How the Liaison Trojan horses have & are changing the

course of mental healthcare in England

• Why is liaison MH a key area of priority for PM policy and MH Taskforce

• Implementation: What are the current enablers and challenges

• The future: can you continue to shape the future & sustainable healthcare

Dr. Geraldine Strathdee, C.B.E. MRPsych, NCD 2013-2016 ( April)

@DrG_NHS : join and exchange news, views & new intelligence with other dynamic leaders

The report in a nutshell:

• 20,000+ people engaged• Designed for and with the NHS Arms’ Length Bodies• All ages (building on Future in Mind)• Three key themes in the strategy:

o High quality 7-day services for people in crisis o Integration of physical and mental health careo Prevention

• Plus ‘hard wiring the system’ to support good mental health care across the NHS wherever people need it

• Focus on targeting inequalities• 58 recommendations for the NHS & system partners • £1bn additional NHS investment by 2020/21 to help

an extra 1 million people of all ages• Recommendations for NHS accepted in full and

endorsed by government

Five Year Forward View for Mental Health

Prime Minister: “The Taskforce has set out how we can work towards putting mental and physical healthcare on an equal footing and I am committed to making sure that happens.”

Simon Stevens: “Putting mental and physical health on an equal footing will require major improvements in 7 day mental health crisis care, a large increase in psychological treatments, and a more integrated approach to how services are delivered. That’s what today's taskforce report calls for, and it's what the NHS is now committed to pursuing.”

Priority 1: A 7 day NHS – right care, right time, right quality

Key recommendations for 2020/21:

• No acute hospital should be without all-age mental health liaison services

in emergency departments and inpatient wards, and at least 50 per cent of

acute hospitals should be meeting the ‘core 24’ service standard as a minimum.

• A 24/7 community-based mental health crisis response should be

available in all areas across England and services should be adequately

resourced to offer intensive home treatment as an alternative to an acute

inpatient admission. For adults, NHS England should invest to expand Crisis

Resolution and Home Treatment Teams (CRHTTs); for children and young

people, an equivalent model of care should be developed within this expansion

programme.

• At least 10% fewer people should take their own lives through investment in

local multi-agency suicide reduction plans.

Liaison services have the capability to address the problem:

Presence of poor MH drives a further 50% increase in costs

3,430

2,290

1,200

0

1,000

2,000

3,000

4,000

5,000

Annual physical healthcare costs

per patient, 2014/15 (£)

Type 2

diabetes and

poor MH

Mostly

healthy

+50%

Type 2

diabetes with

good MH

Physical healthcare costs 50%

higher for type 2 diabetics with poor

MH

Additional costs due to increased

hospital admissions and

complications including blindness,

amputations, loss of income

270270

460720

1,310

2,070

3702500

1,000

2,000

3,000

4,000

Type 2 diabetes & poor

MH

Type 2 diabetes & good

MH

Annual physical healthcare costs

per patient, 2014/15 (£)

2,290

3,430

Note: Does not include spend on prescribing psychiatric drugs and other mental health servicesSource: Hex et all, 2012; APHO Diabetes Prevalence Model for England 2012; Long-term conditions and mental health: The cost of co-morbidities, The King's Fund

Presence of poor mental health is responsible for £1.8bn of the £8.8 bn

of spend on type 2 diabetes pathway

Excess inpatient

Other Complications

Primary care

Prescribing & OD

The solutions: MH & diabetes treatments are not integrated so we need to

expand liaison services

85% of diabetes services without

access to specialist psychological

services

• Only 25% of diabetes services have

access to some form of psychological

support service

• 40% of these are generic MH

services

• 80% have no protocols for patient

referrals with common mental health

conditions

• Large waiting times for routine

referrals

• Less than 30% of services able to

see patients from routine referrals

within 1 month

1. Long term conditionsSource: Minding the gap (2008), Diabetes UK; Team interviews

"Integrated, multi-disciplinary teams are the

answer, but the two systems [i.e. mental and

physical health] are divided"

"Currently the flows of money in the system

mitigate against joined-up care"

"The Forward View's integrated LTC1

models are an exciting opportunity to bring

together mental and physical LTC care"

National clinical experts confirm

this view

Liaison: an exemplar of how to become a PM’s priority

• Liaison has been an exemplar clinical specialty campaign

• Identified leaders willing to commit time to speak out

• You understand the need for initial public, policy makers engagement

• Clear clinical & commissioning model of care

• Economic evidence of outcomes

• NHS Choices U tube ‘live’ liaison service

• Commitment to support the wider system ie A/E

• ‘Can do” attitudes

• Communication, communication, communication

How the Liaison Trojan horses are changing the course of

mental healthcare in England

• Implementation:

