Bob ricketts - commissioning and finance rationale

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Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning


Tuesday 24 June 2014: 15Hatfields, Chadwick Court, London

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Bob ricketts - commissioning and finance rationale

  1. 1. The importance of integration of physical and mental health: The commissioning and finance rationale Bob Ricketts, Director of Commissioning Support Services Strategy & Market Development NHS England Better Outcomes, Better Value: integrating physical and mental health 24th June 2014 1
  2. 2. The importance of integration of physical and mental health: Why is the integration of physical & mental health in commissioning important? • Ethical imperative for commissioners The commissioning and finance rationale: • To begin to make parity of esteem a reality • To deliver better outcomes & experience • To secure a better return on resources So what does all this mean for commissioners?
  3. 3. The importance of integration of physical and mental health: Parity of esteem: • Key strategic objective & commitment: “making sure we are just as focused on improving mental health as physical health and that patients with mental health problems don’t suffer inequalities, either because of the mental health problem or because they don’t get the best care for their physical health problems” NHS England: Everyone Counts
  4. 4. The importance of integration of physical and mental health: Parity of esteem: • People have a right to expect equally high quality services for their mental and physical health, which are person-centred & ‘joined up’: “My family and I 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.” NHS England: Everyone Counts
  5. 5. The importance of integration of physical and mental health: Better outcomes & experience: Scale: • Every year 1 in 4 adults experience at least one mental health disorder • Mental health is the single largest cause of disability in the UK (23% mental health; 16% CVD; 16% cancer) • Mental & physical health are indivisible & unitary and should be considered together by commissioners Condition: % of people with depression with… Diabetes 27% Hypertension 29% Stroke 31% Cancer 33%
  6. 6. The importance of integration of physical and mental health: Disparity in Outcomes: • People with schizophrenia are: 2x more likely to die from CVD 3x more likely to die from respiratory disease • Life expectancy: average for men …………………………………… 79 years average for men with mental health problems… 68 years • People with diabetes who also have co-morbid mental health problems are at increased risk of poorer health outcomes & premature mortality. Co-morbid mental health problems are associated with poorer glycaemic control, more diabetic complications & lower medication adherence
  7. 7. The importance of integration of physical and mental health: Return on investment: Mental health problems = 28% of morbidity, but receive only 13% of NHS spend But potentially high return on resources: ROI for each pound invested in: • £84 for school-based social & emotional learning programmes to prevent conduct disorder • £18 for early interventions in psychosis • £10 for work-based mental health promotion • £8 for training interventions with parents with conduct disorder • £5 for early detection & treatment of depression at work
  8. 8. The importance of integration of physical and mental health: Why commissioning for integration makes financial sense: • 12-18% of all NHS expenditure on LTCs is linked to poor mental health & wellbeing = £8bn-£13bn pa (King’s Fund: Long-term conditions and mental health The cost of co-morbidities, 2012) • When people with LTCs also have mental health issues the cost of treatment can rise significantly. 1/3 people with long-term physical conditions also increase mental health problems, increasing treatment costs • Co-morbid mental health problems raise total health care costs by at least 45% for each person with a LTC & co-morbid health problem • At least £1 in £8 spent on LTCs such as CHD or diabetes is linked to poor health & wellbeing; savings far outweigh the cost of psychological interventions (NHS Confederation Mental Health Network and King’s Fund)
  9. 9. The importance of integration of physical and mental health: Why commissioning for integration makes financial sense: “A growing evidence base suggests that more integrated ways of working … offer the best chance of improving outcomes for both mental health and physical conditions.” “There is also evidence that the costs of including psychological or mental health initiatives within disease management or rehabilitation programmes can be more than outweighed by the savings form improved physical health and decreased service use.” King’s Fund: Long-term conditions and mental health The cost of co- morbidities, 2012
