Geraldine Strathdee, parity of esteem, foundation trust network

1. Valuing Mental Health
Geraldine Strathdee, National Clinical Director of Mental Health, NHS England
October 16th 2013
Geraldine.strathdee@nhs.net

2. Valuing mental health in the NHS
Why does the NHS need to value mental health
 The impact of mental health on outcomes & costs
Parity between mental health & physical health
 what would it mean in practice
Fast tracking Value in the NHS
 what role can the FT network have in delivering it?
Asking for your narrative, brains, expertise, insights & leadership for England

3. The clinical and economic impact: 2012
Figure 1: Morbidity among people under age 65
Physical illness (e.g.
heart, lung, musculoskeletal, diabetes)
Mental illness
(mainly depression,
anxiety disorders,
and child disorders)

4. Why does the NHS need to value mental health
because mental ill health it is very common & it impacts on all outcomes
How common is mental
ill health
Common Conditions
Outcome impact
Primary care :
Depression & anxiety
Substance misuse
Children's conditions
Psychosis
Premature mortality : 15-25 years
Quality of life in LTCs
Recovery from illness
Patient safety
Alcohol & drugs
Depression & self harm
Dementia
Psychosis relapse
Premature mortality
Quality of life for LTCs
Recovery from illness
Patient safety
Patient experience
ADHD, ASD
Depression
Substance misuse
PD
Premature mortality
Psychosis
Neurodevelopmental
Substance misuse
Personality disorders
Complex multi axial
Premature mortality : 15-25 years
Quality of life
Recovery from illness
Patient safety
30-50% of daily workload
Acute care
40% of A&E in London
40% acute beds in London
50% acute outpatient clinics
Prisons & offenders
70-80% especially young men
Specialist mental heath
services

5. Mental health Value: depression and anxiety are the commonest healthcare comorbidities
& have major impact on Costs Chris Naylor, Kings fund
• Between 12% and 18% of all
expenditure on long-term
conditions is linked to poor
mental health and wellbeing –
at least £1 in every £8 spent on
long-term conditions.
180%
160%
% increase in annual per patient costs
(excluding costs of MH care)
• International research finds that
co-morbid MH problems are
associated with a 45-75%
increase in service costs per
patient (after controlling for severity of
physical illness)
140%
120%
100%
80%
Depression
Anxiety
60%
40%
20%
0%
http://www.kingsfund.org.uk/publications/long-term-conditions-and-mental-health

6. Commissioning for Value with partners
Life span care pathways focusing on downstream
Prevention &
health promotion
Early identification
& early
intervention
Timely Access to
services offering
choice, quality
outcome focus
Care at home or
in the least
restrictive
settings,
Crisis response
that is easy to
access & expert
Parity for people with physical & mental health
& in relationships with our service users
Integrated physical & mental health & social care
Where every contact is a kind enabling, coaching experience

7. Parity and equalities:
There is a disparity in the number of people with mental illness in
contact with services, compared to physical health, yet it is a major
cause of premature death & lives lived in distress and misery
26% of adults with mental illness receive care
92% of people with diabetes receive care
By condition….
Anxiety and depression
PTSD
Psychosis
ADHD
Eating disorders
Alcohol dependence
Drug dependence
% in
treatment
24
28
80
34
25
23
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Mental health problems are estimated to be
the commonest cause of premature death
Largest proportion of the disease burden in
the UK (22.8%), larger than cardiovascular
disease (16.2%) or cancer (15.9%)
People with schizophrenia die 15-25
years earlier
Depression associated with 50%
increased mortality from all disease

8. Prevention & Early intervention (Knapp et al, 2011)
highly effective treatments deliver value
For every one pound spent the savings are:
Parenting interventions for families with conduct disorder : £8
Early diagnosis and treatment of depression at work: £5 in year 1
Early intervention of psychosis £18 in year 1
Screening & brief interventions in primary care for alcohol misuse £12 Yr 1
Employment support for those recovering from mental illness: Individual
Placement Support for people with severe mental illness results in annual savings of
£6,000 per client (Burns et al, 2009)
Housing support services for men with enduring mental illness: annual savings:
£11,000–£20,000 per client (CSED, 2010).

