Plenary symposium: Local translation of public mental

health into practice

Dr Jonathan Campion

Jim McManus

Paul Calaminus

8th World Congress on Promotion of Mental Health and Prevention of Mental and Behavioural Disorders

London, 25th September 2014

Development of public mental health guidance and

intelligence platform

Dr Jonathan CampionDirector of Public Mental Health and Consultant

Psychiatrist, South London and Maudsley NHS Foundation Trust

Visiting Professor of Population Mental Health, University College London

Director of Population Mental Health, UCLPartners

London, 26th September 2014

Key messages

• Mental disorder is responsible for 30.3% of global burden of disease in UK

• Cost effective interventions exist to treat mental disorder, prevent mental disorder and promote mental wellbeing

• However, only a minority of people with mental disorder receive any intervention, far fewer receive interventions to prevent mental disorder or promote mental wellbeing

Key messages

• Public mental health intervention gap represents a systematic contravention of rights to health contravenes ethical principles of beneficence, non-maleficence,

justice and respect for autonomy has a huge set of broad impacts across sectors has associated economic costs even in the short term

• Size, impact and cost of public mental health intervention gap can be estimated at local, regional and national level which can facilitate improved coverage and addressing of rights

Impacts of mental disorder

Impacts of mental disorder

• Burden by Years Lost due to Disability (YLD) (WHO, 2014) 22.8% of global disease burden of disease 29.2% of burden of disease in Europe 30.3% of burden of disease in UK

• Size of impact of mental disorder due to combination of

a) Arising early in the life course

b) Broad range of impacts/ outcomes

c) High prevalence of mental disorder which varies according to local level of deprivation

Source: WHO, 2014

Annual economic impact of mental disorder

• Globally: €1906 billion annually (Bloom et al, 2011)

• EU: Almost €800 billion annually (Olesen et al, 2011)

• England economy: €132 (£105) billion annually (CMH, 2010)

• Possible to estimate local annual costs for different mental disorders

Intervention gap for treatment of mental disorder

• Range of cost-effective interventions to treat mental disorder

• Despite evidence based interventions, only a minority with mental disorder in UK except psychosis receive treatment (Green et al, 2005; McManus et al, 2009)

• Across EU, 10% of people with mental disorder receive notionally adequate treatment (Wittchen et al, 2011)

• Much less coverage in lower and middle income countries

• Important rights issue which requires action

Interventions to prevent mental disorder and promote mental wellbeing

Range of cost-effective public mental health interventions across the

life course to

• Prevent mental disorder

• Promote mental wellbeing

• Many interventions result in net savings even in the short term

Source: RCPsych, 2010; Campion & Fitch, 2012; Knapp et al, 2011

Potential of upstream approaches for sustainable reduction in burden of mental disorder

• Potential to sustainably reduce burden of mental disorder arising through coordination with agencies whose role it is to address particular risk factors

• Note Andrews et al, 2004 - even if all with mental disorder received best available treatment, burden reduced by less than 30%

• Importance of a twin track approach of treatment for mental disorder and prevention

• Reflected in twin track approach of UK cross government mental health strategy (HMG, 2011)

Intervention gap for prevention of mental disorder and promotion of mental wellbeing

•Duty to protect/ right to be protected from risk factors

•Right to access prevention/ promotion if at greater risk of mental disorder/ poor mental wellbeing (higher risk groups)

•Minimal access to interventions to prevent mental disorder and promote mental health

•Similar lack of access to interventions to address health risk behaviour and physical illness in people with mental disorder

•Much less in lower and middle income countries

Impact of public mental health intervention gap?

Impact of intervention gap

• Results in broad range of associated human suffering, impacts and economic costs even in the short term

• Since majority of life time mental disorder arises by mid 20's, these impacts continue over a large part of life course

• Represents a systematic contravention of rights to health

• Contravenes ethical principles of beneficence, non-maleficence, justice and respect for autonomy

Source: Campion & Fitch, 2012

Why such a large public mental health intervention gap?

Why such a large public mental health intervention gap?

• Systematic discriminatory attitudes towards mental disorder• Lack of mental health policy in 40% of countries (WHO 2011)

• Lack of knowledge/education about: numbers affected by mental disorder associated impacts including in areas outside health risk/ protective factors associated costs evidence based interventions and associated impacts

• Lack of inclusion of this information in needs assessments to inform strategic planning and commissioning

• Mismatch between resource allocation and size of burden of disease

Joint Strategic Needs Assessments and commissioning

• JSNAs provide information about local levels of health and social care needs as well as information about broader determinants (DH, 2012)

• JSNAs informs actions which local authorities, local NHS and other partners need to take to improve the health and wellbeing of their population (DH, 2012)