  10. 10. The importance of integration of physical and mental health: Why commissioning for integration makes financial sense: • Hillingdon Hospital – incorporating a psychological component into breathlessness clinics for COPD led to 1.17 fewer A&E attendances & 1.93 fewer hospital bed day admissions per person, saving £837 per person – saving 4 times the cost • CBT- based programme for angina led to patients needing 53% fewer hospital admissions, saving £1,537 per person
  11. 11. The importance of integration of physical and mental health: Commissioners & providers should address the factors that enable good integrated care: • Information-sharing systems Shared protocols • Joint funding & commissioning Co-located services • Multidisciplinary teams Liaison services • Navigators Research • Reduction of stigma Mental Health Foundation: Crossing Boundaries Sept. 2013
  12. 12. The importance of integration of physical and mental health: So what does all this mean for commissioners? • Make improvements now through incentivising incremental changes in service specifications (CQUIN) • Put individuals at the centre of commissioning decisions • Work effectively with key local partners & communities – influencing education, work, housing, leisure, lifestyles • Designing integrated mental health & physical health services • Develop and incentivise the delivery of integrated mental health & physical health outcomes • Use the Better Care Fund creatively • Where appropriate, exploit the power for transformation of population- based commissioning for outcomes
  13. 13. The importance of integration of physical and mental health: So what does all this mean for commissioners? Can it be done? Integrating Physical and Mental Health in Nottingham: More joined-up & strategic approach across commissioners & providers: • GP training around mental health • Mental health staff training around physical health • Improving access to health improvement • CQUIN to incentivise physical health checks & smoking support • Mental health incorporated within long-term conditions pathways Dr. J. Copping, Dr. M. Bicknell & Dr. Michele Hampson : Integrated Health Care Summit April 2012
  14. 14. Community Health and Well being Integrated Practice, Care For HIV Patients Veronica Ford
  15. 15. COVENTRY’S INTEGRATED SERVICE • An integrated Sexual Health and HIV service, including Family Planning and GUM • Trust clinical strategy to develop Integrated Practice Units
  16. 16. Prevalence of HIV in Coventry • General population in Coventry of 323,132 • Over 600 HIV patients accessing Integrated Sexual Health Service • Prevalence of HIV is 3% per 1,000 people aged 15-59
  17. 17. Integrated Practice Unit’s (IPU) • Organized around the need’s of patient’s • Provides the full cycle of care for a condition, including patient education, engagement and follow-up • Involves a dedicated team who devote a significant portion of their time to the medical condition • Providers are part of a common organizational unit • Co-located in dedicated facilities Source: Michael Porter 2010
  18. 18. Background • HIV is a complex disease and is considered to be a treatable Long-Term Condition • Antiretroviral Therapy has improved survival dramatically • Co-morbidities including mental heath issues have been identified as important co-morbidities • Management of HIV patients need multidisciplinary team approach • Lifestyle advice and Mental Health Support can improve survival with improved quality of life (BHIVA Guideline)
  19. 19. IPU - Work to Date • Development of Screening Tool • Complies with BHIVA Standards of Care for People Living with HIV • Leading to Single Assessment • Integrated working/joint clinics • Effective use of existing resources • Increased range of services to clients
  20. 20. Previous Pathway HIV Consultation Dietician THT iAPT Psychosexual Counselling
  21. 21. Current progress HIV consultation Lifestyles service THT service Dietician iAPT service Physiotherapy Specialist Psychiatric and Psychological services Alcohol support Smoking support Weight support
  22. 22. Lifestyle Health Checks • Individuals aged 18 and above to identify risks and make healthy lifestyle changes. • Initial 45 minute assessment includes: • BMI measurement • BP, Glucose & Cholesterol testing • Smoking status, diet, physical activity, alcohol consumption • GAD/PHQ for Mood & Anxiety.
  23. 23. Lifestyle Health Checks • Following initial assessment, the client can attend a structured six week programme to improve lifestyle and reduce risk: Eat & Drink Healthy, Be active, Reduce Smoking & Alcohol, Feel good and sleep well Move onto Case Management or Stop Smoking Programme
  24. 24. •Delivering parallel healthy lifestyle and IAPT clinics within the service • Team encouraging HIV patients to attend Lifestyle check •Closer liaison and working between MDT • Onward support offered with a range of external agencies IPU in Practice
