Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning Tuesday 24 June 2014: 15 Hatfields, Chadwick Court, London

1. Better outcomes, better value
24th June 2014
THE HEALTHY LIVERPOOL
PROGRAMME – Joining Up Services
NHS Liverpool Clinical Commissioning Group

2. Liverpool CCG
498,000 Patients
18 Neighbourhoods
94 Practices
3 localities
1 Organisation

3. CONTEXT
• Poor health outcomes
• Growing demand
• Congested provider landscape
• Estates changes and opportunities
• Local authority cuts
CONTEXT

4. Vision
Provides a
sustainability
model of care
Improves &
maximises
health
outcomes
Delivers first
class quality
care
Outcomes Characteristics Programmes Settings
Securing
additional years
of life
Improving quality
of life for people
with LTCs
Reducing
Emergency
Admissions
Improve
experience of
hospital care
Improve experience
of outside hospital
Fully engaged
citizens
Wider primary
care at scale
Modern model of
integration
High quality urgent
and emergency care
Highly productive
elective care
Concentration of
specialist services in
centres of excellence
Prevention
Neighbourhood
Teams
Specialist
Community
Services
Hospital Services
Mental Health
Healthy Ageing
Long Term
Conditions
Children
Learning Disabilities
Cancer

5. Outcome
Ambitions
Securing additional
years of life for the
people of England with
treatable mental and
physical health
conditions
Improving the health
related quality of life of
the 15 million+ people
with one or more long-
term conditions,
including mental health
conditions
Reducing the amount
of time people spend
avoidably in hospital
through better and more
integrated care in the
community, outside of
hospital
Increasing the
proportion of older
people living
independently at
home
following discharge
from hospital
Increasing the
number of
people having a
positive
experience of
hospital care
Increasing the number
of people with mental and
physical health conditions
having a positive
experience of care outside
hospital, in general
practice and the
community
Making significant
progress towards
eliminating
avoidable deaths in
our
hospitals caused by
problems in care
Outcome Ambitions

6. Strategic Outcome Ambitions by 2018/19
Reduce life years lost by 24.2%
Improve quality of life for people with long term
conditions from the second worst in the country at
65.3% to 71%
Reduce avoidable emergency admissions by 15.3%
To improve hospital patient experience to average of
top 10 CCGs
To improve out of hospital patient experience to average
top 5 CCGs

7. Why Mental Health
• Premature Mortality – excess mortality for SMI SMR 425.8
• High prevalence of common mental health problems in LTC
• Prevalence three times higher for SMI for Diabetes and BMI
40+, twice as high for other LTC
• Lower proportions under control or on treatments e.g.,
anticoags
• 1 in 3 GP presentations for mental health issues
• Significant pressures on secondary care
• Integration of physical and mental health and focus on causes

8. New model for mental health
4.Hospital Based
3.Community based specialist
service
2.GP & Neighbourhood
1. Prevention &
Self Care
Skilledandconfidentworkforce
StrongcommissioningpartnershipwithLCC
Cultureofcollaboration
Shorter lengths of stay
New assessment
and care service Integrated care model that
focuses on recovery, personalised
care and independence.
Delivered from x4 new community
recovery
and wellbeing centres***
Primary care team
extended to include
mental health
practitioners,
psychological
therapists, benefits
advice workers
Community development initiatives
include advocacy, peer support,
counselling, bridgebuilding,
timebanking, community learning, all
accessible through a new directory
for mental health and well-being.
Assisted signposting for people who
don’t have access to the internet
Access to Recovery
Campus and similar
One gateway into both
psychological
therapies and wellness &
preventative services= no
‘wrong door’ for referrersPeople with long term
conditions
and other risk factors
have
access to a range of
psychological
treatments
Clinical liaison and collaborative
working across all steps
and all providers
One point of access to all local mental health services 24/7
Street triage & reduction in inappropriate
presentations & use of section 136
Fast response for
urgent needs
1 – 3 week
response
for routine
needs
Modern accommodation with single
en-suite rooms
Centre of excellence for acute mental health
care PICU and Section
136 suite at Clock View
Fewer people treated
out of area
Fewer admissions
Strongserviceuserandcareparticipation
Shiftfrompaternalismtoco-production
Sustainablethirdsectorcontribution
Improved
access to
psychological
therapies for
people with
SMI
15% of people with anxiety &
depression have access to
psychological therapies & 50%
recovery

