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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
2
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
3
• 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
5
• 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
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