( ) Developed in Partnership with. North Essex Clinical Commissioning Groups. & Essex County Council

Transcription

1 North Essex Mental Health Joint Commissioning Strategy for Adults ( ) Developed in Partnership with North Essex Clinical Commissioning Groups & Essex County Council Feb 2014 Final 1

2 CONTENTS Content Page Section 1: Introduction 3-4 Section 2: Background 4-5 Section 3: Scope 5 Section 4: Challenges 6-7 Section 5: Achievements 8-10 Section 6: New model of care Section 7: Monitoring success Section 8: Enablers Section 9: Strategy for Implementation Appendices Appendix 1: DH Shared Objectives 22 Appendix 2: Supporting Strategies 23 Appendix 3: Consultation & Engagement Appendix 4: Early Local Models Appendix 5: Supporting information including mental health demographics and financial information This strategy is being produced within a very challenging financial context for both CCG s and Local Authorities. It is acknowledged that any service redesign and improvement will require a full business case to be developed and agreed through the appropriate CCG and Local Authority governance processes. This may necessitate the need to achieve efficiencies or make savings over the life of the strategy. 2

3 Section 1: INTRODUCTION Our vision for mental health care in north Essex This joint Health and Social Care Strategy sets out the vision and provides a detailed explanation of the standards and course to commissioning mental health services in north Essex moving to The strategy has been developed through dialogue with a wide cross section of mental health stakeholders. It will ensure that all services are integrated, including mental health, physical health and learning disability and with a seamless transition between adults moving from children s services and adults moving into older adult services. Our 1 vision is that the mental health services we commission will deliver the following health and social care outcomes for people in north Essex: People will have good mental health People with mental health problems will recover People with mental health problems will have good physical health, and people with physical health problems will have good mental health People with mental health problems will have the best possible quality of life Key Messages This Strategy shows how we plan to improve outcomes to all aspects of mental health care. We aim to: Develop and support community well-being and encourage people to maintain healthy lifestyles and keep themselves mentally well. This includes offering therapies to people at times in their lives when they feel particularly anxious and at an early stage, to prevent their mental health from deteriorating into more serious problems. Enable people to make choices, take control and be supported by their peers. Support individuals to be free from dependency on health and social care services recognising appropriate housing; employment and healthy relationships play an important role. This strategy centres on services that will support people to maintain and strengthen these aspects of their lives. Equip GPs, primary care staff and other community health and social care providers to recognise, assess and support people with mental health needs and to be more effective in treating people s mental health needs alongside their physical health. Improve the access and gateway into services so people are directed and provided with the right support at the right time and in the right place. Ensure specialist services continue to develop and are available for people who have severe mental health conditions. It is our intention that wherever possible, short term intensive support will be provided to help people develop skills that enable their recovery. Ensure people experiencing a mental health crisis will get help quickly, from a range of services. Full use will be made of available technology and social media to keep in touch with people at times when they need additional reassurance but do not want or need more intensive health intervention. Actively support individuals who may not have had access to services previously, including those who are socially excluded services to fit around individuals, not individuals to fit into services. 1 Clinical Commissioning Groups (CCGs) & Essex County Council (ECC) on behalf of the north Essex population Mid Essex, North East Essex and West Essex. 3

4 Throughout the consultation process and the development of this strategy it has become clear that this will be a challenging strategy to deliver and it will be imperative that in order to make such substantial changes to service provision there will be a need for excellent engagement from all stakeholders. It is proposed that a North Essex Clinical Network will be established, membership will include clinicians from both commissioning and provider services to support the pathway development, service user groups will work alongside these clinicians and social care colleagues in the redesign programme. Section 2: BACKGROUND National policy & local context The Prime Minister and the Deputy Prime Minister have made it clear that success for the Coalition Government will be assessed not just on bringing about a healthy economy but also on the wellbeing of the whole population. Moreover, good mental health and wellbeing also bring wider social and economic benefits. In February 2009 the Department of Health (DH) published their National Dementia Strategy 2. In addition to this they produced a complementary strategy in February 2011, No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages. These strategies set out the DH ambitions to mainstream mental health, and establish parity of esteem between services for people with mental and physical health problems. It shows how the Government is working to improve the mental health and well-being of the population, and achieve better outcomes for people with mental health illnesses. A wide range of partner organisations, including user and carer representatives, providers, local government and government departments, worked with the Department of Health to agree a set of shared objectives to improve mental health outcomes for individuals and the population as a whole. (See Appendix ONE). It is these strategies and outcomes that influence the north Essex strategy whose commissioning intentions will be transparent through the involvement of local people in shaping services. We recognise that mental health problems do not exist in isolation. Therefore this strategy has been cross referenced against where work has already been undertaken including that of social care, learning disabilities and children services and will need to be linked into other strategies. (See Appendix TWO) There has been an effective consultation process (representatives from clinical groups, carers, users and providers) throughout the development of this strategy (See Appendix THREE) and we recognise the need for change. By investing in a better model of mental health care there are opportunities to improve quality of services without additional cost. The key areas for immediate attention are: Identifying and making better use of good quality services that already exist within the community and voluntary sector, primary and secondary and social care Effective integration across health and social care commissioning and provision to maximise opportunities with regards both service delivery and financial effectiveness Strengthening the interface between mental and physical healthcare, particularly for older people, those with drug and alcohol related dependency and people with long-term conditions 2 Living well with dementia: A National Dementia Strategy Putting People First. DH February