• How does this implementation plan and thinking look to you

• What are the current challenges you face in developing services

• Lessons & survival techniques from the last major changes in service transformation in

mental healthcare

• including the 1980 and 1990s closure of the large instructions and painful and challenging

movement to develop community care services

The Implementation Model: designed using the best of international implementation & improvement methods

Right Time

Right Care NICE standards for each crisis condition

✓ Information

✓ Physical health

✓ Medication optimization

✓ Psychological therapies

✓Right suicide prevention

✓ Rehabilitation & Recovery

for QOL, training/ employment

✓ Right carer & social

network

✓ Crisis & relapse &

prevention

Right Outcomes

Right Team

✓ PROMs

✓ PREMs

✓ CROMs

✓ Employment

Right team

- Compassionate,

- Coaching,

- Coproduction

- Recovery focus

- Multi disciplinary/ agency

Right implementation & Continuous Quality improvement

✓ Commissioning guidance

✓ Baseline national audit

✓Regional implementation teams

✓ Workforce plans

✓ Data collection plans

✓Clinical dashboards for teams

✓ Accreditation networks

✓Incentives & payment & levers

✓Digital Maturity plans

✓ 5 ALB & Regulation

✓ Big Data & innovation plans 8

Between 2015 -2020 evidence based clinical integrated pathways are in development for the 16 MH pathways : MH Taskforce page 36

How can the Liaison Trojan horses continue to

shape the course of mental healthcare in England

Clinical model of care: is your model

• empowering, holistic, integrated, a role model for the rest of healthcare

Culture:

• Your bilingual tradition; will you become time tri & quadrilingual working across acute,

primary care, MHT care in patients and communities

• Can you be the generation that avoids stigma and drift away from SMI

Prevention: the time has come to consciously include prevention & help local

communities tackle causes for better outcomes and for sustainability

Integration: are you planning that :

by place: A/E, delirium units, acute , MH wards, OPCs, primary care, MHTs MCPs

by condition: integrated teams, consultation, groups, skillmix

Innovation: Big Data, Data science, new discovery

11

NHS Choices information & self management: is there enough on liaison?

Please look and if you think more is needed , volunteer!

Crisis Concordat : Prevention & improving population mental health in your CCG

10 key questions for every service to start the journey to prevention & integrated care

12

Who: Are the people who present in crisis to your service Age, gender,

ethnicity, housing, employment, carers

Why Do they present, & are the causes preventable?

New /known Are they new to services or known, frequent presentations

When: What time of they day, night, weekdays, weekends do they present ?

Where from : Who refers them: self, family, GP, CMHT, police etc.

What services and

interventions do they get

Home, CMHT, Psychol therapy, bereavement counseling, domestic

violence, admission

MH act Are they on a mental health act section: 135, 136, 4, 2

Information Sharing for

safety

Do you have information sharing protocols & access to records, DOS,

JSNA & Suicide prevention:? Is crisis care, suicide prevention, mental health and alcohol services is in

your JSNA

Working smart & fast to reduce avoidable repeat crises, admissions, detentions ..is there a

stratification approach to identify frequent attenders

Causes of Crisis: what can we prevent with community assets, self management, early intervention

A. Social causes:

Accommodation: Finances: Debt: Gambling / benefits

Life transitions:Migration/ leaving home students/ unemployment/ redundancy,

retirement,/ leaving care children/veterans

Traumatic life events:Domestic abuse/ Bereavement/PTSD/ anniversaries/ relationships / carer

stressRTA

CYP & Child safeguarding Gangs, bullying, self harm,

B. Mental illness episodeMood disorders: depression/ suicide, self harm Psychosis: acute

or relapse episodes;Perinatal MH related

C. Cognitive impairment : Dementia, Delirium Learning disability

D. Behavioural health:Alcohol harmful use, intoxication, depression, psychosis

alcohol dementias: Korsakoffs and Werkncke

Drugs misuse:

E. Physical health / mental heath:RTA

traumaStroke Cancer Back pain

F. Criminal justice system

Integrated care by condition in acute trusts/ Primary care

A/E

Acute wards: 40% admissions & longer LOS

Clinics in order of prevalence of presence of mental illnesses

Pain

70%

Liver

70%

ICUs

70%

IBS

50%

Cancer

50%

Diabetes

40%

CVD

40%

Respiratory

30%

Commissioners need your help to produce a 2 page summary for each:

