Portsmouth Mental health and wellbeing summit June 2014

Mental Health Summit for
Portsmouth
Janet Maxwell, Director of Public Health
5th June 2014

www.portsmouth.gov.uk
Mental Health and Wellbeing
• No Health without Mental Health - 2010
• Everybody’s business
• Individuals, families, communities, schools, workplaces
• Not just NHS commissioned MH services
• Needs to be embedded in all our work
• Prevention, treatment, recovery
2

5 Ways to Wellbeing
3
Connect.
.
Be
Active..
Take
Notice..
Keep
learning.
.
Give..

Mental Health resilience
• Life course approach – Marmot
• Understanding of links with social inequalities
• Children and Young people
• Adults, Families, Older people
• Start early with prevention and early intervention
4

Young people
• Parenting and early years
• School years
• Entry to work
• Sense of value and purpose
• Educational and work opportunities
• Relationships
• Risk taking behaviour
5

Mental health resilience
• Early years
• School setting
• Workplace
• Safer resilient communities
• Environment
6

Inequalities
• Lead to poor mental health
• Result from poor mental health
• Inequalities in access and provision and experience of
services
7

Recovery model
• Towards a vision of recovery –
William Anthony 1993
‘growing beyond the catastrophe of mental illness and
developing new meaning and purpose in one’s life …’
‘taking charge of one’s life even if one cannot rake
complete charge of one’s symptoms.’
‘developing stronger social relationships, skills for living
and working, improved chances in education, employment
and housing.’
8

No health with out mental health
6 key objectives:
• More people will have better wellbeing and good mental
health
• More people with mental health will recover.
• More people with mental health problems will have good
physical health.
• More people will have a positive experience of care
and support.
• Fewer people will suffer avoidable harm
• Fewer people will experience stigma and
discrimination
9

Links to other strategies
• Shaping the Future
• Education and jobs
• Flourishing city of culture
• Housing, planning, transport, environment
• Health and Wellbeing Strategy
• Integrated health and social care – Children and Adults
10

Implementation plan – July 2012
• Translates NHwMH strategy into action
• Parity of esteem
• Practical ideas of how organisations work together
• Builds on outcome frameworks
• Create dashboard to evaluate outcomes
11

Local action
• CCGs, primary care, community and acute providers, LA
– public health, adults and children services, H&WBB,
Healthwatch, Scrutiny, Community groups, schools and
colleges, employers, CJS, housing.
• Needs assessment
• H&WB Strategy and priorities
12

National action
• Mandate to NHSE
• Payment by Results
• Links to other strategies- suicide, alcohol, veterans,
equality
• PHE - better data and evidence, campaigns
• Education, training, professional bodies
• Work with national organisations – Mind, Rethink – Time
to Change
13

Closing the Gap Jan 2014
Priorities for essential changes in MH
Identifies 25 aspects where we can make tangible changes
in the next 2 years:
• Increasing access to MH services
• Integrating physical and mental health care
• Starting early to promote mental wellbeing and prevent
mental health problems
• Improving quality of life for people with MH problems
14

15
6. IAPT for children and YP
7.Payment reflect quality and
outcomes
8.Adults to have right of choice
9.Reduce restrictive practice
10.Friends and Family Test
1.Service quality, recovery, need
2.Information revolution
3. Waiting time limits
4.Tackle inequalities
5.Increased access to IAPT
16. Support new mothers
17..Support Schools to identify
early
18.Transition from CAMHS to
adult services
19.Longer healthier lives
20.Recovery approach in
homes
21.National liaison and for
offenders
22.Support for victims of crime
23.Employment support
25.Support for unemployed to
work
26.Stop discrimination
11.Inspection to identify poor
quality
12.Better support for carers
13.Integration of MH and PH care
14.Self harm response at frontline
15.Crisis response 24/7

Next steps
• What are we currently doing well?
• Where are the gaps?
• How can we address these?
• How will we know things are better?
• How can a city wide MH Alliance help?
16

Mental wellbeing – needs assessment
Mental Health Summit, May 2014

www.portsmouth.gov.uk18
Barton H and Grant M (2006). A health map
for the local human habitat. The Journal of
the Royal Society for the Promotion of
Health. November 2006 126:252-253

