Mental Health and WellbeingTime

9.00 Registration and Refreshments

9.30 Introduction

Mike Wedgeworth – Chair of Third Sector Lancashire9.45 Mental Wellbeing for all: A vision for Lancashire

Stewart Lucas – Chief Executive Officer, Lancashire Mind

10.15 Prevention is better than cure or why mental health services are often too little too late

Warren Larkin – Clinical Director, Lancashire Care NHS Foundation Trust

10.45 Break and Refreshments

11.15 Discussion SessionQuestion and Answer Session

12.00 Closing Summary

Introduction

Mike WedgeworthChair of Third Sector Lancashire

H and WB Boards: What are they for?

• “A forum for key leaders from the health and care system in Lancashire to work together to improve the health and well-being of the local population and reduce health inequalities.”

• No money of its own

• Therefore persuasion!

Health and Well-Being Board

• Starting Well… Living Well... Ageing Well

• Better Care Fund

• The Six Shifts - Self Care and Technology- Joint Working- Narrowing the Gap- Prevention- Community Assets- Better ‘Flow’

Evolution

• Shadow H and WB Boards 2011

• Health and Social Care Act 2012 makes them statutory

• Parity of Esteem a legal requirement under this Act: to be achieved by 2020

• 23% of the Burden/ 11% of the budget

• Five Year View October 2014 “The NHS will take decisive steps break down barriers in the way care is provided…….between physical and mental…….”

• ‘Lancashire System Response’: Healthier Lancashire December 2014(Key objectives include achieving parity of esteem)

• Now measuring waiting times in just 2 MH areas: IAPT and early intervention following first episode of psychosis

Consensus!!

• Prevention• Out of Hospital services• Parity of Esteem• Person-centred care• Reform of primary care• New models of care• Workforce development• Digital Solutions• Social Value and Localism

HealNHS and Social Care Expenditure

“The Five Year Forward View”

October 2014: Simon Stevens, Chief Exec of NHS England

Encouraging Words

• “Too often, the NHS conflates the voluntary sector with the idea of volunteering, whereas these organisations provide a rich range of activities , including information, advice and advocacy, and they deliver vital services with paid expert staff...”

• We will seek to reduce the time and complexity associated with securing local NHS funding by developing a short national alternative to the standard NHS contract where grant funding may be more appropriate than burdensome contracts and by encouraging funders to commit to multiyear funding wherever possible”

Forward View page 14

Implementing 5 Year View

Triple Integration

Primary and SpecialistPhysical and Mental HealthHealth and Social Care

Mid February 2015

65 CCG’s take on full responsibility268 ‘two page’ applications for new models of care

Lancashire Health Expo

Mental Wellbeing for all: A vision for Lancashire

Stewart LucasChief Executive, Lancashire Mind

Mental Wellbeing for All:

A vision for Lancashire

Vision:Mental Wellbeing For All

Mission:To revolutionise attitudes

to mental health conditions and improve the mental wellbeing of everyone in Lancashire.

Strategy aims:Revolutionise attitudes,Challenge perceptions,

Alter provision

We believe:Making Lancashire a beacon

county for mental wellbeing will reduce the number of people

who experience a mental health condition

We believe:Ensuring that everyone living with a mental health is treated

as an equal will not only improve their lives but the lives

of everyone in Lancashire

This is a vision for Lancashire, this

strategy is a ‘Blueprint for Lancashire’.

Core beliefs drive, inform and fuel the

vision

Everyone can achieve and maintain mental wellbeing.

Mental wellbeing is as important a factor in someone’s life as physical

wellbeing.

Everyone has a central role to play in their own happiness and mental

wellbeing.

Mental wellbeing is far more than simply the absence of a mental health

condition and is associated with a range of social and health benefits.

High levels of mental wellbeing reduce the likelihood of someone

developing a mental health condition and plays a crucial role in how well

someone with a mental health condition manages it.

Resilience is our metal wellbeing immune system. Its what stops

each setback being a catastrophe

40% of everything that happens to us we control,

60% of things we don’t,resilience is what helps deal with

the 60%

Resilience is a combination of:Social Capital

Coping MechanismsPersonnel Wellbeing

Strategy has clear proposed Outputs.

We can not deliver all of these on our own.

We all have a role to play.

Resilience is our emotional bank account

We need to keep topping it up otherwise you’ll be bankrupt

Living with a mental health condition is not a barrier to having a full life and

playing a full and active role in society.

Whilst 1 out of every 4 people will at some point in their life experience a

mental health condition, less than one in a hundred will ever develop a

severe condition.

The focus should be on someone’s strengths and abilities and not on

their mental health condition. When barriers appear it is society as

opposed to the person’s mental health condition that creates those

barriers.

Living with a mental health condition is not a negative, bad or maligned

state of being.

Negative impacts come from societal attitudes and the inability to provide

or offer appropriate support.

Most mental health conditions can be effectively managed without specialist

clinical intervention.