How common are

mental health

conditions

What is the type of

condition

What NICE treatments

are effective

What is the most efficient and effective

model of care

Where is it happening in

practice

What is the business

case

Integrated care by Place The great international debate: how best to do integration and not reduce MH focus

in A/E 24/7:

Productivity gains

Reductions in 4 hour wait breaches

Admissions by 40% into acute hospital wards & care homes:

Repeated Attendances for self harm and other conditions

Acute delirium assessment wards

Productivity gains

80% go back home with a well organized personal health care package

and are not admitted into a care home

Acute wards 40% +

Mental illness

Productivity gains

Increases the discharge rates

Reduces LOS

Reduces expensive unnecessary investigations and operations

LTC clinics in

acute care & primary care where 40-70%

have untreated depression & anxiety

70% people with liver disease, 40% people with cardiac disease, 40% with long disease, 60% with irritable bowel syndrome, 80% in pain clinics

Patients get treatment and

Repeat OPCs are reduced

Unnecessary diagnostics are avoided 15

Liaison mental health teams: 4 components of productive care

Integrated care systems: the future Chris Hilton

Daily GP advice line

Integrated Care Programme

Monthly multidisciplinary care

planning groups for patients with

long term conditions

Integrated mental health in

Intermediate Care team

(Consultant and RMNs)

Whole systems

integrationPlanning model of care for

Early Adopter projects and

future Local Hospital

Primary care

education and

supervision

Palliative Care Hospice

and Community Pilot

HIV Mental

Health

assessments

Community dementia

Liaison nurse

Integrated long term

condition

psychotherapy

services

Support for Primary

Care Mental Health

Workers

IAPT & Clinical

Psychology

Interfaces

Outpatient clinics

for MUS/LTC

Liaison needs Digital maturity, Big Data, Innovation can you showcase the way forward to increasing access, safety, effectiveness & integrated care &

sustainability of NHS & workforce

Electronic care records

Safer, quicker, 21st century

✓ Interoperability of records between sectors

• Primary, MHT, acute, community social care, SU

✓Functionality

• E prescribing, monitoring

reminders, GASS

• On line diagnostics order & see results

• Clinician decision support templates e.g.Bradford, lithium

• Skyp/ tele consultations

• Text reminders

• On line Outcomes tools PROM PREM. CROM

•✓Freeing time to care

• Digital dictation

Efficient safe care

Faster, safer, community care

✓SCR one click for

medicines reconciliation

✓Directory of Services / Mobile app.

✓Capacity Management system to reduce junior

doc & nurse time spent finding acute, PICU, CAMHS Tier4 beds/ OATS

✓Remote access tablets to

access records from the community

-

Innovation, SU in control

A care plan by any other name

✓Apps for fitness and literacy

✓Big Data to self manage & stop relapse

✓Self Management apps

✓ Psychosis avatars

✓ Interactive digital treatment sessions

✓On line city platforms & white label

digital therapies

✓Sim City to show case what can be done

1

7

Continuous Quality improvement:• Clinical team digital dashboards

• Touch screen in wards and teams every day

Admission/Attendance

Referral

Assessment

Care

Planning

Investigations Treatments

Discharge

I can receive referral

electronically that integrate into

the electronic records system

reducing duplication of work

I can write one entry in one

record system and it is shared

with other linked records

systems, or there is one record

systems across trusts

I can recommend

technology-enabled

care that integrates

well with other IT

systems – e.g Apps or

remote sessions using

videocalling.

I have access to pathology

systems within the electronic

patient record for mental

health service. I can order

investigations online and

remotely

Information about t physical

health investigations is shared

with primary care and

community services

electronically

I can contribute to an

electronically integrated

discharge summary

Discharge plans (eg. appointment

times) are routine shared and updated

through an electronic system .

Notifications are sent about changes to

staff who will see the patient

Care plans are shared in real

time across systems and can be

updated and) accessed by all

involved (including patients.

My team are able to receive

timely alerts through an

integrated system that

enable us to respond quick

and triage our work more

effectively

In to the future...

Liaison Services – “I statements” for professionals in 5 years James Wollard:

March 2015 v3

Thank you for listening

Its been a huge privilege to work with you

Very best of luck for your future & that of the millions of lives

your work will benefit

and remember take good care of each other…..this is marathon, not a sprint !

Dr. Geraldine Strathdee, C.B.E. MRPsych, NCD 2013-2016 ( April)

@DrG_NHS : join and exchange news, views & new intelligence with other dynamic leaders