5 Reducing unnecessary bed use in acute and secure psychiatric wards Improving workforce productivity Increasing the use of personalisation to deliver a model of service driven by supporting individuals to have more choice and control over their situation Section 3: SCOPE This strategy covers the north Essex commissioning intentions for north east, mid and west Essex CCGs until March For the population of north Essex and those registered with a north Essex GP. It is understood that people with serious mental illness do not access the best available health care and on average people with severe mental illness die 25 years earlier than the general population 3. Therefore, the scope of this strategy is to provide high level developmental plans that are applicable to all adult 4 mental health service users irrespective of condition and older people 5 with both organic (such as dementia) and functional 6 mental health problems. The spectrum of conditions included within this strategy range from common mental health problems such as anxiety and depression, to serious mental health problems such as schizophrenia, bi-polar disorder and personality disorders (see Appendix FOUR). Over the lifetime of this strategy we aim to move from separate commissioning based on age ranges (e.g. adult services and older people s services) and commission on the basis of need so that access to services will not depend on age. During the next three years we will focus on four key priorities: To improve mental health through the development and active promotion of wellbeing and prevention services To improve access to services thus reducing waiting times for assessment and treatment To work with our service providers to develop agreed care pathways for mild, moderate and severe need To maintain people s mental health post-treatment through better primary and community care services The strategy supports the delivery of a comprehensive range of services building on promoting health and wellbeing to specialist care and support, through secondary care provision within communities. It has been developed to improve outcomes and has been written to align with a number of complimentary overarching mental health strategies produced by partners in Essex to ensure a joined up approach. (See Appendix TWO). As previously noted this strategy seeks to ensure that services will support individuals at any stage of the mental health pathway and will enable a smooth transition from adolescent to adult, adult to older adult services. The aim is to create a much more integrated service delivery approach for individuals with both long term and mental health conditions to ensure parity between mental and physical health needs. 3 National Association of State Mental Health Program Directors (NASMHPD) Morbidity and Mortality in People with Serious Mental Illness The term ADULTS refers to services users of 18 years of age and over 5 Older people refers to service users of 65 years of age and over 6 Functional Mental Disorders are caused by a malfunction of the mind and are more common overall 5

6 Section 4: THE CHALLENGES The population of north Essex is circa 978, However there are just fewer than 997,000 8 patients registered with north Essex GP practices. Mid Essex has the largest population with circa 382,000 patients, followed by north east Essex (NEE) with C. 326,000 and west Essex (WE) the smallest population at C. 289,000. Consideration needs to be given to the population changes over the next decade as the population in all areas will not only become increasingly older the continual redevelopment of land for housing will see a significant rise in the overall number of people living in north Essex. Because of demographic differences, the prevalence of different Mental Health conditions varies between and within the localities of north Essex Key Messages Mental ill health constitutes a heavy burden in terms of suffering, disability and mortality contributing substantially to both health and social care costs. Currently 1 in 4 British adults experience at least one diagnosable mental health problem in any one year and 1 in 6 experiences this at any given time 9 in their lives (almost 17% of the adult population). In north Essex that is approximately 77,471 adults. The prevalence of mental illness is predicted to increase with population growth (a predicted increase in demand of 2.7% by 2020). However the use of specialist mental health services has increased by 4% over the last 3 years. There is a predicted increase in prevalence of dementia as a consequence of the increase in elderly people in north Essex. This has an impact on carers as well as people with dementia. Certain groups are at higher risk of mental illness and/or may experience difficulty having their mental health needs met; there are a number of reasons for this, including difficulties with service access for cultural or language reasons, discrimination, and circumstance. There is a strong relationship between physical health and mental health. People with long term physical health conditions often have poor mental health and people with mental health problems often have poor physical health. Within north Essex there are areas that are significantly deprived; Bocking South within north east Essex, Golf Green (mid) & Staple Tye (west) - there is an association between high deprivation and mental ill-health, with some areas having high levels of mental health benefit claimants. Insufficient housing and reablement leads to delayed discharges - good housing and employment are important to mental wellbeing, rehabilitation, recovery and wellbeing. There is variation in service level and provision across the three CCGs. Redefinition of the scope of specialised services and the separation of local and specialist budgets (resulting from the changes in the NHS) has necessitated greater collaboration between commissioners to avoid the creation of commissioning boundaries and fragmentation of clinical care pathways. 7 ONS, population estimates: 8 Q GP registered population, taken from ESSA IM& T Information Services 9 The Office for National Statistics Psychiatric Morbidity 6

