Transcript of Being Sad makes me ill Dr Geraldine Strathdee, National Clinical Director for Mental Health. Stadium...
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- Being Sad makes me ill Dr Geraldine Strathdee, National
Clinical Director for Mental Health. Stadium of Light 15 October
2014
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- The interaction between mental & physical ill health The
challenges: Physical ill health & premature mortality in people
with psychosis & SMI Depression as a major risk factor for
physical ill health Mental ill-health and premature mortality
people with long term physical illnesses Baseline data for the
North from MH Intelligence network & NAS, Oct 10th The start of
the solutions The national physical cardiometabolic and care CQUIN
Moving to action ASAP for improvement in SMI Call for examples of
evaluated what good looks like The enabling role of the SCN &
AHSNs Bringing every possible local network together for action
Focus on the life saving clinical priorities Support new
collaborative relationships between users & carers, primary and
specialist care Disseminate at pace the fastest ways to
implementation Save lives and have fun in the North
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- Culture change! Reversing the damage of the separation of
physical & mental health practice Chris Manning, extraordinary
thinker
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- 1. Premature mortality in people with psychosis People with
mental ill health are more likely to have poor physical health 1.
Source: Health Survey for England (2010), those with common mental
health problems are identified by scoring 4 or more on the GHQ12
questionnaire; 2. Source: Adult Psychiatric Morbidity Survey
(2007). Note that those with psychotic disorders are also likely to
be included among those with Long term mental health problems and
those with severe depression may be included among those with
Common mental health problems and those with Long term mental
health problems. 3. Answers positively to Whether smokes cigarettes
nowadays? question; 2. Weekly alcohol consumption >21 units
(men), >14 units (women); 3. Body Mass Index >30; 4. Weekly
physical exercise does not exceed 30 minutes on five days. This
used to be the prevalence in general population 30 years ago!
Mental illness has a similar effect on life-expectancy to smoking,
reducing life expectancy by: 7 to 10 years: in people with
depression 10 to 15 years: in those with schizophrenia Almost 15
years: in those who misuse drugs or alcohol
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- Those with long term physical health conditions are at higher
risk of experiencing mental health problemsespecially depression /
anxiety % of people affected by depression People who experience
persistent pain are four times as likely to have an anxiety or
depressive order as the general population 2. Premature deaths due
to untreated depression & anxiety In long term condition -
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- 6 I ntegrated physical and mental health care for long term
conditions in primary, acute care and community services Depression
& anxiety is common in long term conditions & is associated
with: -Higher rates of cardiovascular, diabetes & cancer,
liver, renal disease -Higher rates of suicide -Higher rates of
service use in primary care, A/E, LTC outpatient clinics -Premature
mortality & reduced treatment adherence -45-75% increase in
service costs per patient (after controlling for severity of
physical illness) - Overall, international research finds that
co-morbid MH problems are associated with a 45-75% increase in
service costs per patient (after controlling for severity of
physical illness) Between 12% and 18% of all expenditure on
long-term conditions is linked to poor mental health and wellbeing
at least 1 in every 8 spent on long-term conditions. Provision of
integrated psychological therapy into LTC care pathways and tariffs
offers value and reduces premature mortality, disability and
improves Quality of life & reduces crisis presentations,
admissions and increases employment rates.
