The Sustainability of Therapeutic Communities Daniel Maughan Royal College of Psychiatrists Sustainability Fellow

Outline What is sustainability? What is sustainable health care? Why sustainable health care? Are PD services sustainable?

What is Sustainability? The capacity for something to endure despite potential constraints The Triple Bottom Line economic, environmental, social 3 P’s: people, profit, planet To understand constraints we need to see what the organisation interacts with, where it takes resources from and where it impacts – tbl.

Environmental Social Economic BIOSPHERE Bearable Viable Sustainable Equitable BIOSPHERE

£ Social – have we trained and retained a good workforce Are services socially acceptable, do they help to rebuild the social capital in the community that might have been lost because of mental illness

? an average inpatient bed day in mental health costs £429 An average admission has a carbon footprint of 479 kgco2e, this is equivalent to driving from lands end to john o’groats then back again and then halfway back up. The entire NHS spews out 25 million tonnes of CO2 each year. That is a lot EU countries 2/3 staff concerned about their stress levels and ability to continue + social cost of admission

Outline What is sustainability? What is sustainable health care? Why sustainable health care?

Social Sustainability Society is changing – more living alone People’s expectations are changing New opportunities are present What happens to someone socially when they become unwell, they lose housing employment relationships etc…. This is perhaps the opposite of what happens when you get for instance a cancer diagnosis where you might gain relationships, opportunities, community support Broadening of our role to restore social capital AND Improved social capital leads to improved mental health resilience Social capital is defined as… and achieved through personal recovery: hope, agency ,and opportunity standard treatment might help the first 2 but will not create opportunity Disability model: illness, personal and societal factors all affect independence, we need to concentrate on personal and societal issues too BUT WHY DO WE NEED TO BE SOCIALLY SUSTAINABLE???? Very much in favour of the NHS – less wasteful but has engendered a sense of dependency in the public, my health is your business Increasing expectations, rise in long term co-morbid problems, ageing population all leading to increased dependence on health care -- we need to maximise independent living as much as possible

THE FORGOTTEN PART OF MENTAL HEALTH SUSTAINABILITY BIOSPHERE Environmental Bearable Viable Sustainable Social Economic Equitable ENVIRONMENT IS MISSING PART. Do you prefer to act out of a legal imperative or a moral imperative? Do you manage patients in such a way because you want to avoid GMC scrutiny or because you care about the patient in front of you? Would you change your clinical practice because you have been hit by a stick? Or do you change because you see a carrot?   I like to think that we base our clinical practice on moral or ethical reasons or because of vocation, rather than purely pay or fear of litigation. Life is better chasing carrots when compared with being hit by sticks… But when it comes to acting sustainably it doesn’t matter, we have both! But lets talk about moral imperative first BIOSPHERE

Climate change is a reality. This isn't a fantasy Climate change will have an effect What about 1940’s??

What is the MORAL imperative? The WHO and the Lancet Commission both state that climate change is the largest threat to human health in the 21st Century There is increasing evidence that floods, heat waves, drought and cyclones all impact on mental health The NHS contribution to this is significant during the 1995 heat wave in England suicide increased by 46.9%. This study also found that every 1 degrees C increase in mean temperature above 18 degrees C was associated with a 3.8% and 5.0% rise in suicide and violent suicide, respectively.

Climate Change Act 2008 SDU. (2013). Goods and services carbon hotspots,

SDU. (2013). Goods and services carbon hotspots,

Outline What is sustainability? What is sustainable health care? Why sustainable health care? Are PD services sustainable?

Why analyse complex needs? This is a new innovative service that is -- preventative and empowering The service potentially has a low carbon footprint – no meds, group based work, some occur in YERTS!!! People with untreated PD may have high health care costs; both economic and environmental The service is likely to be socially sustainable

A financial and environmental impacts analysis of the Oxfordshire Therapeutic Community Design Retrospective observational study Four year study period; 2011-14 Two groups TC=40; Control=45 Controls= those referred but DNA’d

Oxfordshire Complex Needs Outcome measures: Primary care GP appointments Medications (physical and psychotropic) Secondary health care Physical OPD Physical admissions A&E attendances Mental health OPD Mental health crisis appointments Mental health admissions

Measures National tariff costs were used for the different clinical activities Cost of medications obtained from the BNF Environmental costs are based mostly on financial costs of resources used and then converted to carbon footprints using carbon conversion factors published by DEFRA

Financial cost savings

Average financial cost of all health care service use per patient per year

Environmental savings

Average carbon footprint of all health care service use per patient per year

Primary Care

Conclusions Therapeutic communities have the potential to reduce the financial and environmental costs of the wider health care system. The NHS should invest money into these types of services to ensure that maximum value and sustainability are achieved.

Thank you