• However, mental health is poorly covered in JSNAs

Coverage of public mental health intelligence in JSNA’s

Review of child and adolescent mental health in JSNAs assessed content and quality of data intelligence of 145 JSNAs (Lavis and Olivia, 2013)

• Two thirds of JSNAs had no section which specifically addressed child and adolescent mental health needs

• One third of JSNAs did not include an estimated or actual level of need for child and adolescent mental health services in their area

Coverage of public mental health intelligence in JSNA’s

UCLPartners audit of 23 JSNAs covering 6 million population found that public mental health intelligence inadequately and inconsistently covered - often only in passing (Campion & Coombes, in press) •Mental wellbeing mentioned in 44% JSNAs, one JSNA cited annual ONS survey •Child and adolescent conduct and emotional disorder mentioned in 50% JSNAs•Adult mental disorder: depression mentioned in 72% of JSNAs, SMI 67%, personality disorder 28%, dementia 89%•Little information about impact of broader determinants on mental health required by DH (2012) or how poor mental health impacts on other areas e.g. tobacco•Poor coverage of higher risk groups, costs of mental disorder, savings from interventions•Lack of information about size or impact of unmet need

Causes and implications of lack of public mental health intelligence in JSNA’s

• No clear structure for what PMH intelligence is required (DH, 2012) or where to find

• Extremely time consuming for public health teams to pull together most up to date public mental health intelligence

• Quality and extent of coverage of intelligence within JSNAs influences Health & Wellbeing Board strategy, commissioning and de-commissioning decisions

• Lack of accurate public mental health intelligence prevents appropriate commissioning

• In part accounts for size of public mental health intervention gap

England example of allocated budget not reflecting size of burden of disease

• Annual cost of mental disorder to England economy: £105 billion (CMH, 2010)

• £12 billion spend on treatment of mental disorder in England in 2011/12 DH (2013) = 11% of NHS budget

• But 30.3% of burden of disease in UK due to mental disorder (YLD) WHO, 2014)

• Case that since only a minority receive intervention case, spend should be closer to proportion of disease burden

• Note £3 million annual national spend on adult mental health promotion = 0.03% of mental health budget and lack of available public health spend figures

Public mental health intelligence

Different types of public mental health intelligence

• Level and impact of mental disorder and well-being across populations

• Risk factors for mental disorder and protective factors for mental wellbeing

• Coverage of effective interventions to treat mental disorder, prevent mental disorder and promote mental well-being

• Size, impact and cost of public mental health intervention gap

• Size of economic savings including when and where they are realised from investing in public mental health interventions

Source: Campion & Fitch, 2012

Impacts of public mental health intelligence

• Size, impact and cost of public mental health intervention gap can be estimated at local, regional and national levels

• Transparency and available to all

• Informs commissioning and strategic development across sectors

• Facilitates greater coverage of public mental health interventions

• Supports evaluation of impact of interventions on population mental health

• Prioritises mental health across sectors

JCPMH public mental health commissioning guidance

Public mental health intelligence resources

• Endorsed by Association of Directors of Public Health, Royal Society of Public Health and Local Government Association (Campion & Fitch, 2012 and updated in August 2013)

• Brings together different local PMH intelligence Level of risk and protective factors Numbers from higher risk groups Levels of well-being and mental disorder Proportion receiving effective PMH interventions Outcomes of PMH interventions Economics

o Cost of mental disordero Spend on PMH interventions o Economic savings of PMH interventions

• Informs need assessments, strategic development and commissioning

Regional application of PMH commissioning guidance

• Work with public health department in East of England to apply JCPMH public mental health commissioning guidance to their 700,000 population

• Included collection of local data not available in nationally available datasets

• Presentation of findings to a range of local stakeholders including commissioners/police commissioner and Health & Wellbeing Board

Feedback from Northamptonshire

Lessons from regional application of PMH guidance

• Value in providing local mental health needs assessments

• Time intensive to bring together PMH intelligence

• Opportunity to: Support localities and public health by bringing together all

relevant and most recent public mental health intelligence data in a single place

Communicate local PMH intelligence Facilitate inclusion of local PMH intelligence in needs

assessments and commissioning cycles Facilitate more coordinated cross-sectoral response to mental

health at different levels – treatment/prevention/promotion

UCLPartners Mental Health Informatics platform

UCLPartners Mental Health Informatics platform

• Over past year, further development of JCPMH guidance

• UCLP mental health informatics platform incorporates All nationally available mental health relevant datasets in

England Local public mental health intelligence not available from

such datasets Analysis and interpretation

• Supports provision of comprehensive local public mental health needs assessment

UCLPartners mental health informatics platform

• Whole system approach including primary care, secondary care, public health, social care, other providers