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- The interaction between mental and physical ill health Moving
to solutions SMI: immediate action needed The national physical
cardiometabolic and care CQUIN 5 top tips for fast tracking action
for CQUIN implementation Access to treatment for common mental
health conditions New era progressing for Integrated physical and
mental assessment & treatment in primary care, acute care &
community providers Access standards set for treatment New
commissioning guidance
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- The target causes that can be addressed to reduce premature
mortality : the patients Lifestyle Food & exercise Lack of
exercise: due to negative symptoms & sedating medicines Diet:
Less likely to eat fruit and vegetables (high cost of healthier
foods, lack of nutritional knowledge or cooking skills ). 2-3 times
more likely to be obese which is linked to raised cardiovascular
mortality Smoking Increased smoking causes much of the excess
mortality of people with mental health problems. Those with
schizophrenia have a 10 fold increased death rate from respiratory
disease. Drug Interactions Smoking induces metabolism of some
antipsychotic medication, resulting in smokers requiring increased
doses which can be reduced by up to half following smoking
cessation. Access to early identification & timely treatment
76% of those in their first episode of psychosis are smoking
regularly Lowered reporting of physical symptoms: People with
schizophrenia are less likely than healthy controls to report
physical symptoms The suffering of untreated illness leads to self
medication with drugs, alcohol, smoking
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- NAS 2 (blue) v NAS Physical Health monitoring Standard 4
monitoring of physical health risk factors Monitoring of five risk
factors (family history excluded) 33%29% Monitoring of
smoking89%88% Monitoring of BMI52%51% Range across Trusts for
monitoring of BMI 5 92% 27 87% Monitoring of glucose control57%50%
Range across Trusts for monitoring glucose control 16 99% 25 83%
Monitoring of lipids57%47% Monitoring of blood pressure61%56%
Monitoring of five risk factors in those with established
cardiovascular disease 37% Monitoring of alcohol consumption
70%69%
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- This outlines practical actions for Board Executive team
Learning and development dept. Operational management Clinical team
Every clinician
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- 5 fast track proven innovations for CQUIN physical health
Clinical decision support templates for GP & MHT clinicians
Bradford MHT & CCG MH lead has implemented a brilliant template
for primary care clinicians & for secondary care which guides
the physical examination, estimates Q risk, and prints off as an
instant report for the patient GP practices commissioned for wards
GP practice commissioned to provide care, training, supervision
& skill share on wards in Broadmoor Rampton, several MSU &
LSUs & some rehab units leading to smoke free units 2.5 hour
Master class training for practice & MH nurses Sheila Hardys
cascade master class training has resulted hundreds of practice
nurses and mental health nurses working together to skill share
Football, aerobics, recovery programmes, 7 day outreach, fun!!
Using staff & service user skills Physical health can be fun if
staff & SUs join in Coaching, football, sports, aerobics, dance
Safer medicines prescribing & administration within MH services
Never start a medication without education re the lifestyle changes
needed to reduce the likelihood of obesity and diabetes Always
assess and address side effects
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- Other first world countries modern healthcare systems are
acting on the facts. If a person has a physical health major
illness, 40% will have a depression and anxiety as a result &
if that is not treated they will die earlier, have more disability
and use a lot of health care services .it just does not make
economic let alone clinical sense to Mental health is the commonest
comorbidity and raises costs in all sectors Overall, international
research finds that co-morbid MH problems are associated with a
45-75% increase in service costs per patient (after controlling for
severity of physical illness) Between 12% and 18% of all
expenditure on long-term conditions is linked to poor mental health
and wellbeing at least 1 in every 8 spent on long-term
conditions.
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- The availability of treatment & the costs of effective
treatment
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- NICE guidelines for the treatment of depression in LTCs show
stepped care model
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- 2012 publication Compendium of examples of cost effective
programmes for people with physical illnesses in acute trust,
primary care settings
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- Additional slides with details if asked to show
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- What does every clinical team need to do & what support do
they need to do it Co produced Care Plan with the 7 core components
of NICE/SCIE effective care : 1. Information 2.healthy lifestyle
& physical health rx,3. Psychological therapies 4. Safe
medicines and routine GASS 5. Recovery social, training &
employment plans, 6. Carer education & support; 7 what to do in
crisis ICD physical & MH codes recorded on ECR Coproduced
formulation with service user Mental health & Lester plus
cardiometabolic physical assessments Template Letter to GP to get
the summary record with Reed/ICD codes, medications, physical blood
etc results
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- NAS 2 (blue) v NAS Physical Health - interventions Standard 5
intervention offered for identified physical health risks
Intervention for BMI > or = 25kg/m 2 71%76% Intervention for
abnormal glucose control36%53% Intervention for elevated blood
pressure25% Intervention for alcohol misuse74%72%
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- NAS 2 (blue) v NAS Antipsychotic prescribing
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- Indicator 1: 65 % funding for demonstrating, through the
National Audit of Schizophrenia, full implementation of appropriate
processes for assessing, documenting and acting on cardio metabolic
risk factors in patients with psychoses, including schizophrenia.