7 Work continues to ensure continuity across the whole pathway particularly when service users return to local care following specialist placements. Mental health services will need to respond to financial challenges - the public sector financial constraints means that we will need to make significant efficiencies over the course of the next 3 years. Personal health budgets are currently provided through social care and are slowly being introduced into health services, clearly these budgets can provide opportunities to improve individual engagement with services they can however also present a range of challenges including a fragmentation in the delivery of established services. Financial overview The tables below show where the CCGs total investment of 93,657k for mental health (exclusive of IAPT 10 services) for the financial year 2012/13 is broken down within each individual service and social care spends of 13,777k for 2013/14(exclusive of older adults). Investment for IAPT service is 6,417k. Table One(a): Cost of mental health services in 2012/13 (health) Mid Essex North East Essex West Essex Total Substance misuse ,407 Organic disorder 3,350 3,680 4,856 11,886 Psychotic disorder ,626 Child & Adolescent 2,155 2,669 3,022 7,846 Other services* 24,214 27,732 18,946 70,892 93, /14 Investments 34,689 28,937 26,649 90,275 Total IAPT service 2013/14 1,967 3,194 1,256 6,417 *This includes supported housing, group homes, voluntary sector and advocacy Table One (b): Cost of mental health services in 2013/14 (social care)( 000s) Service Category Assessment and Care Management Residential and Nursing Care Essex County Council 4,131 7,836 Carer Services 2 Day Services 268 Home Support 1,437 Advocacy 103 Health investments for the financial year 2013/14 of 90,275k are not shown in the format above as programme budgeting is not fully completed until the late Summer Total Direct Costs 13, Increasing Access to Psychological Therapies 7

8 Section 5: OUR RECENT ACHIEVEMENTS North Essex Mental Health Joint Commissioning Strategy for Adults Whilst developing the strategy it was felt important that in addition to identifying current challenges in service provision, achievements should also be included, particularly where it is felt that recent redesign or service developments support the direction of travel with regards the development of community well-being and the wider provision of mental health services in primary/community care settings. Improving Access to Psychological Therapies (IAPT) Each CCG area has its own locally commissioned core IAPT compliant primary care mental health service in place, although these were commissioned at different phases of the national IAPT rollout cycle. Over the past few years of operation each CCG area has invested in their IAPT service through local commissioning initiatives. For example Step 3.5 (NEE & WE), community counseling (NEE), Learning Disabilities services (mid). Therefore it is true to say that they remain unique locality IAPT schemes tuned to meet local needs. Both NEE and mid have decided to re-procure their IAPT services with effect from April At the time of writing it is expected that west will follow with a re-procurement for 2015/16. The North Essex CCGs are all committed to the continuing improvement of mental health services in the primary care environment. Development of Recovery Hub A Recovery Hub and college approach has been established in mid Essex. The aim is to move from therapeutic to an educational approach. This carries with it core changes in focus and relationships that are central to promoting recovery. Key Outcomes show that experiencing an educational rather than a therapeutic approach enables a greater ability to manage their own lives, stronger social relationships, a greater sense of purpose, the skills they need for living and working, improved chances in education, better employment rates and a suitable and stable place to live The overall aim of the model promotes social inclusion and community wellbeing by having services that promote and enable greater involvement in mainstream activities within local communities. Joint commissioning with social care There are a number of mental health contracts with public, private and third sector providers. These contracts are funded by both health and social care under a 256 agreement, Essex County Council (ECC) manage these services as one across north Essex and have shown positive results in gaining greater flexibility and avoiding duplication of services. (These services are expanded in Appendix FIVE) Health and Social care partners also work together to ensure that commissioned dementia services are aligned across north Essex. This has been through transfer of funds to a lead commissioner under a section 75 agreement. Improving dementia pathways These services have been formulated around the individual s journey through the pathway and have been developed collaboratively in each of the CCGs with our main provider. Transparency is vital so service users and their carers will know what to expect, from clarity around the different diagnostic needs to the outcomes. Support 8

