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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