• Benchmarks data against Other local authorities, region and national levels Deprivation - correlates different data against deprivation and

assesses degree of outlie• Examines interaction between different sectors e.g. primary and

secondary care• Identifies key local opportunities to treat mental disorder, prevent

mental disorder and promote mental wellbeing• Supporting number of local authorities covering population of more

than 4 million population

Four types of assessment

1) Mental disorder treatment needs assessment

2) Secondary mental health care assessment

3) Mental disorder prevention needs assessment

4) Mental wellbeing promotion needs assessment

1) Mental disorder treatment needs assessment

•Estimated local levels/numbers with different mental disorder including from higher risk groups

•Numbers/ proportion receiving treatment in primary/secondary care and associated outcomes

•Local spend on mental disorder treatment

•Local economic savings if all with different mental disorder received interventions including origin/time span of savings

2) Secondary mental health care assessment

•Access to secondary mental health services •Hospital admissions for mental disorder•Bed occupancy/discharges from secondary care•Detention under the Mental Health Act•Levels of Community Treatment Order and outpatient attendance •People on Care Programme Approach (CPA) receiving secondary mental health services•Secondary care associated harm •Patient, carer and staff experience of secondary mental health•Provision of social service support for people with mental disorder

3) Mental disorder prevention needs assessment

• Level of risk factors for mental disorder • Numbers from higher risk groups• Numbers receiving intervention to address risk factors • Spend on interventions to prevent mental disorder• Economic savings from interventions to prevent mental disorder

including origin/time span of savings

4) Mental wellbeing promotion needs assessment

• Level of protective factors for mental wellbeing • Levels of mental wellbeing• Numbers receiving intervention to promote mental wellbeing

including in higher risk groups • Spend on mental wellbeing promotion• Economic savings from interventions to promote mental

wellbeing including origin/time span of savings

Use of UCLP Mental Health Informatics Platform to

inform Camden and Islington Mental Health Needs

Assessment

Paul Calaminus (Chief Operating Officer, Camden and Islington NHS Foundation Trust)

London, 26th September 2014

Why Camden and Islington Mental Health Trust wanted a mental health needs assessment

• To support a new model of working based on care pathways• To help us understand our impact on mental health and where we can

best focus effort• To help us understand our relative impact and performance against

the needs of the population and other organisations.• To assist us in developing strategies and plans with commissioners

and service users.• To see where service provision and demand are not as “expected.”

Why Camden and Islington Mental Health Trust wanted a mental health needs assessment

• To enable us to see what outcomes are achieved in the areas they work, and how they compare. There is a danger in the NHS that each individual outcome measure is seen as a target to be achieved rather than as a part of a bigger picture.

• Help understand physical health as well as mental health outcomes in the local population and the interaction between the two.

• To help us with planning over a five year timescale, particularly in the era of ever reducing resources.

Examples of different types of public mental health intelligence

Estimated proportion/number of children and adolescents with conduct/emotional/ADH disorder by London borough

 

Source: Green et al, 2005; Campion & Fitch, 2012; Friedli & Parsonage, 2007

Mental ill-health of looked after children vs. deprivation

Source: DfE, 2013; DCLG, 2012

Total expenditure (£M) per 100,000 population for child and adolescents with mental disorder vs. deprivation (2012/13)

Source: NHSE, 2014

Estimated local costs due to conduct disorder by London borough

 

Source: Green et al, 2005; Campion & Fitch, 2012; Friedli & Parsonage, 2007

Estimated total lifetime costs (£m) of a one year cohort ofchildren and adolescents with conduct disorder (based on Friedli

and Parsonage, 2007)

Estimated total lifetime crime cost (£m) of a one year cohort ofchildren and adolescents with conduct disorder (based on Friedli

and Parsonage, 2007)

Estimated annual cost (£m) of crime by adults who had conductdisorder and sub-threshold conduct disorder during childhood

and adolescence (using local prevalence estimates and nationalcosts) (based on SCMH, 2009)

0 100 200 300 400 500 600 0 50 100 150 200 250 300 350 400 450 0 100 200 300 400 500

NEWHAMCROYDON

ENFIELD

BRENTEALING

WALTHAM FOREST

LEWISHAMHARINGEY

GREENWICH

LAMBETHHACKNEY

BARNET

TOWER HAMLETSREDBRIDGE

SOUTHWARK

BARKING AND DA..HILLINGDON

HOUNSLOWBROMLEY

WANDSWORTH

BEXLEYHAVERING

ISLINGTON

HARROWCAMDEN

WESTMINSTER

HAMMERSMITH A..SUTTON

MERTON

KENSINGTON AND..RICHMOND UPON ..

KINGSTON UPON ..