9 tools have been developed which allow individuals to be managed within the community by their GP - this will happen only after individuals have been reviewed by the consultant and his team and the service user is stable. Essex County Council A new Community Dementia Support Services contract has been awarded to The Alzheimer s Society effective from the 1st April This three year contract aims to provide a range of low level interventions to support people at every stage of their dementia journey. These include: An information and signposting function to include specialist information as well as raising awareness for professionals, Dementia Cafes, Carers Support and Peer Support groups. In addition a further service will be provided in collaboration with Age UK (Essex). Dementia Connections provides up to 12 hours of specific support to people newly diagnosed. Individual Placements Commissioners have been working closely together to develop the process for the application for funding Individual placements. These are made when assessments or placements are required outside the local north Essex area only when all local treatment pathways have been exhausted with lack of positive outcome. Individual placements are also made where people are on the path to recovery and are returning from (for example) low secure placements. A more robust procedure is now in place and this has been achieved through the; Introduction of the Mid Essex Continuing Health Care/ Section Panel Pilot Contribution to the review of the pan Essex section 117 protocol Scoping for the development of an Essex-wide placements service for the purpose of developing placements service reliance and economies of scale Patient and service profiling and the identification of QIPP opportunities As part of this process commissioners asked the local provider of secondary care services to identify particular areas of achievement that have been developed recently that aim to deliver some of the requirements included within this strategy, particularly with regards improving access to services and making care more responsive to patient s needs. North Essex Partnership University Foundation Trust (NEP) NEP has provided services to 20,000 people, 95% in the community and hosted numerous events across north Essex to promote mental health awareness. They have been awarded top marks for quality for four of their centres for older adults in Epping, Chelmsford, Clacton and Colchester. By providing home treatment to frail elderly with memory problems (and other health concerns) hospital admissions have been avoided at times of crisis with quality services being provided around patient need rather than convenience for professionals. As well as: 11 The provision of aftercare services to an individual on leaving hospital or place of care 9

10 Veterans First (in partnership with the MOD and Combat Stress to help ex-service personnel) won the Care Innovator Award in the Great East of England Care Awards Piloted new services like Mother and Baby psychotherapy and a Personality Disorder Service jointly with the Probation Service Edward House low secure recovery service was opened ( 5m) and building work commenced at the Derwent Centre, Harlow Five unannounced CQC visits to wards; all passed NEP is currently developing a new service delivery model across the whole Trust. With over 20,000 referrals from GPs last year, it is hoped that all benefits will be realised spring Care pathway & service redesign includes patients having quicker access to treatment and better outcomes. Section 6: THE NEW MODEL OF CARE The National Institute for Health and Care Excellence (NICE) commissioning guidance 12 identifies the benefits of using a stepped care approach to commission services for people with common mental health problems. NICE recommends that a stepped-care model is used to organise the provision of services and to help people with common mental health disorders, their families, carers and healthcare professionals to choose the most effective interventions. The core principle of stepped care uses different levels of care which are fluid to ensure the consistent flow of services between the steps, the ability of a team being able to discharge individuals into other services provides additional security to individuals resulting in reduced waiting times. The steps are graduated from low to high intensity. Individuals may begin their journey at any step of the pathway as the care pathway is integrated to reflect that recovery is built into each of the steps, there will be more support to GPs from specialist care service to ensure a joint approach to care so that people are managed within the community. People are matched to an intervention that is appropriate to their level of need and preference through timely referrals to mental health services. The person can step up or down the pathway according to changing needs and in response to treatment. Therefore, these services are likely to be cost effective and less invasive. Key Messages The model will support the wellbeing agenda. There is recognition that suicide prevention is a responsibility for all. All people with a mental health condition will receive care in the most appropriate place for their treatment end experience a smooth transition from adolescent to adult and adult to older people through a seamless service. There is a need to ensure there is a holistic approach with true integration of mental health services with physical health provision; for example Long Term Conditions and patients considered to be frail. There is a need to transfer low intensity services into the community to develop greater provision and better integration with primary care. We will maximise our impact by commissioning services through jointly agreed strategies; such as Children and Adolescent Mental Health, learning disabilities, older people and the recently produced mental health clinical outcomes framework. 12 NICE National Institute for Health and Care Excellence: publications.nice.org.uk/commissioning-stepped-care-for-people-with-common-mental-health-disorders 10