What we know –
risks to good mental health
19
Portsmouth
England England
worse
England best
“Systematic differences in mental health by gender, age, ethnicity, income,
education or geographical area of residence are inequitable and can be
reduced by action on the social determinants.”
WHO, Calouste Gulbenkian Foundation. Social determinants of mental health. June 2014.
http://apps.who.int/iris/bitstream/10665/112828/1/9789241506809_eng.pdf?ua=1

What we know – local inequalities
20
• 60.6% of adults in contact with secondary MH services live in stable and
appropriate accommodation – ranked 9/12 comparator LAs
Section E2:Households found to be eligble for assistance,
unintentionally homeless and in priority need during the quarter, by
priority need category
9 month total %
1. Applicant homeless in emergency 2 1
2. Households with dependent children 213 62
3. Households with pregnant member & no other dependent children 26 8
4.Aged 16/17 years old 2 1
5. In care and aged 18 to 20 4 1
6. Old age 6 2
7. Physical disability 42 12
8. Mental illness or handicap 27 8
9a. Drug dependency 0 0
9b. Alcohol dependency 0 0
9c. Former asylum seeker 0 0
9d. Other 1 0
10. Been in care 2 1
11. Served in HMforces 0 0
12. Been in custody/on remand 0 0
13. Violence/threat of violence 21 6
13a. Domestic violence 14 4
14. Total households 346
Source: PIE. https://www.gov.uk/government/statistical-data-sets/live-tables-on-homelessness
Homelessness
April-Dec 2013

21
Homelessness
April-Dec 2013
Section E3: Main reason for loss of last settled home for housholds
found to be eligible, unintentionally homeless and in priority need
during the quarter
9 month total %
1. Parents no longer willing or able to accommodate 38 11
2. Other relatives/friends no longer willing or able to accommodate 27 8
3. Non-violent relationship breakdown with partner 9 3
4. Violence a. Violent relationship breakdown, involving partner 42 12
b. Violent relationship breakdown involving associated persons 13 4
c. Racially motivated violence 0 0
d. Other forms of violence 6 2
5. Harassment, threats or intimidation a. Racially motivated harassment 1 0
b. Other forms of harassment 0 0
6. Mortgage arrears 4 1
7. Rent arrears on: a. LA or other public sector dwellings 0 0
b. Registered social landlord/other housing association dwellings 1 0
c. Private sector dwellings 17 5
8. Loss of rented or tied accommodation due to: a. Termination of assured shorthold tenancy 79 23
b. Reasons other than a. 78 23
9. Required to leave National Asylum Support Service accommodation 9 3
10. Left an institution or LA care a. Left prison/on remand 6 2
b. Left hospital 5 1
c. Left other institution or LA care 1 0
11. Other reason for loss of last settled home a. Left HM-Forces 0 0
b. Other reason 10 3
12. Total households 346
Source: PIE. https://www.gov.uk/government/statistical-data-sets/live-tables-on-homelessness

22
Unemployment
• NEETS
• JSA claimant rates highest in most deprived wards (5% of working age
population in Charles Dickens)
• Increasing median duration of unemployment – 13 weeks in March 2011 to
22.3 weeks in March 2014
• 68.1% point gap in employment rate for those in contact with secondary
MH services and overall employment rate – ranked 2/12

Local research - mental wellbeing
• Tackling poverty needs assessment and strategy
23

• Positive Family Futures
• Children’s survey
• You say - survey of secondary school pupils
• Children with autism spectrum conditions needs
assessment
• Looked after children needs assessment
• CAMHS service review
24

• Adults with autism spectrum conditions profile,
consultation and strategic plan
• Alcohol needs assessment
• Substance misuse needs assessment
• Profile of carers
• Profile of adults with learning disabilities
• Veterans needs assessment
• Dementia profile, strategy
• Suicide audit
25

Life satisfaction (overall well-being)
9%
13%
67%
8%
16%
12%
17%
14%
11%
19%
79%
70%
19%
81%
65%
0% 25% 50% 75% 100%
My life is going well
My life is just right
I wish I had a different kind of life
I have a good life
I have what I want in life
Disagree Neither Agree
What we know - childhood