9. Parity and premature mortality
Annual primary care QOF assessments of people with mental illness and those
with diabetes
Parity mapping between people with diabetes cf those with
Diabetes
Severe mental illness
SMI
%age assessed
No. patients
2,488,948
422,966
BMI ( Body Mass Index)
94.9%
79.4%
Cholesterol
96.1%
71.7%
HbAC1
97.5%
64.8%
BP
98.4%
84.1%
Total
97.3%
74.7
All with p<0.001

10. Commissioning for Parity :
what it means in reality
NHS Mandate:
what does it mean in practice in a GP’s surgery
• I was struck the other day when I saw a patient - who has been off work for 3 months waiting for
CBT. He is depressed and was just told to go on sick leave- no medication, just a referral for CBT in
the distant future.
• When I saw him , what upset me most was that if he had broken his leg, he would have been treated
asap, given rehab, told to go to work on crutches and would not have just been abandoned.
•
I want to make it impossible for mental health problems to be treated as second class illnesses with patients with treatable conditions languishing on waiting lists or worst still with no treatment at
all
Clare Gerrada, president of the Royal College of GPs
GPs are trying to do everything for everyone, too much of 21st Century care
is being provided through 19th century organisational models………
Professor Michael Porter is a world authority on strategy in business, & has spent the past decade
working in healthcare systems in dozens of countries.

11. Value based Integrated care pathways design:
commissioning for 60% volume, 60% spend; top 10%
Depression: is the most common MH condition in PC, acute, MHT, addictions, adolescents , veterans
• 30-50% of the daily work of GPs is MH related, especially depression
• Post graduate training for GPs, PNs, HVs, PC has been less available and tailored to PC mental health
• 78% of people who commit suicides have seen their GP in the month before the suicide
• Long term conditions: 70-80% of all healthcare & depression is the common comorbidity in 25-40%
• Untreated depression in COPD, CHD, cancer, stroke, diabetes, means patients die early & cost more
• 60-90% of those who misuse alcohol and drugs have depression
• Children and young people can be helped to develop resilience against depression
• Transport hub suicides are high in London and can be prevented
• RCGP & AHSCs are keen to develop new population & pathway based approaches to depression in all
sectors
The young people with psychosis & complex needs in high cost top 10% tier
• 95% patients are treated in the community, but 60% spend is on beds
• The Top 10% patients who account for 50-60% spend are not well recognized, helped by
caseload zoning and risk stratification
• Our detention rates are rising year on year despite CTOs
• 70-80% of those in MSUs and LSUs are young black men with long LOS
• Substance misuse is a very common comorbidity which triggers 60% high risk events e.g.
suicide , homicide, partner impact, but the commissioning & provision are not understood

12. What is NHS England doing to support commissioners and
providers move to an outcomes based value system
1. CCG: building capacity and capability in mental health
leadership
2. Primary care mental health
3. Care of people with psychosis : „industrializing‟ improvement
4. The acute care pathway and suicide prevention
5. Integrated physical & mental health care pathways
6. Mental health intelligence informatics network programme
• new model of information led commissioning & integrated provision
• Whole pathway commissioning of Tiers 1-4
Underpinning Value based commissioning and care
• Outcome measurement
• Service specifications aligned to PbR
• Reducing burden to free up time to care

13. “Crossing the Quality Chasm”
Ohio State Psychiatry Grand Rounds
12.05.2012
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14. Value in mental health NICE/SCIE
1. Right information
2. Right physical health care
3. Right medication
4. Right psychological therapies
5. Right rehabilitation, training for employment
6. Right care plan addressing housing, work, healthcare, self management
7. Right crisis care
Mental health : Is the problem that we have no evidence or value based guidance?
 Mental health has over 100 NICE Health Technology appraisals, NICE
guidelines, Public health related guidelines and Quality standards…..
 The problem is not lack of guidance
 The problem is that we have not focused on how we learn and disseminate from
those that can and have implemented
Can the FT network lead a new NHS Change model?
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15. To FT leaders
• Can you help build a very different comms. platform
• Narrative stories of recovery and success
• Narrative stories of how mental health has led the health services in the world in
our deinstitutionalisation & community care……..
• Can you put on all your websites service specifications of your services to
prepare NOW for choice and PbR
Can you lead for transformation to make England's services the best in the
world for our wonderful service users:
• Can you plan for one point of access for all crisis response streamlining from
current 12 access points
• You have brilliant services, but we have wide variation : to upscale and
industrialize improvement PLEASE can you share good practice & have fun
We have enough brains, energy & track record in collaboration….let’s use it
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