Item 5 - London Clinical Senate Council 29 November 2016 Improving - - PowerPoint PPT Presentation

Improving physical health for individuals living with serious mental illness

The Stolen Years Project

Dr Mary Docherty

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Item 5 - London Clinical Senate Council 29 November 2016

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• The London Health Commission identified the need to care for the most mentally ill in London

so they live longer, healthier lives. Despite knowing that people with mental illness are less likely to access physical healthcare little had been done to proactively address it.

• To improve the care of those living with serious mental illness (SMI), the Better Health for

London report (2014) set the goal with the leaders of all the mental health trusts in London to reduce the gap in life expectancy between adults with SMI and the rest of the population by 10% within 10 years. Improving the mortality gap is also a key focus nationally, recent national reports and strategies

• utlining this include:
• The coalition government’s No health without mental health (2011), the annual report of the

Chief Medical Officer (2013), the BMA’s report on achieving parity of outcomes (2014), The Kings Fund’s Bringing together physical and mental health (2016), The Academy of Medical Royal Colleges’ Working across medicine to improve the physical health of people with severe mental illness (2016).

• The NHS Five Year Forward View (2014) outlined the need for NHS to break down the barriers

in how care is provided between physical and mental health and for patients with mental illness to have their physical health addressed at the same time.

• The Five Year Forward View for Mental Health (2015) outlined the requirement for 280,000

more people living with severe mental illness to have their physical health needs met by 2020/21 by increasing early detection and expanding access to evidence-based physical care assessment and intervention.

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Prevention Gaps- Inequality and the Health and Well being Gap

• In the UK men with SMI are estimated to die 8–15 years and women 7–18 years earlier than those without mental
• disorders. The overall life expectancy or mortality gap has been estimated at between 10-25 years. This is a three-fold

risk of premature mortality compared with the general population.

• The vast majority of preventable deaths are due to chronic physical health conditions such as cardiovascular,

respiratory and metabolic disease. Individuals living with SMI relative to the general population have double the risk

• f obesity and diabetes, three times the risk of smoking, hypertension and metabolic syndrome and five times the risk

for dyslipidemia. Diagnosis and Treatment Gaps- Inequity in healthcare utilisation and the Care and Quality Gap

• Nearly half (46%) of people with SMI will have a long-term physical condition yet the evidence base for treatment

inequalities extends across a range of conditions: hyperlipidaemia, cancer, diabetes, arthritis, stroke, surgical procedures including lower rates of surgical procedures for cardiovascular disease.

• Individuals living with mental health have three times more accident and emergency attendances and five times

more unplanned inpatient admissions the the general population with significantly higher length of stays. Health outcomes gaps- Inefficiency and the Cost and Efficiency gap

• The estimated economic cost of smoking among people with mental ill health was £2.34 billion in 2009/10.
• From emerging London based analysis, costs of physical health co-morbidity for those living with SMI between

doubled and quadruple care costs. This mirrors international data where co-morbidity with physical health conditions added between 20% to 90% to costs. When further co-morbidity with substance misuse is added, costs have been estimated to escalate dramatically with up to a further tripling of costs.

• 5 year survival rates for some LTCs are lower in individuals living with SMI than the general population - 22% of

people with coronary heart disease and SMI had died compared to 8% of people without, 19% of people with diabetes and SMI had died compared to 12% of people without, 28% of people who had suffered a stroke and had SMI had died compared to 12% of people without SMI.

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The he ca case se for

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The Stolen Years programme summary

• A large component of the mortality gap is due to preventable and treatable physical health conditions. Individuals living with SMI

experience gaps in prevention, diagnosis, treatment and treatment outcomes for physical health risk factors and conditions. They fail to benefit equally from current configurations of health care services providing primary, secondary or tertiary disease prevention.

• Progress in achieving change has been slow due to the complexity of the determinants of excess mortality and morbidity and lack
• f a systematic cross sector approach targeting the primary drivers. Lack of clarity about roles and responsibilities and system

related barriers that inhibit joint accountability perpetuate the challenge.

• There is significant variation in care available to support the physical health of those living with SMI but where pockets of excellent

practice exist there is an absence of a co-ordinated effort to sustain and scale up this progress.

• Despite consistent service user and carer feedback , the request for personalisation, holistic care and responsive services that flex

according to individual preferences and optimise both health and non health based community approaches has not been met.

• In late 2015 the Stolen Years programme engaged with key stakeholders from across mental health, social care and physical health

sectors to identify priorities and understand the key challenges in addressing the mortality gap in London. A comprehensive scoping exercise and literature review was conducted to identify gaps and opportunities. Hundreds of service users contributed to identifying priorities and recommendations. A mapping exercise of all current sector challenges was conducted. It was evident that despite the existence of high quality reports with robust recommendations there was a lack of guidance on how to deliver these changes.

