Epidemiology of Mental Health in Brighton and Hove

• Population approx 250,000

• High levels of self harm

• Consistently in top three suicide rates and drug related deaths in the country

• 2480 patients with a diagnosis of psychotic illness/bipolar affective disorder

SMILES background to development

Reconfiguration of MH services in 2008, with Community Mental Health teams bring divided in to Access and Recovery services

This was to incorporate the Recovery and well being agenda and was also in response to the introduction of IAPT

Patients who didn’t meet the threshold for Recovery services but still had severe and enduring mental health problem, were increasingly being discharged to primary care

Looked at what was happening across the city for QuOF

Huge variation in physical health templates – almost all did BMI, BP, Smoking , Alcohol, Lipids. Less good results for side effects, diet, exercise or sexual health

Absence of risk screening and recovery planning on annual care plan - only 30% asked about suicide risks

No care plans recorded as being given to patient

• ..and more detail,

• ..and more detail,

• ..and more detail until we covered everything.

• No nasty surprises!

Eligibility for the LES

Practice must score 85% for MH9 [annual review including health promotion]

Patients 18 + in stable accommodation and registered with a GP participating in the scheme

Diagnosis of SMI including schizophrenia, bi polar affective disorder and personality disorder

Low risk, or omnipresent and well managed risk. Patient, GP and consultant all in agreement for

transfer of care

Eligibility for the LES

Practice must score 85% for MH9 [annual review including health promotion]

Patients 18 + in stable accommodation and registered with a GP participating in the scheme

Diagnosis of SMI including schizophrenia, bi polar affective disorder and personality disorder

Low risk, or omnipresent and well managed risk. Patient, GP and consultant all in agreement for

transfer of care

Two tier approach Level two

All patients are discharged from secondary care to maintain through put in services

Annual care plan and bi annual review with Nurse and GP using standard template

Reviewed by Liaison Nurse at least every twelve weeks

Referral from primary care to CRHTT if needed Fast track back to recovery if mental health

becomes unstable

Barriers to usual discharge processes identified in primary care

GPs (and sometimes service users) did not understand why patients were being discharged

Sometimes not clear plan of care for patient Sometimes no relapse signatures /risk

management plan GPs unfamiliar with mental health medication,

and apprehensive about responsibility for this patient group

Limited resources to support with medication issues and risk management issues

Fractured relationships between primary and secondary care

The client

• 20 year history of psychotic disorder

• Stable on treatment

• Insight, motivation, confidence

• Lives alone in one bed flat, sub let scheme

• Supportive family

• Discharged to SMILES

• Worked with SMILES for 2 years

The work we do

• Recovery planning

• Wellness and Recovery Action Plan

• Work and learning, part time work, relationship, needing to move home

• Regular meetings with SMILES nurse

• 6 monthly supported GP reviews

• Physical health monitoring at GP surgery

SMILES drop in group, The Recovery Star

A closed group for SMILES users once a monthRecovery Star Model10 Ladders of changeEach session focuses on a area for change Open and supportive discussionPersonal experience of servicesRehearsing the plan for difficult times

What would we do differently? It was a very detailed spec

– to the point that we got a bit lost in it at times!

More service user participation and consultation earlier in the process -although this hasn’t been problematic

Lots of time spent scoping and initial patient lists soon became defunct in terms of suitability

Ways forwards

Physical health template now universally available for all GP IT systems and recommended by CCG for standard QuOF template for all practices

Planning to pilot and introduce Clozapine monitoring as part of shared care agreement under LES.

Opened Clinical Network Mettings to all practices and invited staff form Recovery

Looking to include more practices

Ways forward May consider skill mix/peer support if we

grow the project Broadening the eligibility by

diagnosis/referral route Considerations about how to support

clients in practices that don’t want to get involved,

?Shared care arrangement for patients on depots who are still under secondary care