10. Co-production and community ownership is central to the

development of any initiatives designed to either improve mental wellbeing or support people living

with mental health conditions.

Strategy has Fifteen Proposed Outputs.

We can not deliver all of these on our own.

We all have a role to play.

This includes: Building social connections /capital,Interactive online resource for mental wellbeing and resilience,Developing mental wellbeing and resilience skills,Resilience from an early age,Wellbeing in the workplace,

Awareness campaigns and promotion of mental wellbeing,Transitional personal support,Pre and Post Crisis support,Peer and Group Support,Remote access self-assessment,Targeted training to normalise attitudes to mental health conditions

Normalisation of societal attitudes to mental health conditions via campaigns and promotion,Reactive and responsive provision of information and advice,Altering the opinions of key decision makers, influencers and policy setters

Next Steps:1) Formation of a ‘Steering Group’;2) Creation of a delivery plan for each output;3) Use of existing structures to unify, interlink and drive all of our work;4) Make Lancashire the beacon county for mental wellbeing.

We are all changing people’s lives

Together we can change the world

Prevention is better than cure or why mental health services are

often too little too late

Warren LarkinClinical Director, Lancashire Care NHS

Foundation Trust

Third Sector Lancashire - 5th March 2015

"Prevention is better than cure or why mental health services are often too little, too late“

Dr Warren Larkin Consultant Clinical Psychologist

Network Clinical DirectorChildren and Families Network

Lancashire Care NHS Foundation Trustwarren.larkin@lancashirecare.nhs.uk

The affordability/ Sustainability challenge

Children and Families

£• Complexity• Expectations• Demand• Costs

Impact of mental disorder: Most lifetime mental disorder arises early adulthood

Age of onset of lifetime mental illness – predates subsequent illness by several decades

Source: Kim-Cohen et al, 2003; Kessler et al, 2005; Kessler et al, 2007

Mental disorder during childhood and adolescence in the UK:

£11,030 to £59,130 annually per child

Lifetime cost of a 1-year cohort of children with Conduct Disorder: £5.2 billion

Including costs of various agencies

• Health• Social services• Education• Justice

Costs of adult crime with history of CD

• £60 billion in England and Wales

• £22.5billion attributable to CD

• £37.5 billion to subthreshold CD

Evidence-based practice has substantial clinical & cost benefitsLittle & Edovald, 2012; Suhrcke, Puillas & Selai, 2008

Only 6% of current spending on mental health goes to services aimed at children and young people

Kennedy, 2010With permission P Fonagy

Invest to save - Preventative Interventions

• Social emotional programmes to prevent conduct disorder: £84 net saved for each £ spent

• Bullying prevention: £14 net saved for each £ spent• Parenting interventions for children with conduct

disorder: £8 for each £ spent • Early detection and treatment of depression at work

£5 for each £ spent• Early intervention for the stage which precedes

psychosis (Clinical High Risk State) £10

Sources: Knapp et al 2011, Campion & Fitch, 2012

What is Psychosis?

“Psychosis” is a term that refers to the presence of the following symptoms (APA, 1994):

• Hallucinations• Delusions• Disorganised speech/formal thought disorder• Grossly disorganised or catatonic behaviour

The W.H.O. Ten Country Study(Jablensky et al, 1992)

Benign course leading to full

remission

Worst Outcome

Group

NeverHospitalised

Taking neuroleptics throughoutFollow up

DevelopedCountries

37% 42% 8% 61%

Developing Countries

63% 16% 55% 16%

The ethical argument for EI in Psychosis…

Any long term ‘damage’ occurs within 3 years DUP is major public health problem Need youth friendly services to improve

engagement & reduce stigma Early experience of psychosis and

services/treatment has a formative impact Hope and optimism not therapeutic pessimism

The Early Intervention Paradigm

Early detection of

psychosis

Sustained intervention

through the ‘critical period’

Reducing treatment

delay

Why doeDoes EI Work? EIP work?

• CMHTs: 15% made full or partial functional recovery at 2 years.

• EIP workers in a CMHT: 24% made full or partial functional recovery.

• EIP with fidelity to PIG: 55% made full or partial functional recovery.(Focus on reducing DUP & early detection, prompt assessment, lower caseloads, access to high quality CBT & Family Interventions, clinical supervision, well

trained staff & recovery focus)

Does EI Work?

• Safety: Suicide and Homicide • Early Intervention Services have been shown

to be effective in reducing the risk of both suicide and homicide. Associated cost savings from the reduction of suicide risk (through costs to the NHS and the lost productivity of the deceased) are estimated at £481 in the first year of psychosis.

Does EI Work?

• Recovery: Employment

• Early Intervention Services have a positive impact on the retention and gain of competitive employment. McCrone et al. (2010) estimate that 12% of standard care patients will be in employment, compared to 35% of people supported by EIS.

Does EI Work?

• Economic evidence:• (LSE study suggests) reduced admissions to

hospital and use of CRHTs mean EI services are cheaper than standard care.