The following cardio metabolic parameters (as per the 'Lester tool'
and the cardiovascular outcome framework) are assessed; Smoking
status Lifestyle (inc. exercise, diet, alcohol and drugs) Body Mass
Index Blood pressure Glucose regulation (HbA1c or fasting glucose
or random glucose as appropriate) Blood lipids Hepatitis C The
results recorded in the patient's notes/care plan/discharge
documentation as appropriate, together with a record of associated
interventions according to NICE guidelines or onward referral to
another clinician for assessment, diagnosis, and treatment eg
smoking cessation programme, lifestyle advice and medication
review. The following cardio metabolic parameters (as per the
'Lester tool' and the cardiovascular outcome framework) are
assessed; Smoking status Lifestyle (inc. exercise, diet, alcohol
and drugs) Body Mass Index Blood pressure Glucose regulation (HbA1c
or fasting glucose or random glucose as appropriate) Blood lipids
Hepatitis C The results recorded in the patient's notes/care
plan/discharge documentation as appropriate, together with a record
of associated interventions according to NICE guidelines or onward
referral to another clinician for assessment, diagnosis, and
treatment eg smoking cessation programme, lifestyle advice and
medication review.
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- Indicator 2: 35% funding for completion of a programme of local
audit of communication with patients GPs, focusing on patients on
the CPA, demonstrating by Quarter 4 that, for 90 per cent of
patients, an up-to-date care plan has been shared with the GP,
including the holistic components set out in the CPA guidance: ICD
codes for all primary and secondary mental and physical health
diagnoses. Medications prescribed and monitoring and adherence
support plans. Physical health condition(s) and ongoing monitoring
and treatment needs. Recovery interventions including lifestyle,
social, employment and accommodation plans where necessary for
physical health improvement. The local audit will cover a sample of
patients in contact with all specified services for more than 100
days and who are on the CPA. ICD codes for all primary and
secondary mental and physical health diagnoses. Medications
prescribed and monitoring and adherence support plans. Physical
health condition(s) and ongoing monitoring and treatment needs.
Recovery interventions including lifestyle, social, employment and
accommodation plans where necessary for physical health
improvement. The local audit will cover a sample of patients in
contact with all specified services for more than 100 days and who
are on the CPA.
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- Primary care innovations learning from the best of
international primary care MH leaders & role modeling
collaborative partnerships Registration & annual checks:
include 1 min self completion behavioural health assessment Primary
care team skillmix 30% of the work. ? % of staff with NICE training
psychological health training Supporting hard pressed primary care
: the basics Clinicians decision support templates Annual checks :
zero exclusion of SMI Family and 3 rd sector outreach Primary care
at scale initiatives integrated Living well care stroke, diabetes,
pain, COPD, bariatric surgery care Named workers in primary care
Population based focus based on local need Enhanced SMI care in
inner cities ? Enhanced MUS care Enhanced SMI care Alliance
commissioning models
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- Psychosis : National audit of Schizophrenia 2013 and 2014 show
the gap between the standards and the current pattern of care in
England Current services: - Standard care means that duration of
untreated psychosis is now 8-30 months: with lifelong poor outcomes
- Only 29% receive Cardio metabolic assessment & only 25%
receive treatment - 34% do not have NICE psychological therapies -
16% of medicines prescribed do not adhere to guidelines. - The
Variation ranges from 0-70% across England Future services: - Early
intervention psychosis teams which: Treatment in the first critical
8 weeks -full NICE compliance -home based care -recovery to
employment