Estimated net savings for 100% coverage of treatment for conduct disorder by London borough

 

Source: Green et al, 2005; Campion & Fitch, 2012; Knapp et al, 2011

Net savings (£m) if the parents of all childrenwith conduct disorder received parenting

interventions (assuming £9,288 savings perfamily) (Knapp et al., 2011)

Net criminal justice related savings (£m) if theparents of all children with conduct disorderreceived parenting interventions (assuming

£7,492 savings per family) (Knapp et al., 2011)

Net NHS related savings (£m) if the parents ofall children with conduct disorder receivedparenting interventions (assuming £1,278savings per family) (Knapp et al., 2011)

Net education related savings (£m) if theparents of all children with conduct disorderreceived parenting interventions (assuming

£1,278 savings per family) (Knapp et al., 2011)

0 10 20 30 40 0 10 20 30 40 0 10 20 30 40 0 10 20 30 40

NEWHAM

CROYDONENFIELD

BRENT

EALING

WALTHAM FORESTLEWISHAM

HARINGEY

GREENWICH

LAMBETH

HACKNEYBARNET

TOWER HAMLETS

REDBRIDGE

SOUTHWARK

BARKING AND DA..HILLINGDON

HOUNSLOW

BROMLEY

WANDSWORTHBEXLEY

HAVERING

ISLINGTON

HARROW

CAMDENWESTMINSTER

HAMMERSMITH A..

SUTTON

MERTONKENSINGTON AND..

RICHMOND UPON ..

KINGSTON UPON ..

Total expenditure (£M) per 100,000 population for adults with mental disorder vs. deprivation (2012/13)

Source: NHSE, 2014

Proportion of sexually abused children receiving intervention by London borough

Source: Bebbington et 2011; DfE 2014

Estimated net savings arising from school and workplace based interventions to promote mental health

by London borough

Source: Knapp et al, 2011

Net savings (£m) over 10 years, for each one year cohort of 10year olds receiving social and emotion learning programs to

prevent conduct disorder (based on £10,032 net savings over10 years) (Knapp et al., 2011)

Number of adults employed (2012/13) (ONS, 2014)Net savings (£m) if all employed adults received workbased

mental health promotion after one year (based on Knapp et al.,2011)

0 5 10 15 20 25 30 35 40 45 0K 20K 40K 60K 80K 100K 120K 140K 160K 0 20 40 60 80 100 120

CROYDONBARNETENFIELD

NEWHAMEALING

REDBRIDGEBROMLEY

BRENTHILLINGDON

WALTHAM FORESTLEWISHAMHARINGEYLAMBETH

GREENWICHBEXLEY

HACKNEYTOWER HAMLETS

SOUTHWARKHARROW

HOUNSLOWHAVERING

WANDSWORTHBARKING AND DAGENH..

SUTTONMERTONCAMDEN

RICHMOND UPON THA..ISLINGTON

WESTMINSTERKINGSTON UPON THAM..HAMMERSMITH AND FU..KENSINGTON AND CHE..

LONDON

Impacts of PMH guidance

Highlighted local•Level, impact and cost of mental disorder •Lack of coverage of PMH interventions•Spend on PMH interventions•Size of savings from PMH interventions at current levels and with increased coverage

Informed and influenced•Health and Wellbeing Board priorities•Strategic development•Service specs •Commissioning•Investment by other agencies e.g. police offer to support parenting interventions

Use of UCLP Mental Health Informatics Platform to

inform Hertfordshire Mental Health Needs

Assessment

Jim McManus (Director of Public Health, Hertfordshire County Council)

London, 26th September 2014

Summary

Summary

• Mental disorder is responsible for 22.8% of global burden of disease which results in annual global costs of ZAR26,746 billion

• Effective interventions exist to treat mental disorder, prevent mental disorder and promote mental wellbeing which result in broad set of impacts and associated economic savings even in the short term

• However, only a minority of people with mental disorder receive any intervention, far fewer receive interventions to prevent mental disorder or promote mental wellbeing

Key messages

• Public mental health intervention gap represents a systematic contravention of rights to health and

contravenes ethical principles has a huge set of broad impacts across sectors has associated economic costs even in the short term

• Size, impact and cost of public mental health intervention gap can be estimated at local, regional and national level

• Such information can facilitate improved investment and access to such interventions

• A rights and ethics approach is important to include to support the use of public mental health intelligence

References and contact

• Campion J, Fitch C (2012) Guidance for the commissioning of public mental health services. Joint Commissioning Panel for Mental Health http://www.jcpmh.info/resource/guidance-for-commissioning-public-mental-health-services/

• Campion J, Bhui K, Bhugra D (2012). European Psychiatric Association guidance on prevention of mental disorder. European Psychiatry 27: 68-80.

• Campion J (2013) Public mental health: The local tangibles. The Psychiatrist 37: 238-243

• Campion J, Bhugra D, Bailey S, Marmot M (2013) Inequality and mental disorder: opportunities for action. The Lancet 382: 183-184

• Bhugra D, Campion J, Bailey S (in press) The right to mental health and parity

• Email: j.campion@ucl.ac.uk Jonathan.Campion@slam.nhs.uk