9. Working with complexity
Low income,
debt,
isolation
Ill health
Mental
distress

10. Liverpool primary mental health care strategy for adults
• Psychological: all services will
operate as a single system across
steps and providers
• Practical: advice on prescription
• Social: peer support, education
& employment support+++
• Physical: integration of mental
and physical health care

11. Collaborative working CQUIN – secondary mental
health care
• Liverpool-wide system of liaison and collaborative working
between primary and secondary mental health care
• 5 CMHTs, 5 named liaison workers
• Linking systematically to practices & neighbourhoods
• Identification and treatment of the physical health care needs
of people with SMI and LD
• Shared learning & capacity building
• Supported by a community of practice
• Y2 includes improvements to discharge planning & LD liaison,
reduction in MH presentations at A & E

12. Collaborative working CQUIN - psychological
therapies
• System of liaison and relationship development with primary
care and secondary care
• Identification of people with LTCs who have co-morbid
common mental health problems.
• Increased access to psychological therapies by people with
LTCs
• Focus on diabetes year 1
• Test out collaborative care approaches to joint assessment and
joint working eg COINCIDE model
• Primary care should feel that there is only one system of
liaison

13. The pyramid of psychological
need accompanying long term
conditions
LEVEL 1
General difficulties coping with illness and the perceived consequences of this for the person’s
lifestyle, relationships etc. Problems at a level common to many or most people receiving the diagnosis
LEVEL 3
Psychological problems which are diagnosable / classifiable,
but can be treated solely through psychological interventions,
eg mild and some moderate cases of depression, anxiety states,
obsessive compulsive disorders.
LEVEL 2
More severe difficulties with coping, causing significant anxiety or lowered
Mood, with impaired ability to care for self as a result
LEVEL 4
More severe psychological problems that are
diagnosable and require biological treatments,
medication, and specialist psychological interventions
LEVEL 5
Severe &
complex
mental illness/
disorder requiring
specialist mental health
intervention(s)

14. Stepped model of care for psychological
therapies
STEP 1
GP: ACTIVE MONITORING
DIRECTORY OF MENTAL HEALTH & WELLBEING SERVICES
HEALTH TRAINERS
ASSERTIVE IDENTIFICATION OF PEOPLE WITH MULTIPLE RISK FACTORS: SMI,
LTCs, BME,
ADVICE ON PRESCRIPTION
MENTAL HEALTH & PSYCHOLOGICAL LIAISON
STEP 2
INTEGRATED GATEWAY
PWP (PSYCHOLOGICAL WELLBEING PRACTITIONERS)
ACTIVE LISTENING, ASSISTED SIGNPOSTING & DIRECT ACCESS TO ADDITIONAL (non-clinical)
SUPPORT
CLINICAL ASSESSMENT & LIAISION
TREATMENT: GUIDED SELF HELP; BRIEF INTERVENTIONS; CARE PLANNING
COLLABORATIVE CARE
STEP 3
HIT (HIGH INTENSITY THERAPIST)
TREATMENT AT STEP 3
CBT, IPT, DIT, CCfD, CfC, EMDR etc.
STEP 4 SPECIALIST THERAPISTS
TREATMENT AT STEP FOUR
ADDITIONAL
SUPPORT
CLINICALLIAISON
ACROSSSTEPS

15. Next Steps to a Better Model for Mental
Health in Liverpool
Mental Health Transformation Board
Inter Agency Working
Better Use of Intelligence
Innovation
Commissioning for Outcomes