• Where improvements in outcomes are contingent on multiple different activities in and between different sectors it was agreed

that strategic guidance on commissioning and implementation were needed.

• A programme of work was agreed to support closure of the implementation gap. A support tool would be developed to deliver

evidence based or consensus activities in different sectors and settings addressing the key drivers of premature mortality. Building on current progress and system assets, a systematic approach would be taken that supported evaluation, scale up and iterative closure of evidence gaps whilst tracking the impact on key outcomes over time. Key clinical leadership networks have been created and linked up across sectors to support delivery.

• The programme is now commencing consultation on the draft tool kit. Feedback on its format and content is being sought

alongside identification and clarification of roles, responsibilities and opportunities to support delivery and implementation.

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The Stolen Years Strategy Development of a whole system quality improvement framework to close the mortality gap

• A cross sector strategy was developed to address the current variable, uncoordinated and frequently unevaluated

efforts to close the mortality gap and to optimise key existing policy and other system levers and enablers.

• Priority, evidence based activities to address the key drivers of the mortality gap were identified from the literature

review and whole system consultation.

• These were broadly grouped into efforts or interventions that target key drivers of the mortality gap namely health

risks and behaviours, healthcare utilisation and treatment outcomes.

• The recommended activities and guidance on how to complete them are ambitious in raising standards but

compatible with economic constraints and responsive to concurrent system wide work to develop STPs and deliver the Five Year Forward View.

• These activities were then mapped to their intended outcomes and potential indicators to enable tracking of

progress in short, medium and longer-term goals towards closure of the mortality gap. e.g. changes in smoking rates, changes in smoking related disease burden, changes in premature deaths from smoking related conditions.

• The strategy serves as a quality improvement framework for commissioning and provision to deliver multi level

improvements in care for those living with SMI.

• It can be used as a whole system map to enable planners and providers in different parts of the health and care

system to see how small changes and improved pathways and relationships across sectors can fit together on aggregate to accelerate efforts to close the mortality gap. The early strategy outline was delivered to STP planners in March 2016 to facilitate forward planning and accommodation of these service improvements in each London region’s 5 year plan.

Short-term

PLAN - Benchmark unmet need, asset map, collaborate & plan strategy & embed indicators

Medium-term

DELIVER adjusted targeted & tailored evidence based interventions, pathways & services

Long-term

EVALUATE, adjust, refine & scale up effective interventions or pathways Establish baseline & gaps

Baseline measures:

• Health risks/ behaviours
• Healthcare utilisation
• Health outcomes

Increase coverage & uptake from appropriate and accessible interventions Measure changes in healthcare utilisation:

• Measures of access
• Measures of uptake

Change health risks/ behaviours, healthcare utilisation & health

• utcomes

Measure changes in

• utcomes:
• Health risks/ behaviours
• Disease rates

Prevention Primary Care Mental Health Services Acute Trusts

Map activities to intended outcomes Allocate appropriate measures optimising existing data

MEASURE MEASURE MEASURE

Reduce the Mortality and Disability Gap

Use evidence & system wide scoping to recommend priority core activities to address them in and across sectors Identify primary drivers & determinants of the mortality gap and service user priorities and recommendations

1 2 3 4 5 6 Deliver recommended activities optimising existing system

assets & levers & enablers

DELIVER DELIVER DELIVER DELIVER

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Plan, deliver and evaluate activities using a QI approach to develop, adjust or scale provision to meet service users’ needs

Evaluate impact over time

A whole system commissioning strategy was developed and used as a framework for the implementation toolkit

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Development of a toolkit to implement the strategy

An implementation support tool was then developed around the strategy to support planning and delivery of the recommended activities.

• It was constructed to reflect current configurations of the health and social care system and demarcations between sectors whilst

also accommodating the emerging newer models of care and payment mechanisms that promise to support improved integration or coordination over the coming years.

• Used as whole it provides a strategy and implementation plan and implementation guidance for geographical areas to plan, deliver

and evaluate a systematic cross sector approach to improve outcomes for those living with SMI over the next 5 years.

• It is also designed to be accessible and used by sector specific commissioners and providers to address particular areas of concern.
• Key roles and responsibilities in planning, delivery and assurance are highlighted to improve clarification about how the whole

system can work together to improve outcomes. Implementation guidance included in the toolkit was developed around three core principles:

• The need to use existing health structures, systems and community resources to integrate effective interventions for the physical

health of those living with SMI into routine care.