The Good Childhood Index:
national comparisons
6.8
7.3
7.4
7.4
7.6
7.8
8.1
8.3
8.4
8.5
7.2
7.0
6.8
7.3
7.5
8.3
8.1
7.5
8.2
8.5
0 1 2 3 4 5 6 7 8 9 10
Appearance
Choice
Future
School
Time use
Health
Friends
Money
Home
Family
National This area

Prevalence and incidence of
bullying
Have you been bullied in the past year?
Yes
30%
No
45%
Didn't
want to
answer
12%Not sure
13%
9%
15%
44%
21%
12%
0% 20% 40% 60%
Don't want to answer
Not sure
More than three times
Two to three times
Once

• ½ of all lifetime mental health problems emerge before the age of 14 yrs and ¾ before mid 20s
• Rates of mental disorder rise steeply in middle to late adolescence. By 11–15 yrs it is 13% for
boys and 10% for girls, and approaching adult rates of around 23% by age 18–20 yrs
• Self-harming in young people is not uncommon (10–13% of 15–16 yr olds have self-harmed)
• 11–16 yr olds with an emotional disorder are more likely to smoke, drink and use drugs.
National data from Report of the Children and Young People’s Health Outcomes Forum – Mental Health sub-group, July 2012
29

Looked After Children
• Health of children and young people in care is often poor before entering care system – may
reflect poor early life experiences, family influences and environmental risk factors
• About 60% of Looked After Children and 72% of those in residential care have some level of
emotional and mental health problem. A high proportion experience poor health, educational
and social outcomes after leaving care
• Looked After Children and care leavers are between four and five times more likely to attempt
suicide in adulthood
Youth Justice System
• 1/3 of all children and young people in contact with the youth justice system have been looked
after
• NB A substantial majority of children and young people in care who commit offences had already
started to offend before becoming looked after
• Young people in prison are 18 times more likely to take their own lives than others of the same
age.
National data from Report of the Children and Young People’s Health Outcomes Forum – Mental Health sub-group, July 2012
Local data from www.jsna.portsmouth.gov.uk
30

Self-reported wellbeing, people aged 16+ yrs,
2012/13
31
Indicator
Liverpool
Salford
NewcastleuponTyne
Sheffield
Leeds
Plymouth
Southampton
Bristol,Cityof
Portsmouth
BrightonandHove
Southend-on-Sea
Bournemouth
Portsmouth
ComparedtoEngland
2.23i - Self-reported well-being - people with a low satisfaction score 8.4 6.3 7.0 7.3 6.1 4.5 4.4 5.4 6.2 4.9 6.4 6.7
2.23ii - Self-reported well-being - people with a low worthwhile score 6.0 5.1 6.2 5.4 4.5 5.4 3.7 - - 5.3 - 4.9 -
2.23iii - Self-reported well-being - people with a low happiness score 15.2 13.3 11.9 11.5 9.7 10.4 10.1 11.8 12.7 12.1 9.9 10.1
2.23iv - Self-reported well-being - people with a high anxiety score 29.0 22.8 21.0 23.5 21.7 24.1 23.0 20.9 17.5 25.4 22.0 20.0
Fourth highest or worst values Significantly worse
Fifth to eighth highest worst values values No different
Lowest four values Significantly better
Significance not tested
* Value suprressed Value not recorded -
(Where not all the data has been provided for regional comprators, tri-colouring split by thirds of number of values given for indicator)
Source: ONS. First annual experimental Annual Population Survey of Subjective Well-being, 2013. Reported in Public Health Outcomes
Framework, May 2014

What we know – adults ...
• In 2012/13, compared to England, Portsmouth had a
lower prevalence of people aged 18+ yrs with
unresolved depression since April 2006 QOF
• Estimated 22,100 Portsmouth residents aged 18-64 yrs
are affected by at least one common mental disorder.
Predicted to increase to c22,700 by 2020 Adult Psychiatric Morbidity Survey, 2007. and
ONS Mid Year Populations Estimates 2011(Census-based) Via PANSI, 2014
• .
32