11 There is a need to work more closely and collaboratively with voluntary and community services to support local populations to develop a holistic care regime Local commissioning intentions Our vision for the future is that all services will be designed around the NICE commissioning guidelines with strong foundations within the community which will then support the stepped care approach and meet local need. The transitions between each step, including the transition to and from inpatient secondary care services, should be experienced as seamless and the whole approach is predicated on the active involvement of service users and their family and friends. The case for change Despite substantial investment there is considerable scope to improve the range of mental health services, access to them and their quality. For example we want to: Establish community wellbeing, supporting and empowering individuals to manage their own mental health Establish integrated primary/community based care for the delivery of mental health services and the management of Long Term Conditions Develop improved crisis pathways to reduce A&E attendances, admissions and the time people stay in acute beds Improve access to services and reduce waiting times for assessment, diagnosis and treatment Increase the number of carers receiving support Increase the number of people on direct payments or self-directed support Provide more coordinated care for people with a dual diagnosis Provide a more coordinated and seamless service approach for people considered to be frail; and Improve value for money, e.g. on accommodation and specialist services this includes moving from residential care to supported housing We will not only improve existing pathways (including a review of the care pathway for personality disorders (PD)), we will work with specialist commissioners with regards to the development of a tier 4 PD pathway (specialised services). North Essex Commissioners are developing a community based approach to provision, (see diagram one below). The intention will be to use innovative service models to improve the mental health of people with long-term physical conditions and enable individuals to support themselves and their peers by providing emotional support and appropriate resources, and initiatives to strengthen communities and build resilience. Examples include liaison mental health services, talking therapies for people with long term conditions and services for people with medically unexplained symptoms. This approach will be the basis for a local stepped care approach to providing services. We will encourage people to maintain healthy lifestyles through the promotion of mental health wellbeing. Some examples of intervention include services which will provide guided self-help, assistance with housing, employment & finance, advice & support and education and work closely with children s services (including looked after children) to ensure smooth transition into adult services. Currently around 60% of those looked after in England have been reported to have emotional and mental health problems after leaving care. 11

12 Diagram One: North Essex Stepped Model of Care North Essex Mental Health Joint Commissioning Strategy for Adults Step 0 It is recognised that public health and wellbeing is crucial in supporting people with lower levels of mental health problems. Access to health promotion, education and well-being programmes and will be key to enable people to manage their own condition and their lives effectively and to prevent becoming unwell. Commissioners will work closely with Public Health and local authority colleagues to ensure maximum access to wellbeing programmes. Step 1 We will improve access to services through the development of a single point of entry delivered by a clinical triage to ensure people are directed to the right level of assessment and care. Within this step services will be developed to support patients with common mental health problems, very mild depression or feeling low and will 12

13 be built on a good understanding of how and when to refer to mental health services across health and social care including in the non-statutory sector, good relationships with mental health providers and clear boundaries of responsibility between primary and secondary care (including community care). Step 2 and 3 This level of care aims to support patients experiencing minor problems of depressed mood or anxiety but with no distressing symptoms through to moderate to severe depression and/or anxiety with increasing complexity of needs. The proposals are for more people to be seen in primary care (coordinated under the care of their GP) through expanding the scope and capacity of IAPT and other therapy services. Working together with other statutory and non-statutory providers to encourage early identification and treatment of problems will be key and patients may require more specific intervention than step 1 such as self-guided material, individual therapy through to possible medication. Care will need coordination if needs are greater with a care package that may contain high intensity psychological interventions. Step 4 Services will provide earlier, more intensive interventions to support people to recover and will be delivered in a community care setting. Alternatives to secondary care (whether community or inpatient care) will be developed, particularly for people eligible for personal budgets. This step is aimed at individuals who may be accessing services for the first time and displaying psychotic symptoms of varying degrees to someone with a mild cognitive impairment including early stage dementia. Step 5 The crisis pathway will manage more crisis episodes in a community setting (delivered by secondary care providers) therefore reducing the need to admit people to inpatient facilities and avoid the use of the mental health act. It is essential that individuals requiring admission or access to specialist services are treated in a timely manner with respect and dignity. The opportunities for discharge are identified and pursued positively and in partnership with all stakeholders. This level of care will provide care for Individuals who have significant and complex mental health needs and who are either in crisis or unable to care for themselves with some form of cognitive impairment These steps support the Essex Health and Social Care Mental Health Outcomes for people as detailed on page TWO. For the local models of delivery for mid, north east and west Essex CCGs see appendix FOUR (page 26) 13

