INTEGRATED MENTAL HEALTH COMMISSIONING STRATEGY
2013-2018
nhS SALFORD CLINICAL COMMISSIONING GROUP
SalFORD CITY COUNCIL
1) Introduction
1.1 An Overview of Mental Health and Service Provision in Salford
According to the most recent Salford Mental Wellbeing Needs Assessment (2010), around 36,500 adults (20% of people aged 16+) and 6,000 children (12% of people aged 0‐18) living in Salford might have some kind of mental wellbeing need.
Of these:
· 7,900 adults are likely to have extreme anxiety or depression
· almost 7,700 claimed benefits in 2009 due to mental health reasons
· over 6,500 were in contact with community mental health teams in 2008/09
· nearly 7,000 adults and children were treated as outpatients in 2008/09
for all mental and behavioural disorders or in psychiatry departments
· over 3,500 were treated as inpatients in 2008/09 for mental and
behavioural disorders, 1,500 related to psychoactive substance use
· around 650 people were treated as inpatients for self harm in 2008/09
· 60 people died from suicide or undetermined injury from 2006 to 2008
· 68% of people with dementia are registered with a GP
· The most deprived populations are currently identified as having the
greatest need for services
The main mental health provider in Salford is Greater Manchester West Mental Health NHS Foundation Trust (GMW) who provide most of our out-patient and in-patient mental health services, with a small proportion of referrals going to neighbouring mental health trusts. GMW covers a range of district mental health service including
· Community Mental Health Teams,
· Inpatient services (Meadowbrook and Woodlands)
· Rehabilitation
· Memory Assessment Treatment Service (MATs)
· Crisis Resolution Home Treatment
· Early Intervention in Psychosis
· Day Opportunities
· Psychology
Central Manchester Foundation Trust (CMFT) provides our Child Adolescent Mental Health (CAMH) service for children and young people up to the age of 18 years. The Core CAMH Service is funded by the CCG. There are a range of additional Targeted CAMH Services that are funded jointly by the CCG and the Local Authority. Specific targeted services related to transition are EMERGE (16/17 yr old service) and the services around Looked After Children (LAC).
As one of the Improving Access to Psychological Therapies (IAPT) project sites, Salford’s IAPT services are well-developed. Our local CAMH service is also fully engage with the Children and Young People’s Improving Access to Psychological Therapies (CYP-IAPT) programme. Our main IAPT provider was the provider arm of the PCT, but that service opted to use the Right to Request opportunity and is now a social enterprise, ‘Six Degrees.’
Local Authority adult mental health services are commissioned and provided jointly with Greater Manchester West NHS Foundation Trust, through a Section 75 partnership agreement for integrated services.
Salford also commissions a range of community services from providers in the independent or voluntary sector including Start In Salford, Making Space, Mind In Salford, Age UK Salford, 42nd St and Salford Mental Health Citizens Advice Bureau. In addition, the Independent Sector manage the significant majority of Salford’s mental health supported accommodation services. Salford has developed a guide which details the range of services and activities for people with mental health issues
http://www.salford.gov.uk/d/Guide_for_people_with_mental_health_issues_-_2011.pdf
There is also an Emotional Health Service Directory available for children and young people (which includes transition services) available at:
http://www.partnersinsalford.org/youngemotionalhealth.htm
However, while there is clearly significant investment in ‘mental health services’ it is also important to not overlook the vast amount of support which is provided in Salford that maintains people’s mental wellbeing and supports them to have control over their life
1.2 Mental Health & Wellbeing: the bigger picture
Salford City Council is developing an approach they are calling ‘just enough support’ to describe how the Council will be commissioning, planning and delivering services in support of the drive to personalisation. This model will form the basis of the Council’s dialogue and decisions they take with service users and carers about the allocation of support.
The Council has developed the model below to illustrate it’s approach
In broadening thinking beyond ‘mental health service provision’ it is useful to think of this model in terms of supporting people with their mental health and wellbeing
The majority of the mental health service provision described in Section 1 fits into ‘Just Enough Support’ ensuring that we are providing the required intervention but at the same time finding the balance between not over or under-supporting the individual.