  25. 25. Results so Far • IAPT has already identified patients who need help including Cognitive Behavioural Therapy – Management plans agreed with consultant through MDT discussions – Positive feedback from patients and clinicians • IPU assists with the early intervention to reduce the complex co morbidities and also help with the identification of comorbidities such as hyperlipidaemia.
  26. 26. iAPT 15% 42% 43% % patients offered IAPT Service % patients signposted to another service % patients who either did not need or want futher support
  27. 27. Life Style Support 15% 17% 17%25% 2% 24% patients to stop smoking support patients on counterweight patients on to IAPT patients referred to Physiotherapy patients on to Alcohol Support Services patients on to additional case management support
  28. 28. Case study 1 • Male, aged 56 years diagnosed positive for 5 years on ART for 4years • Completed lifestyle health check and was motivated to make lifestyle behaviour changes. • Completed support with ‘Eat Well’ sessions with Lifestyle advisor. • He achieved his goals relating to the frequency of eating, portion size and types of food groups eaten. His starting weight was 103kg and is now 99kg. • Quote – ‘Quite surprising the things you take for granted that are wrong in your life, you think you are doing good but you can do better, fine tuning needs to be done.’
  29. 29. Case Study 2 • Female, aged 53 years diagnosed 6 years ago • Supported with behaviour change to ‘sleep well’. • Her sleep improved and she is also now accessing physiotherapy after being referred following check for her leg problem. • Following the sleep improvement she is now accessing • Counterweight, a weight management programme, with our lifestyle advisor and is following a personal health plan. • She has lost 4.6 kg already and is still on the programme. (Starting weight 75.6kg, now 71kg) • Quote ‘Feel more self-aware and in control of my eating and sleeping; realising that you have habits and somebody is helping you to stop and think. ‘No thank you’ is now my mantra for the week.’
  30. 30. Healthy Lifestyles Sexual Health Feedback Data Analysis Q6 Do you feel the staff listened to you? Q7 Is the place where you go for your appointment convenient for you to get to? Q8 Do you think the support offered by the Health professional has helped you adopt a healthier lifestyle? Q10 What is your overall view of the service? Q11 Focus group NB N/A = Not answered
  31. 31. Healthy Lifestyles Sexual Health Data Analysis Q2 Q3 Q4 Q5 How would you rate the appointment times offered to you? How would you rate the greeting you received from reception staff/Health professional on arrival? How would you rate the approach ability and professionalism of the health professional? How would you rate the explanation of the programme and the information given to you? Q9 What is your overall view of the service? Excellent, 4 Excellent, 7 Excellent, 6 Excellent, 6 Excellent, 5 Good , 7 Good , 4 Good , 5 Good , 5 Good , 5 N/A, 2 0 1 2 3 4 5 6 7 8 Q2 Q3 Q4 Q5 Q9 Excellent Good N/A NB N/A = Not answered
  32. 32. BHIVA STANDARDS Standard 3 • Provision of outpatients treatment and care for complex co-morbidity- the IPU may assist with the early intervention to reduce the complex co morbidities and also help with the identification of comorbidities such as hyperlipidaemia. • Access to emotional support and smoking services •
  33. 33. Standard 6 • Psychological care – promotes emotional and cognitive wellbeing that will impact on the quality of care and wellbeing for people attending the service Standard 9 • Promote self-management – smoking cessation to support wellbeing- encouraging a self- management weight plan
  34. 34. Standard 10 • Participation of people with HIV in their care – empowering patients to be involved in the their care pathways . • The IPU helps patients to participate in identifying need and identify and select other areas of care that may help them to live well.
  35. 35. • By implementing an IPU we are working to ensure HIV patients have the best programme of health care • Supporting/encouraging self management to • Wrapping services around the patients, and ensuring the clients do not need to be referred onto other services • Reduction in client waiting time to access other health services Benefits of IPU
  36. 36. • Reducing admin time to book new appointments • Reduces DNA rates • Reducing time and money spend by healthy lifestyle services promoting services e.g. promotional material • Shared equipment and administration support Benefits of IPU
  37. 37. Future Plans • Single set of medical records • Expanding screening tool • Inclusion of additional services • Formalising outcome framework • Training for Sexual Health Staff to undertake the screening
  38. 38. QUESTIONS

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