14 Section 7: MONITORING SUCCESS North Essex Mental Health Joint Commissioning Strategy for Adults Commissioning priority Outcome One: Well Being of community, working collaboratively with public health o Public Health Outcomes Framework Quality outcomes Targets to be agreed as part of the strategy development process as currently not available. Tackling Wider Determinants of Health: o Ensuring adults in contact with secondary mental health services live in stable and appropriate accommodation o Reducing the gap in the employment rate between those with a long-term health condition and the overall employment rate o Social Isolation: % of adult social care users who have as much social contact as they would like Health Improvement: o An increase in the emotional well-being of looked-after children o An increase in self-reported wellbeing Health Protection: o % in the reduction of suicide rates (to be agreed) Outcome Two: Access to services o directing into services more effectively o improved use of existing provision o smooth transition of CAMHS 13 and older people Reduction in waiting times for assessment and treatment. 10% improvement of delivery year on year for all mental health services. o A year on year reduction of 8% reduction in the number of people with LTC being treated for mental ill-health. 100% of people accessing mental health services will have a physical health check. Reduced inequality in mortality rates especially where there is co-morbidity. (local targets to be agreed) Reduction in A&E attendance and admissions year on year by 5% o A reduction in service users attending A&E with LTC and mental ill-health o A reduction in the number of service users known to the drug and alcohol teams within A&E. Each IAPT service to see 15% of local prevalence of common mental health disorders by the end of 2014/15. Outcome Three: Services and discharge o right support at the right time in the right place Reduction in the length of stay for service users o Using an integrated approach with the accommodation strategy there will be a 10% reduction of people living in mental health residential care: (The percentage of the number of service users who move in a planned way from supported accommodation to independent living.) (ECC) 13 Children and Adolescent Mental Health Services 14

15 o ensure a speedy return to an optimum level of health o Number of service users receiving support to make life style changes will increase year on year.(ecc) People with less complex cases to be managed within their communities o The development of local clinics led by other primary care clinicians with a specialist interest in mental health. A 10% reduction in the number of attendances in secondary care services. There will be more people accessing recovery and reablement services o A measured improvement in people s health and wellbeing o 80% of social care eligible individuals to have a personal budget each year (ECC) o 35% of working age adults using mental health services will be gainfully employed by 2016 (ECC). The number of follow up appointments for medication review carried out in a primary care setting with support from secondary care clinicians will increase by 20% year on year. Outcome Four: Patient and Care experience of services o positive experience and service user involvement. Year on year improvement of patients, carers and their families who report a positive experience will increase. Local targets to be agreed using; o Patient Reported Outcome Measures (PROMs) o Patient Reported Experience Measures(PREMs) Section 8: THE ENABLERS FOR DELIVERY Service Users, carers and families There are a number of local voluntary groups within the communities of north Essex that provide a voice for people with mental health needs and their carers and families. It is vital that these voices are heard and that service users, carers and families are central in designing any services for change. Health improvement Public policy and structural approaches address issues that affect mental health, for example; unemployment, poverty, inequality, social exclusion, housing, public safety, racism and discrimination. There are a number of advantages for working with public health colleagues to address and support: o Promoting associated activities that improve the overall quality of life of people o o Increasing wellbeing (ie the absence of mental ill-health) through community based activity Public policy and structural approaches: addressing issues known to affect mental health, for example; unemployment, poverty, inequality, social exclusion, housing, public safety, racism and discrimination 15