• A commitment to a data driven approach whereby health planners assure the support and investment needed to develop, collect

and interrogate composite indicators (e.g. structural, process and outcome measures) relating to the determinants of the mortality gap and efforts to address them. This is necessary to drive sustainable improvements in this area and close evidence gaps.

• The embedding of service user and carer perspectives and recommendations in all improvement plans. This is necessary for the

translation of the evidence on effective interventions into improved outcomes. Many current inequalities, inequity and inefficiencies relate to current configurations of care not being responsive or attuned to the needs of those living with SMI. In order for them to benefit from care, providers need not only to provide guideline consistent care, it needs to be adjusted, available and delivered in a way that those who it is designed for find it accessible, acceptable and useful.

Information to support planning & delivery

Key evidence summaries & data & service user priorities Current & future states case study examples Current system / area challenges from London scoping and mapping Interfacing policy, levers & work streams to

• ptimise plans

& maximise impact

PLAN

• Key high impact activities in each sector
• Roles and responsibilities for planning and

delivery assigned

Short-term Plan Establish baseline provision, need & assets. Collaborate & strategy Medium-term Deliver Intervention, specification or pathway Long-term Evaluate & adjust Review coverage, uptake and benefit

RAG: Self Assessment Tool A task-list to help complete each sector activity is generated which is responsive to local progress

PREVENTION

Stop smoking services Co-existing substance misuse pathways Health Promotion Programmes

PRIMARY CARE

CVD screening & interventions Enhanced integrated models of care

MENTAL HEALTH SERVICES

Preventative role Liaison role

ACUTE TRUSTS

Mental health trust interfaces/pathways U&EC Adjustments to elective care

Levers & Enablers- Digital & data, workforce, commissioning and contracting

High level cross sector overview of a 5-year plan and core activities Tools to support delivery & evaluation

Case examples- getting the basics right and gold standard innovation Service evaluation templates Expert produced care pathways and standards Service specification checklists & standards

Sector specific priority activities

Structure and content of the implementation tool kit

Benefits realisation map

A key focus is provision of guidance, standards, checklists, tools and examples to support effective & efficient cross system working

Care pathways and service specification checklists are designed to be applicable to all models of care

Pathways

Focus on improving pathways between care sectors and the community

Roles and Responsibility

Focus on clarification of roles and responsibilities between sectors and settings and develop new roles

Reciprocity

Focus on developing responsive & receptive interfaces

Communication

Focus on improving communication between care sectors, settings and the community

Relationships

Focus on improving culture, contact and associated standards and opportunities for innovation

Commissioners:

• provide optimal

environment for action plans

• assure delivery
• f action plan

Providers:

• make changes

in delivery of patient care as per action plan

• report against

delivery of action plan

Areas of Joint Working Foundations to support coordination, integration and parity

CCG(s)

• Agree data sharing standards and requirements with local authority (LA) for

JSNA – SMI health risks/ behaviours, HC utilisation and health outcomes. Embed data requirements in contracting. Report on data to: STP delivery board, NHSE London, CQC & MONITOR. Support development of interoperable systems to improve data, efficiency and quality of care.

• Commission services and remunerate based on calculations of population

need from linked data sets

• Assure commissioning meets equality and parity test: all commissioned

services benefit those with SMI equally and address mental health needs equally to physical health needs. Deliver reasonable adjustments across primary care (health checks and enhanced MH/ SMI services), acute & community trusts (liaison services), public health/ LA preventative interventions or pathways

• Incentivise or support cross sector provider workforce strategies to address

physical and mental health literacy e.g. sector level training schedules, cross sector staffing, inreach, outreach or new care pathways.

• Contract to support cross sector pathway development e.g. co-ordination,

collaboration & integration

• Embed clear pathways for preventative interventions or well being resources

across health and social care pathways and care settings. Health and Well Being Board(s)

• Agree indicators and data sharing standards and

requirements between CCG and LA for JSNA – SMI health risks/ behaviours, HC utilisation and health

• utcome.
• Optimise public health expertise for data led

population planning approaches

• Assure commissioning meets equality and parity

test: all commissioned services benefit those with SMI equally and address mental health needs equally to physical health needs

• Health & well being strategy (HWBS) include:

targeted, tailored or reasonably adjusted health promotion programmes, well being interventions available and coordinated across sectors and settings; stop smoking and substance misuse screening, referral and treatment pathways available across sectors and settings adjusted with harm minimisation and extended treatment periods for those living with SMI Clear agreed pathways with reasonable adjustments for referral, assessment and treatment for 1°,2°,3° disease prevention Preventative strategies optimising community assets available & coordinated across sectors & settings, adjusted or targeted & tailored for those living SMI and linked to CJS / DWP / housing and well being initiatives Joint accountability for population planning and cross sector prevention strategies

Commissioning activities

Local Authority and Public Health mental health lead/ champion HWBB

• Systematic equality and parity

assessment of local prevention and well being strategies, resources and facilities incl. NHS health check

• Smoking cessation strategy links

across health sectors and care settings meeting population need with tailored referral and delivery models.