“I had a really positive service. The staff were great and it has helped me to have insight into how I feel. I have been overwhelmed in the help and support and would like to show others that a mood disorder is not always a negative diagnosis.”
Comments from someone experiencing a recent stay in hospital.
Regarding ‘Getting a Life not a Service’ , this is about prevention. Prevention takes two forms. First it involves preventing people developing conditions in the first place, and second it involves preventing existing conditions deteriorating.
“A combination of finding the best anti-depressants and talking with the psychology wellbeing practitioner has really helped me and a huge thing I got from Six Degrees was to be open minded and this has helped me so much in my outlook now”.
Comments from a service user a who accessed the Primary Care Mental Health Team
The council and the NHS are working to develop social capital across Salford neighbourhoods (i.e. developing resource within the community). Health and Wellbeing strategies have supported the development of NHS, Social Enterprise and Voluntary Sector provision designed to address key health and wellbeing issues. This has been delivered through the Neighbourhood structure by NHS Salford, Salford Community Leisure, Unlimited Potential, Expert Patients Programme, Salford Sidekicks and other voluntary agencies.
“Gives me an active role, a chance to speak up for other service users, a go between to support them to speak. When things change or I help someone, I get a buzz”
Comments from a service user regarding their volunteer work
Regarding ‘Building on Community Capacity and Resilience’ this is about supporting people to make their own choices and out how to obtain support , providing advice to citizens to help them make lifestyle changes that will reduce the need for care packages
“There is nothing wrong in asking for help. We all feel overwhelmed at one time or another and asking for help can often stop things deteriorating even further.”
Comments from a service user when compiling ‘Top ten tips for self help’
This focuses on low level of prevention, pointing citizens to ways to meet their wellbeing needs either through universal services or alternative delivery routes like the voluntary sector. Salford Clinical Commissioning Group (CCG) has been develop the ‘right treatment – right place’ model which is founded on the principles of self care as the starting point for the ‘patient’ journey through the Salford health care system.
2) THE MENTAL HEALTH COMMISSIONING STRATEGY
2.1 Purpose of the Mental Health Commissioning strategy
This commissioning strategy sets out the commissioning intentions for integrated mental health services in Salford, over the five-year period from 2013 – 2018. By “commissioning intentions” we mean:
2.2 Scope of the commissioning strategy
The commissioning strategy has a primary focus on adults – but will also address issues concerning the mental health of young people making the transition to adulthood and adult services. In parallel to this, an Emotional Health and Wellbeing Strategy for Children and Young People (2013-2015) has been developed by the Children and Young People’s Emotional Health and Wellbeing Partnership, which reports to the Children and Young People’s Trust (CYPT).
2.3 Vision & Principles
2.4 The Financial Context
Salford makes a significant financial investment in mental health services and have long standing and effective joint commissioning arrangements across NHS Salford CCG and Salford City Council which ensures an integrated approach to commissioning across the City.
Given the current financial constraints and uncertainties in health and social care services it is not possible to forecast specifically the future financial resources for commissioning mental health services over the 5-year time period of this commissioning plan. What we do know, however, is that health and social care services can be expected to be operating in a stringent financial climate over the life-time of this commissioning plan.
There is likely to be an ongoing need for efficiencies in health and social care services through the NHS Quality, Innovation, Productivity and Prevention (QIPP) programme and the reduction in funding for councils arising from the Government’s medium term financial planning resulting in lower levels of funding through the Local Government Settlement process. We need to plan for this accordingly and ensure that we target our resources at the most effective ways to support people with Mental Health needs and though commissioning arrangements that secure value for money from all contracts and service providers.
Despite the ongoing financial constraints within which mental health services are likely to be operating, mental health services are, and will continue to be, a key priority in Salford. We are committed to protecting effective services and developing new services wherever possible. This will require an increased focus on building resilience for communities and individuals, together with prevention and early intervention in mental health services to meet rising demand with thre resources available. This is central to our commissioning intentions.