16 o o o Health improvement & early intervention; which might include exercise, support for lifestyle change such as smoking cessation, coping skills, parenting skills, relationship skills, negotiating and self-assertion techniques, opportunities for participation and social inclusion and programmes to build self-esteem Work directed at the primary prevention of mental illness; such as social support for new mothers, reducing the rate of post-natal depression; targeted support for at risk groups such as young deaf people or care leaver; individuals working closely with health and social care professionals to self-manage their health Improving the quality of life and the physical health of people experiencing mental distress There are examples of where this collaborative approach is already in place, these are: o Health Trainers (HT) One to one advice and support on health behaviours, including but not exclusively weight management and smoking, and with particular emphasis on the management of long term conditions. The Health Trainer service also provides a Working Well programme which supports local employers to engage in a workforce volunteer scheme to promote physical and mental wellbeing at work. Health Champions (part of the HT service) provide a link to the community, engaging more people in healthy lifestyles and contributing to an increase in volunteering and associated wellbeing o Exercise on Prescription Provided through leisure centres. This caters for people with a range of needs o Books on Prescription Self-help access to recommended books, available through Essex Libraries General practice, primary care & community resources Approximately 80% of NHS activity occurs within Primary Care General Practice. GPs are well placed to monitor the mental health status of the community and to identify cases of mental illness needing treatment because people are often reluctant to consider they need help for a mental health condition, with presentations often being for physical complaints, the familiarity the GP has with the patient and their social environment, and the continuity of care that GPs can provide. This model of care is being developed at a local level across north Essex and will ensure services are provided closer to home in primary and community settings. Services will work closely together to ensure a holistic approach to an individual s care, including those services provided by social care and the voluntary sector. It is recognised that multi-disciplinary teams working together (wherever possible and appropriate) from single sites establish a more efficient and sustainable service. Integrated commissioning Integrated commissioning can achieve effective outcomes for service users by bringing together relevant expertise, knowledge and experience in one place, placing mental health at the center of a wider public health agenda to mainstream mental health. 14 More specifically, research has shown that integration can contribute to improving the speed of response to identified needs by: o Simplifying the decision-making processes by involving fewer people o Ensuring better use of resources o Reducing communication failure o Increasing satisfaction with services Positive approaches to the integration of health & social care in mental health services, NIMHE Bringing the NHS and Local Government Together, Integrated working: A guide ICN

17 Integrated working can offer the opportunity for health and social care to operate equally, breaking down traditional barriers and creating seamless services. In particular, it provides the chance for the role of social care to be enhanced and recognised as a key contributor to the planning and delivery of services. This work programme has commenced this year with regards to Learning Disability commissioning with a plan to integrate health and social care mental health funding from 2014/15. Additionally the role of the third sector as an increasingly important partner in the planning and delivery of services creates a powerful triad for local health and social care economies. The delivery of this integrated health and social care strategy will require total commitment from all partners who must own the shared vision, supported by a robust governance process and underpinned by an open, honest and respectful communication mechanism. CCGs and ECC have worked effectively in collaboration using a 256 contract for jointly commissioned services across north Essex (see Appendix FIVE under current investment). Services commissioned such as day services, supported employment, housing and advocacy have resulted in good outcomes for those accessing the services. Effective contract management Collaborative contracting arrangements have been introduced to ensure effective management of providers. Under these arrangements, commissioners will review all available quality and performance information and agree on actions to be taken, either informally or using the formal contract mechanisms, to hold providers to account and where necessary to ensure improvement. Service contracts for 2014/15 onwards will also have a clearer focus on outcomes with payment being increasingly aligned to achievement of these. Commissioners will seek to use all available levers, sanctions and incentives, including the CQUIN 16 scheme, in an innovative and effective way to ensure that providers are supported to deliver the best possible quality of service within available resources. Market Development Commissioners recognise the importance of market development both of statutory and non-statutory organisations and will consider the production of a market development strategy to maximise the opportunities for both commissioners and providers with regards the delivery of the new models of care. Commissioners will develop the market for mental health services by working with providers to: o Map service provision in both quantitative and qualitative terms o Identify and measure gaps to determine if and what additional provision is needed o Stimulate the market to ensure sufficient capacity and where appropriate to encourage innovative ways of providing integrated services These activities will support the role of transforming services and provide an environment to deliver change, such as reducing the demand for residential care, stimulating greater community support that allows people to remain in their own homes, and developing the capacity to target services in order to prevent poorer care and health outcomes. 16 Commissioning for Quality and Innovation 17