What we know – adults …
Social isolation
• Effective actions – interventions that prolong/improve
social activities, life satisfaction, quality of life
significantly reduce depressive symptoms and protect
against risk factors such as social isolation.
33
Indicator
Liverpool
Salford
NewcastleuponTyne
Sheffield
Leeds
Plymouth
Southampton
Bristol,Cityof
Portsmouth
BrightonandHove
Southend-on-Sea
Bournemouth
Portsmouth
Comparedto
England
Ranked order of deprivation (Index of Multiple Deprivation, 2010) 64.1 46.1 38.4 34.1 28.6 25.9 25.5 25.3 23.7 22.5 21.8 15.6
1.18i - Social Isolation: % of adult social care users who have as much social contact as they
would like 48.8 37.5 45.5 44.9 47.5 48.7 40.8 42.5 48.6 46.9 46.3 40.2
1.18ii - Loneliness and Isolation in adult carers 27.4 40.0 51.9 43.0 42.1 36.5 47.4 46.2 57.3 34.1 40.5 35.3
Fourth highest or worst values Significantly worse
Fifth to eighth highest worst values values No different
Lowest four values Significantly better
Significance not tested
* Value suprressed Value not recorded -
(Where not all the data has been provided for regional comprators, tri-colouring split by thirds of number of values given for indicator)

Psychological therapies, 2013/14
34
68% female, 32% male
94% aged 18-64 yrs
Number of people who have entered psychological
therapies (ie had first therapeutic session)
3201
Number of people 'moving to recovery' 637
Number of people who have completed treatment who
did not achieve clinical caseness at initial assessment
135
Number of people moving off sick pay and benefits 126
Key KPIs

35
New Service requests beginning in quarters 2 & 3 %
Portsmouth (no) England Portsmouth
White British 720 60 37
Irish 4 1 0
Any Other White Background 22 3 1
Mixed White and Black Caribbean 6 1 0
White and Black African 1 0 0
White and Asian 1 0 0
Any Other Mixed Background 3 1 0
Asian or Asian British Indian 2 1 0
Pakistani 1 1 0
Bangladeshi 5 0 0
Any Other Asian Background 4 1 0
Black or Black British Caribbean 1 1 0
African 8 1 0
Any Other Black Background 2 0 0
Other Ethnic Groups Chinese 1 0 0
Any Other Ethnic Group 7 1 0
Not Stated 107 10 6
Unspecified 0 3 0
Invalid Data Supplied 0 1 0
Not Known 1026 15 53
Total 1921 100 100

36
New service requests beginning in Qtrs 2 & 3 by disability
%
01 Behaviour and Emotional 105 6 11
02 Hearing 20 4 2
03 Manual Dexterity 14 1 1
04 Memory or ability to concentrate, learn or understand (Learning Disability) 64 3 7
05 Mobility and Gross Motor 28 9 3
06 Perception of Physical Danger 13 7 1
07 Personal, Self Care and Continence 24 1 3
08 Progressive Conditions and Physical Health (eg HIV, cancer, MS, fits) 6 2 1
09 Sight 20 3 2
10 Speech 17 2 2
XX Other 20 4 2
NN No Disability 595 65 63
ZZ Not Stated (PERSON asked but declined to provide a response) 18 70 2
No code recorded 0 15 0
Invalid code 0 11 0
Other code 0 0 0
Total 944 100 100

37
New Service requests qtrs 2 & 3 provisional diagnosis
%
F10 - Mental and behavioural disorders due to use of alcohol 0 0.1 0.0
F31 - Bipolar affective disorder 0 0.1 0.0
F32 - Depressive episode 96 11.9 5.0
F33 - Recurrent depressive disorder 37 2.2 1.9
F40.0 - Agoraphobia (with or without history of panic disorder) 7 0.3 0.4
F40.1 - Social phobias 13 0.6 0.7
F40.2 - Specific (isolated) phobias 8 0.3 0.4
F41.0 - Panic disorders 14 1.0 0.7
F41.1 - Generalized anxiety disorder 25 5.6 1.3
F41.2 - Mixed anxiety and depressive disorder 63 11.6 3.3
F42 - Obsessive-compulsive disorder 14 0.8 0.7
F43.1 - Post-traumatic stress disorder 20 0.9 1.0
F45 - Somatoform disorders 6 0.3 0.3
F50 - Eating disorders 1 0.1 0.1
F99 - Mental disorder, not otherwise specified 11 3.5 0.6
Z63.4 - Disappearance and death of family member 7 0.4 0.4
Other ICD10 code 2 3.5 0.1
No code provided 1597 56.7 83.1
Total 1921 100.0 100.0