2.5 The Health Context
· Mental illness accounts for more than 20% of the total burden of disease in the UK – more than cardiovascular disease or cancer.
· 1 in 6 of the adult population experiences mental ill health at any one time – 1 in 4 will experience it at some point in their lives. For half of these people the problem will last longer than one year.
· Half of all mental illness (excluding dementias) start by the age of 14 – potentially 25%-50% of mental health problems are preventable through interventions in the early years.
· Dementias currently affect 5% of people aged 60 and above and 20% of those aged over 80.[7]
Poor mental wellbeing generally corresponds with areas of deprivation but the pattern is not always clear-cut in Salford.
Living in deprived communities is associated with lower levels of mental wellbeing and in Salford we see this trend but the gradient, as deprivation increases across wards, is not very strong. The gradient for anxiety and depression across wards in Salford increases more sharply as deprivation increases. However some wards with higher deprivation measures have slightly lower than expected anxiety and depression: Winton, Ordsall, Blackfriars and Pendleton.
In general, the most deprived communities show a higher rate of contact with mental health services, with 4-5 people admitted to hospital for every 1,000 residents in Langworthy and Broughton. Winton also shows high rates of hospital admission for self-harm.
In the most deprived fifth of areas where 50% of Salford’s population live, over 80 in every 1,000 people of working age claim benefits for mental or nervous reasons. A total of 90-120 in every 1,000 people of working age claim benefits for mental or nervous reasons in the communities with the greatest need: Broughton and Langworthy wards and Urban Challenge[(] areas.
Some wards show much lower levels of self harm than might be expected when taking deprivation into account: Kersal, Irwell Riverside, Little Hulton and Ordsall.
It is not possible to fully determine the causes of difference within the gradient. There may be a number of factors responsible; for example, there may be greater levels of resilience in more affluent areas that enable people to cope with below average wellbeing/severe anxiety or depression without the need for services. We could be seeing this in the wards of Irwell Riverside, Little Hulton, Ordsall and Kersal. Other mechanisms of treatment may be accessed in more affluent communities that are privately paid for – healthcare or social activity.
2.6 Parity of Esteem
The Government has made a clear commitment to ‘parity of esteem between mental and physical health services’, and this is reflected within the Mental Health Strategy No Health without Mental Health.
Mental disorder is responsible for a large proportion of the overall UK disease burden, larger than heart disease or cancer. This is principally due to it being more common, occurring much earlier in life (half of lifetime mental illness arises by age 14), and having a wider range of impacts. The overall economic cost of mental health problems to the English economy has been recently estimated at around £105 Billion.
Lack of parity is reflected in recent national psychiatric morbidity surveys. These surveys have shown that only a minority of those with mental disorder receive services, which is in stark contrast to other disease areas such as cancer where almost all receive some level of intervention.
Research has shown consistently that people with mental illness have higher rates of physical illness and die earlier than the general population. This is largely associated with treatable conditions and modifiable risk factors such as smoking, obesity, substance misuse and inadequate medical care. This not only results in increased long-term treatment costs, but societal costs in terms of lost productivity.
People with mental health problems are more vulnerable to social exclusion, poverty, unemployment and multiple social and family difficulties. This exacerbates the inequalities that they face. When there is co-morbidity of mental health and physical health problems the costs are even higher than having the individual conditions in isolation – the interaction between the mental and physical health conditions drives the treatment and care costs up.
Parity of esteem is seen as long overdue and can be achieved in a number of ways including changes in attitudes, knowledge, professional training, service design and practice. This can lead to a healthier nation with improved wellbeing, as a result of services and interventions that can potentially save money in both the short and the longer term.
Long Term Conditions and Medically Unexplained Symptoms
In relation to the NHS focus on Quality, Innovation, Productivity and Prevention (QIPP), the whole of the NHS must consider how more efficient use of financial resources can be made, whilst maintaining a focus on improving quality. In the field of mental health, one area in which savings can be made is by investing in psychological therapies for people with long-term conditions (LTCs) or medically unexplained symptoms (MUS).