

Product Purpose Update and next stepsCommissioning Framework for CAMHS High quality CAMHS requires close working between local

commissioning partners. The objective is to deliver an evidence based, outcomes focused service specification which facilitates this collaboration.

The work on the service specification has begun, and will be available by December 2014 to support the 15-16 contracting round.

CCG Leadership development To deliver focused, skills based training for mental health commissioners. The training is based on a development programme ran in London in 2012-13.

The programme will be delivered throughout 2014-15, each CCG will be offered a place.

Mental health value packs/ toolkits To develop practical resources for commissioners, including: Value packs highlighting variation, providing service

models and supporting economic cases. Innovative contract models for outcomes.

The project has been scoped and is being discussed with the Commissioning Assembly. Toolkit will be delivered by December 2014.

Financial Framework (including PbR) To ensure that the range of financial levers and incentives are being effectively harnessed to support parity of esteem. This includes PbR, the standard contract, CQUIN, and the quality premium.

A number of financial and contracting tools were issued as part of the 13-14 planning process, including sanctions within the standard contract, a national mental health CQUIN scheme, and CCG Quality Premium.

In terms of PbR, mental health services were covered by care clusters for 2014-15, which were subject to local pricing. We are piloting currencies for IAPT and CAMHS which could potentially inform future tariff setting.

Financial strategy To ensure that mental health is fully integrated into the longer term financial strategy work.

Mental health services are included in the Call to Action modelling work. We have commissioned cost benefit analysis of mental health interventions We will ensure that costs and benefits of mental health interventions are included in the economic study of the impact of data and participation in the NHS.


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Improving clinical services (progress and deliverables)

Product Purpose Update and next stepsAdult IAPT To ensure delivery of the Mandate objective of 15% access to

IAPT services, with a 50% recovery rate. We have produced an IAPT recovery plan, and have worked with the HSCIC to improve data flows. The CCG planning guidance gave a very strong message on IAPT, requiring all CCGs to have credible plans for at least 15% access. These plans will be robustly tested and monitored by area teams.

CYP IAPT To work with 60% coverage of CAMHS services for 0-19 year olds by March 2015

Current coverage is 54%. In March 2014 the programme will advertise for new sites to join the programme and take coverage beyond 60%.

Choice in mental health To implement choice in mental health services To ensure that people with mental health conditions have similar access to services as people with a physical disability.

We are working with the DH to ensure that choice is implemented from April 2014. We anticipate choice to be fully embedded by April 2015

Employment and mental health We know that employment is an integral part of recovery from mental ill health. This pilot programme explores integrated psychological and employment support.

We are working with DWP and the Cabinet Office to design and implement two projects:

The Psychological Wellbeing at Work pilots proposed by RAND Europe;

A pilot testing IAPT on employment outcomes (subject to DWP funding).

These pilots will run from May for 6 months. Mental Capacity Act To embed the principles of the mental capacity act into the

health and care system, resulting in empowered and engaged users with tailored care.

We are working with system partners to ensure that assessments of mental capacity are undertaken as appropriate, and that the act is being supported by commissioners.

Waiting time standards for MH While this is challenging due to the complexity of pathways and lack of data, we are developing costed options for consideration as part of the 15-16 Mandate discussions.

A joint steering group has been established between NHS England and DH. This work is expected to have developed options by June 2014.


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Improving clinical services (progress and deliverables) - 2

Product Purpose Update and next stepsImprovements in Direct Commissioning

Parity of Esteem for victims of rape and sexual assault.

Integrated service provision and support for Substance Misusers

Awareness raising of the needs of Veterans and Mental Health Veterans

Improving outcomes for people within the criminal justice system

Parity of Esteem to be included in the commissioning of healthcare provision for Sexual Assault Referral Centres (SARC) and therapeutic pathways commissioned in the community through Clinical Commissioning Groups and Local Authorities.

Through The Gate Programme which is a ministerial cross department programme with Ministry of Justice and DH with an early adapter led by NHS England North West Health & Justice Area Team commissioning integrated service provision and support for Substance Misusers Through the Gate on prison release to the community.

Parity of Esteem has been an opportunity to highlight the needs of Veterans and Mental Health Veterans provision and responsibility of commissioning through Defence Medical Services and CCGs.

Health and Justice Direct Commissioning is now working with the Health & Justice Oversight Group. Interventions that are key to ensure that Parity of Esteem are understood and integrated throughout and are to be included in the £25m Liaison & Diversion programme


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Improving crisis care (progress and deliverables)

Product Purpose Update and next stepsSystematic review of crisis care pathways

Assess effectiveness of a range of models of mental health crisis care

Negotiating with DH to commission the review.

Programme of support to commissioners

Aid commissioners, based on the evidence from the review and gap-analysis, to commission for best practice in their communities

Will work through Commissioning Assembly to co-design appropriate materials

Mental health scoped in Urgent and emergency care review

Integrate mental health crisis care as required across urgent and emergency care services

Mental health crisis care is part of workstreams in the review, scoping under way for taking work forward

Roll-out of new liaison and diversion services

Assume NHS England’s new responsibility for these services from April 2014

An extra £25m has been made available in 2014/15 for the liaison and diversion services. This has resulted in 10 trial sites been commissioned by NHS England. Trial sites will commence 1/4/2014; Roll-out as agreed to 50% coverage for 2015/16 September 2015 a full business case will be submitted to HM Treasury to secure funding for additional funds to support full roll out.


national perspective - parity of esteem – valuing mental and physical health equally

Documents

north region

mental health disorders

mental illness1

mental disorder5

mental disorderbetween

physical health services

physical health illnesses

drivers2 nhs presentation