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New approaches to implementing mental health programs in
primary care
Professor Helen LesterProfessor Helen Lester
Academy Health, Orlando, June 2007Academy Health, Orlando, June 2007
What I’m going to talk about
Background to UK Mental Health issues Two stories of programme implementation
1. Stepped care models for depression and Access to Psychological Therapies (IAPT) schemes
2. Health checks in primary care for people with serious mental illness
NHS budget for 2006–07 is $190 billion 1.33 million employees Services are free at the point delivery Primary care has a gate keeping role
Primary care policy context
Primary care has been viewed as increasingly important in mental health policy terms since 1999
NSF (1999) and 5 year review (2004) National Plan (2000) Tackling Health Inequalities (2003/6)
Treatment of depression: the problem
Prevalence of 2.1-9.8% (NICE, 2004) 40% of people have a chronic relapsing illness
(Lloyd, 1996) 5,000 deaths p.a. Economic costs particularly in terms of
unemployment and state benefits
Incapacity Benefit recipients by medical condition in the UK (2004)
Nervous system10%
Mental disorder38%
Others17%
Injury6%
CVD and RD9%
Musculo-skeletal20%
The evidence base: NICE guidance on depression (2004)
Uses a stepped care framework
Recognises that depression can be a chronic illness and therefore borrows from chronic disease management models of physical health problems (Wagner, 2004)
Over view of the stepped care system
Step 1: GP, practice nurse
Step 2: Primary care team, primary care
mental health worker
Step 4: Mental health specialists
including crisis team
Step 5: Inpatient care, crisis team
Step 3: Primary care team, primary care
mental health worker
Recognition
Mild depression
Treatment-resistant, recurrent, atypical and
psychotic depression, and those at significant risk
Risk to life, severe self-neglect
Moderate or severe depression
Assessment
Watchful waiting, guided self-help, computerised
CBT, exercise, brief psychological interventions
Medication, complex psychological
interventions, Case management and collaborative care
Medication, combined
treatments, ECT
Medication, psychological interventions, Case management and collaborative care
The implementation gap?
The NICE guidance has few ‘teeth’ in terms of implementation
Lack of therapists so 6-9m waiting lists for people from step 2 onwards…
Recent implementation levers
Bad publicity
- ‘NHS failing to act on talking therapies clinical guidance, says new report’
- ‘Depression: the great happiness pill betrayal’
Pledge to IAPT as part of the 2005 Labour election manifesto
The vision: Lord Layard and the LSE’s ‘New Deal’
High profile media coverage 10,000 more therapists by 2013 Cost of $120 million Working in teams in 250 centres Centrally funded and commissioned Providing 16 weekly sessions lasting 1 hour ‘Should more than pay for itself’ Focused on return to work issues
The practical strategy: IAPT programme 2 very different demonstration sites Some new monies but mainly service
reconfiguration Cooperation between sectors Mental health champions Doncaster is using a high volume low intensity
model with case managers as part of a stepped care framework
Newham is using specialist CBT providers 10 new sites this Summer recognising the
advent of different funding mechanisms for commissioning within the NHS
Early findings
Doncaster: Need: 2,000 people referred in 5m Referral pathways: 95% from GPs Workload: Mean number of sessions = 3 (2-
11) Stepped care model: 10% of people stepped
up to CBT Outcomes: access (including waiting times)
and inclusion (including employment) Waiting times: 1 week
Serious mental illness in primary care: the problem
Lifetime prevalence of 3.48% (Perala et al, 2007)
Often starts at a young age so a lifetime of consequences
Societal exclusion including 4% employment rates
Higher morbidity and standardised mortality rates (151) than the general population (Social Exclusion Unit, 2004)
Serious mental illness in primary care: the evidence base
Variable/poor health promotion and health prevention in primary care (Brown 1997; DRC 2005)
SMR of 156 (Harris and Barraclough, 1998) GPs’ view that the work is too specialised Patients’ view that primary care is the
cornerstone of care (Lester et al, 2005)
Implementation gap
NICE guidance (2002/7) includes roles for primary care but has few teeth
Educational gaps (only 2% of practice nurses and 30% of GPs have postgraduate mental health experience)
Primary care practitioners can be as narrow minded as the rest of the world
Implementation levers
Networked grass roots support for change led by local and national mental health champions
Financial incentives in primary care through the Quality and Outcomes Framework (2004)
The vision: Quality and Outcomes Framework
25% of GPs’ income relates to a set of evidence based quality indicators that apply to primary care
Chronic disease management (18 areas- 4% of the overall points/money focused on SMI)
Practice organisation (5 areas) Additional services (4 areas) Patient experience (consultation length and
patient surveys)
The practical strategy: reorganisation of care for people with SMI
Register of patents with a psychosis Lithium levels monitored and therapeutic Annual relevant physical health check up and
medication review Liaison with secondary care e.g.- Follow up if the patient doesn’t attend- Care plan to include social networks, early
warning signs and crisis plans
Early findings: points achievement in 2005/6
90.0%
91.0%
92.0%
93.0%
94.0%
95.0%
96.0%
97.0%
98.0%
99.0%
100.0%
CHDLV
D
CVA/TIA BP
Diabe
tes
COPD
Epilep
sy
Hypot
hyro
id
Cancer
SMI
Asthm
a
Generalisable lessons Alignment of an agreed problem + evidence
base + policy levers + a clear vision + practical strategy
Variable amounts of new monies
Reconfiguration and co-operation e.g. across the interface has occurred with some new but mainly existing staff rather than whole new systems