What else we know….
• In 2012/13, about 1,960 people (0.9% of registered
patients) were recorded by GPs as having severe mental
illness (compared with 0.8% nationally) QOF, 2012/13
• Compared to England, this is a significantly higher
prevalence of people with severe mental illness
38

0
2
4
6
8
10
12
14
16
18
20
1993/95 1994/96 1995/97 1996/98 1997/99 1998/00 1999/01 2000/02 2001/03 2002/04 2003/05 2004/06 2005/07 2006/08 2007/09 2008/10 2009/11 2010/12
DSRper100,000EuropeanPopulation
Mortality from suicide and injury undetermined : persons aged 15 years and over
Portsmouth UA and comparators, 1993/95-2010/12, crude three year average trend (from annual rates)
Directly age-standardised rates (DSR) per 100,000 European standard populati
England Government Office of the South East Portsmouth *Southampton
Source: Health and Social Care Information Centre. © Crown Copyright. Compendium of Population Health Indicators (indicator.ic.nhs.uk) and National Statistics.
0
5
10
15
20
25
Males Females Persons
DSR(per100,000Europeanstandardpopulation)
Suicide and mortality from injury undetermined, aged 15 yrs and over
Portsmouth City and comparators, 2010-12
England South East Portsmouth
Source: Health and Social Care Information Centre. © Crown Copyright. Compendium of Population Health Indicators (indicator.ic.nhs.uk) and National Statistics.

Current research and gaps in knowledge
Current:
• Tackling poverty needs assessment
• Youth offenders health needs assessment
• Health impact assessment of retrofit of Wilmcote House
• Use of out-of-hours services by people with dual
diagnosis
Gaps
• Health and wellbeing survey of adults
• ???
40

Life course to tackling inequalities in mental wellbeing
WHO/Gulbenkian Foundation

Current Services
Public Health Portsmouth 31 July
201342

Mental Health Services
in Portsmouth
Preeti Sheth
Head of Integrated Commissioning Unit
www.portsmouthccg.nhs.uk

Key Facts
• Majority of statutory services provided by Solent NHS
Trust and Portsmouth City Council in partnership.
• Adult Mental Health services provide care for 1600
people on a longer term basis (months to years)
• Around another 4400 people each year in Portsmouth
access services for a short-term piece of work
44 www.portsmouthccg.nhs.uk

AMH Services
Community
Services
Talking
Change
Voluntary
Sector
Organisations
CAMHS

Talking Change
• Part of the national “Improving Access to Psychological
Therapies (IAPT)” programme
• Talking Change provides evidence based, time limited
psychological therapies for common mental health
problems (mainly anxiety and depression)
• Nearly 4,000 people a year in Portsmouth use this
service
• There is not a long waiting list and people can refer
themselves
• Waiting times and Recovery Rates exceed national
targets

Community Services
• A2i (assessment to Intervention) service – fast access to
MH advice and short term intervention for people whose
problems are more complex than Talking Change.
• Recovery Teams – providing care for around 1500
people who have longer term MH needs.
• IET (Intensive Engagement Team). Working with around
100 people – a mixture of young people at risk of
developing psychosis and people with severe mental
illness who are at risk of disengaging from services.

The Acute Care Pathway (ACP)
Crisis Resolution
Home Treatment Team
(CRHT)
Day Treatment
Hawthorns (Acute
Ward)
Maples (Intensive
Care)
Person in
Acute Crisis

Acute Care Pathway
• CRHT (Crisis Resolution Home Treatment Team). Intervene
when people are at risk of hospital admission. Keep over 500
people out of hospital every year.
• Day Treatment Working with people who need extra support,
but not full hospital admission.
• Hawthorns and Maples Wards Short admissions, for people
who need a period of intensive hospital care. All admissions
preceded by CRHT assessment, to see if care at home is an
option.
• Oakdene – 14 bedded Rehabilitation Unit for people who
need inpatient stays of several months.