18 Community & Voluntary sector The voluntary and community sector is made up of organisations which operate on a not for profit basis. Groups contributing to mental wellbeing include those established to support people with mental ill-health or with particular conditions, and those formed by local people to improve the quality of lives for themselves and/or others in north Essex. Also described as the Third Sector, these include a range of registered charities; voluntary organisations; community groups; peer support groups; faith groups involved in social action; community interest companies and social enterprises. North Essex commissioners recognise that the voluntary sector is: o A strategic partner; contributing to shaping local priorities and the development of plans to meet those priorities o A service deliverer; improving services outcomes through responding to local and diverse needs o An enabler of voice and community representation; by encouraging and supporting local service users and citizens especially those that are vulnerable and marginalised - to get involved in decision making o A key contributor to cohesion and equalities; by building social capital and strong community networks There are a number of voluntary organisations active in the north Essex area. Whilst many provide targeted services or support, for example counselling, support is also provided for those with long-term mental health problems. Some also provide support such as telephone befriending service for older isolated people. Others are commissioned by Essex County Council to provide support for carers, for example, The Alzheimer s Society provides specific support for carers of people with dementia. (See Section 5: Our Recent Achievements) Technology Although telemental health services have been available since the 1950s they only expanded to general use in the 1990s. Online mental health technology has been used most often in North America, particularly Canada, and Australia. A key initial focus of this technology has traditionally been remote or rural service delivery. However, telemental health has great potential benefit for patients and providers in non-rural settings since it offers convenient access to specialists, case conferencing for complex patients, comprehensive discharge planning for inpatients and forensic and suicide risk assessments, as well as standard psychological assessment and treatment. Current research suggests that the delivery of cognitive behavioural therapy via a computer interface (CCBT) may be of value in the management of anxiety and depressive disorders. IAPT services across north Essex may offer CCBT as part of guided self-help within the stepped care model. An online mental health support system for people over the age of 16 known as the Big White Wall has been commissioned in mid Essex. This provides resources, contacts and materials for people with mental health problems, including crisis support via the Tavistock. It is anonymised, and allows self-assessment as well as access to groups and to wall guides. Although there is no upper age barrier, the aspiration is for it to provide better access to help for younger age groups 16 to 30. There is evidence from data collected to date that this service is accessed well and by BME 17 groups and young men, in particular. 17 Black and Minority Ethnic 18

19 Section 9: STRATEGY FOR IMPLEMENTATION North Essex Mental Health Joint Commissioning Strategy for Adults The three north Essex CCGs are currently working on local models of delivery as part of their transformation programmes. Whilst the programmes reflect local need and models vary it is true to say that all are focusing on the key principles identified throughout this document. It is recognised that over the last few years with the development of IAPT services, recovery colleges etc. progress has been made in the delivery of the proposed model. Key areas of work requiring a focussed approach will be the development of primary and community services to provide more complex care outside of traditional secondary care provision. As previously noted all new service redesign and changes to care pathways will be developed with stakeholder engagement including patients, carers, health and social care professionals and the voluntary sector. In addition to this strategy, and local implementation as described above, it is proposed that a north Essex approach will be undertaken to review and develop plans to improve mental health services for areas including suicide prevention, personality disorders pathways, specialist placements and the development of a new rehabilitation pathway. Again the expectation is that strategies will be localised by the three CCGs to meet local need. For ease a draft plan on the next page has been produced which seeks to outline some of the early key areas of work currently underway by both Health and Social Care in the delivery of this strategy. 19

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21 APPENDICES 21

22 DEPARTMENT OF HEALTH SHARED OBJECTIVES The six shared objectives are as follows: North Essex Mental Health Joint Commissioning Strategy for Adults APPENDIX ONE More people will have good mental health More people of all ages and backgrounds will have better wellbeing and good mental health. Fewer people will develop mental health problems by starting well, developing well, working well, living well and ageing well. More people with mental health problems will recover More people who develop mental health problems will have a good quality of life greater ability to manage their own lives, stronger social relationships, a greater sense of purpose, the skills they need for living and working, improved chances in education, better employment rates and a suitable and stable place to live. More people with mental health problems will have good physical health Fewer people with mental health problems will die prematurely, and more people with physical ill health will have better mental health. More people will have a positive experience of care and support Care and support, wherever it takes place, should offer access to timely, evidence-based interventions and approaches that give people the greatest choice and control over their own lives, in the least restrictive environment, and should ensure that people s human rights are protected. Fewer people will suffer avoidable harm People receiving care and support should have confidence that the services they use are of the highest quality and at least as safe as any other public service. Fewer people will experience stigma and discrimination Public understanding of mental health will improve and, as a result, negative attitudes and behaviours to people with mental health problems will decrease. 22