• Substance misuse pathways run

seamlessly across health and care sectors addressing physical heath risks and needs.

• Delivery plans optimise community

assets incl. public and private and VSFOs and SU led organisations

• Signposting and navigation systems

function across health care settings and CJS/ DWP/ housing supporting uptake of community based health promotion programmes, stop smoking services, substance misuse services, well being resources and individual placement and support (IPS) Acute/ Community Trust(s) MH Lead  SMT CCG

• Coding and data quality

schedules allow tracking

• f SMI HC utilisation,

treatment rates and

• utcomes
• Tiered levels of mental

health literacy and skills- training schedule and workforce strategy incl. pharmacy & allied health professionals (AHPs)

• Provision of liaison

services for acute or elective secondary physical health care

• Rapid access service or

response for MH Trusts- advice/ referral/ review

• Reasonable adjustments

to elective or planned care pathways e.g. adjusted, inreach,

• utreach.
• Substance misuse liaison

services linked to MH Trust Mental Health Trust(s) PH Lead  SMT CCG

• Monitor indicators of smoking,

substance use and obesity rates, completion of physical health checks, excess U75 mortality & employment rates.

• Tiered levels of physical health

literacy and skills- training schedule and workforce strategy

• incl. pharmacy and AHPs
• Organisation structure,

infrastructure and strategy to deliver health promotion and screening

• Assure uptake of annual primary

care physical health check and support concordance with recommended interventions

• Optimised prescribing standards
• incl. monitoring and service user

education

• Smoke free trusts, NICE smoking

cessation & drug & alcohol screening & treatment pathways

• IAPT SMI with physical health

competency Primary Care CCG MH Lead CCG SRO

• Data systems monitoring

diagnosis, treatment and

• utcome gaps and measures
• f multi morbidity
• Tiered levels of mental

health literacy and skills- training schedule and workforce strategy incl. pharmacy and AHPs

• Mental health care provision

leadership and oversight through CCG, federation and networks

• Deliver annual physical

health check with appropriate quality markers and/ or enhanced models of primary mental health

• Deliver NICE guidance

standards in smoking cessation, obesity & drug & alcohol prevention and treatment

• IAPT SMI with physical health

competency Joint accountability for delivering screening and 1° and 2° disease prevention Joint accountability for establishing accessible & adjusted heath promotion programs, stop smoking services, substance misuse interventions and pathways that prevent the development of needs

Provider activities and reporting lines

Development:

• The programme is continuing expert consultation on the draft tool kit core content pending broader consultation

commencing early December. Feedback on its format and content is being sought. Delivery:

• System wide consultation is on-going to help identify key opportunities to embed the toolkit in the system e.g.

suggesting high level STP delivery board actions, interfaces with The Mayor’s Inequality Strategy, identifying key roles and responsibilities in supporting uptake and delivery.

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Next steps

1) The core concept underpinning the Stolen Years approach is that improvements in quality of care and translation

• f efforts into improved outcomes and efficiency must be driven by a commitment to indicators and data that

capture the interactions of health and care provision on different components of the mortality gap. Measures of health risks and behaviours, healthcare utilisation and health outcomes can be improved from existing data sources contingent on the commitment to invest in this. A further challenge is the relative poverty of indicators capturing the quality of interfaces and co-ordination across care sectors.

What would the Senate Council recommend are the opportunities or next steps to address these quality issues?

2) Parity of esteem has been broadly defined as ‘valuing mental heath equally to physical health.’ More fully, when compared with physical healthcare, mental healthcare is characterised by: equal access to the most effective and safest care and treatment, equal efforts to improve the quality of care, the allocation of time, effort and resources

• n a basis commensurate with need, equal status within healthcare education and practice, equally high aspirations

for service users and equal status in the measurement of health outcomes. The Health and Social Care Act 2012, the Care Act 2014, the Equality Act 2010 and associated public authority equality duty highlight respectively the legal duties to: address inequalities for those with protected characteristics; assure mental health is valued equally to physical health; prevent the development or deterioration of needs and promotion of well being. We have recommended that all commissioning meets equality and parity tests:

• all commissioned services benefit those with SMI equally to the general population
• all commissioned services address mental health needs equally to physical health needs

This work program identified some inconsistencies in the availability of liaison services that support the mental health needs of those with physical ill health.

What does the Senate Council consider are the implications for organisations providing acute and community services in ensuring mental health needs are valued equally to physical health needs?

Questions for the Senate Council