• 16k saving per Service User over 3 years typically

• That is a potential £119 million saving for the NHS and £125 million for the Exchequer.

Routine Enquiry about Adversity in Childhood(REACh)

What is it?Process by which we routinely ask individuals about Adverse Childhood Experiences (ACEs) during assessment process – with the intent to respond appropriately and plan interventions which longer term, reduce the impact on adult health and wellbeing

Background and Context

• Adverse Childhood Experiences are unfortunately common yet rarely asked about in routine practice (Felitti et al., 1998; Read et al 2007)

• In the English National ACE study, nearly half (47%) of individuals experienced at least one ACE with 9% of the population having 4+ ACES (Bellis et al 2014)

• There is a causal and proportionate (dose-response) relationship between ACE and poor physical health, mental health and social outcomes (Skehan et al 2008; Kessler et al, 2010; Varese et al 2013; Felitti & Anda, 2014)

• People exposed to 4+ ACEs die 20 years earlier compared with those with 0 ACEs (Felitti et al 2014)

• WHO & consider ACE a global PH imperative and data is being collected currently in 14 countries

Children and Families Network

ACE research (Felitti et al 1998) 9,508 Americans completed ACE questionnaire as part of standardised medical

evaluation

• Four or more adverse childhood exposures significantly increase the odds of a person:

• developing cancer (by nearly two times);• being a current smoker (just over two times);• having sexually transmitted infections (by two and a half times);• using illicit drugs (by nearly 5 times increased risk);• being addicted to alcohol (over seven times increased risk);• attempting suicide (over 12 times increased risk).

• The ACE study is still an ongoing collaboration between the CDC and Kaiser’s Dept of Preventative Medicine in San Diego

• More recent findings:• 6 ACES increased the risk of becoming a IV drug user by 46 times• 6 ACES increase the risk of Suicide by 35 times

WHO (Kessler et al 2010) – 52,000 participants from 21 countries

• The authors estimate that the absence of childhood adversity would lead to a reduction in:

• 22.9% of mood disorders• 31% of anxiety disorders • 41.6% of behavioural disorders• 27.5% of substance-related disorders• 29.8% of mental health diagnoses overall• 33% of Psychosis (Varese et al 2013)

The case for routine enquiry in mental health

• Waiting to be told doesn’t work…

• Victims of childhood abuse have been found to wait from between nine to sixteen years before disclosing trauma with many never disclosing (Frenken & Van Stolk, 1990; Anderson, Martin, Mullen, Romans & Herbison, 1993; Read, McGregor, Coggan & Thomas, 2006)

• Read and Fraser (1998) found that 82% of psychiatric inpatients disclosed trauma when they were asked, compared to only 8% volunteering their disclosure without being asked

• Felitti & Anda (2014) report a 35% reduction in doctor’s office visits & 11% reduction in ER visits in a cohort of 444,000 patients asked about ACEs as part of standard medical assessment in the Kaiser Health Plan

Learning from the REACh project

• Acceptable and feasible to routinely enquire in adults in a range of settings

• Staff need to understand why enquiry is important – skills in How are important but not sufficient for sustained practice change (Toner, Daiches and Larkin (2013); Davies, Larkin, et al, in preparation)

• Organisational and peer support is essential• Service Users welcome the enquiry• Workers report ACE-informed formulation increases

empathy and therapeutic alliance and can better target interventions and resources

Prevention is Better than Cure

‘Working in partnership to achieve a healthier future for the children, young people & families

of Lancashire’

• Two guiding principles:1. Prevention, Early Help & Early Intervention2. Continuous Improvements in Quality – better

care costs less (usually)

More NHS Reform?!• Will a new government mean further short term policy change

for the NHS? • Long-term commitments to policy are needed to deliver

transformational change

• Critics suggest the current culture of compliance and fear based on targets & performance management has led to a culture that does not incentivise prevention or improvements in quality of care

(How) We Can Improve Quality in MH Services & Save Money

• Quality Improvement appeals to the intrinsic motivation of staff• Sustainable improvements rely on our commitment to change

rather than compliance with external targets or standards• Massive variation in practice and outcomes – 50% of resources

expended in hospitals is waste (James, 2006)• Very little best practice evidence available• Best practice guidelines don’t guide practice - 50% of time at best

(McGlynn, 2011)• Continuous Quality Improvement: Shared Baseline Protocols-

Trialing this approach in each service line• No single best clinician/ practitioner, best practice lies across

practitioners and from these we pick out the elements of the best process

Conclusions

• Service Quality Matters in MH: evidence based interventions, delivered faithfully by well trained staff = better rates of recovery & lower costs

• A paradigm shift is required: invest in prevention, early help and early intervention to reduce future demand – invest to save…

• Fix the underlying problem or cause rather than temporarily ‘treating’ the symptoms

• Fix it once and break the intergenerational cycle of adversity and poor outcomes

Break

Discussion Session

Question and Answers