Voluntary Sector Organisations
• Employment Service (Solent Mind) Adults aged over 16
who have a mental health issue and an employment-
related support need.
• Peer Support Service (Richmond Fellowship) Peer
Support is embedded in secondary mental health
services and peers focus on supporting individuals to
better manage their mental health and wellbeing
• Advocacy Service (SEAP) Mental health advocacy
services including: Independent Mental Health Advocacy
(IMHA), Independent Mental Capacity Advocacy (IMCA)
and Deprivation of Liberty Safeguarding (DOLS IMCA)
and community mental health advocacy.

Accommodation Based Services
• Community Based Supported Living AMH Service –
(Richmond Fellowship) The service promotes independence
and prevents the need to access higher intensity statutory
services. The service supports about 55 individuals across
12 residential settings in the city.
• Extra Contractual Referrals (ECR’s) Are made when an
individuals clinical circumstances are exceptional or there are
specific requirements to reside outside the area. There are
43 individuals being supported through ECR arrangements
which includes section 117 aftercare placements.
• In addition there are 87 individuals in mental health low
support rest home care across the city.

CAMHS
• Solent NHS Trust provide CAMHS for Portsmouth and
services are commissioned by Portsmouth CCG and
Portsmouth City Council. The service model is made up of
two generic teams and a number of targeted teams.
• The Tier 3 team is a generic multi-disciplinary specialist
healthcare team offering assessment and intervention.
• The Primary Mental Health Worker Team is a generic uni-
disciplinary Tier 2 service for children and young people
whose issues cannot be managed at Tier 1 and don't require
the services of Tier 3.

CAMHS Targeted Teams
• Infant Mental Health team for parents and babies 0-2 years. Offers
intensive home based interventions that focus on attachment.
• Multi-Systemic Therapy team provides intensive home based
targeted family support to young people 11-18, at risk of entering
care or currently part of the criminal justice system or at risk of
permanent exclusion from school or college.
• Paediatric Liaison a dedicated psychiatric and psychological
service for children and young people (0-16 years) at QA Hospital.
• Targeted teams also include the CAMHS Learning Disability team
and the CAMHS Looked After Children’s team for children 0-18.

Adult Mental Health-
What’s going well/
What requires development
Matthew Hall
Operations Director - Adult Mental Health Services

What’s going well
Feedback from stakeholders
• CQC Inspection
• National Service User Survey – 3rd highest in England people
reporting care as “Good” or better.
Supporting people in mental health crisis
• CRHT supports nearly 600 people a year
• Lowest acute bed usage in England
• Back home with support quicker if you do need admission
Value for money
• Providing well rated local service for one of the lowest costs for
any city in England.
• Developing partnerships key to the future

What requires development
Community Staff engagement
• National Staff Survey - Community staff were less happy in their roles than
average for the Trust
Caseloads and throughput in A2i
• New team has been successful, but has been a bit overwhelmed – needs
different resourcing and stronger management
• Need to get more Recovery-based movement, through services.
Carer involvement
• We are working on this, but carers can still get overlooked.

Angela Dryer
Assistant Head Adult Social Care
Adult Social Care & Mental Health Services
5 June 2014

Background
• Adult Social Care are part of the Integrated Adult Mental
Health (AMH) Service led by Solent NHS Trust
• Staffing include:
– Social Workers, Community Development Workers
& Administrators
• Social Worker based within the Older Persons Mental
Health Team
• Dedicated Approved Mental Health Professionals
Service
• Joint working with AMH from community social work
teams and hospital Social Work Team
59

3 Areas that are going well
• Joint working between ASC and OPMH, and
involvement of OPMH service in ‘Virtual Wards’
• Carers are reporting that communication from In patient
wards is valued. They value being able to speak to a
consultant about someone's care and being able to give
their view point.
• Dedicated AMHP service improved service for people
requiring Mental Health Act Assessments in a more
timely way and response times for S136 assessments
best in country.
60

3 Areas for Development
• Personalised social care for people with MH problems
– Direct Payments / Personalised Budgets take up very low
• Impact of Care Act 2014 on people within AMH services
needing Social Care involvement
• Ensuring effective communication with carers - some
staff manage to make carers feel involved even when
consent to share information is limited but this is not
consistent. Some carers feed back that they feel there is
a barrier to communication with Care Co-ordinators.
61

Portsmouth Mental health and wellbeing summit June 2014

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