West Yorkshire Finding Independence 12/06/2019 West Yorkshire Finding Independence Mark Crowe – WY-FI Research and evaluation Lead, Humankind Multiple exclusions, Co-production and Access to Mental Health Services Mark Crowe

12/06/2019 What Is WY-FI? WY-FI works with 800 Adults not engaging effectively with or excluded from services who experience at least 3 of the following: Homelessness Addiction (problematic substance misuse) Re-offending behaviour Mental ill health WY-FI works across West Yorkshire in the districts of Bradford, Calderdale, Kirklees, Leeds and Wakefield Mark Crowe

WY-FI and the National Lottery Communities Fund Fulfilling Lives: Multiple Needs Programme 12/06/2019 Overall aims are: Improved outcomes for service users through person-centred support More efficient and effective services (collaboration) through partnership working and shared information Reduced cost to the public purse by preventing unplanned use of services such as A&E or frequent arrest/ trial System/ Commissioning/ Policy change so that multiple needs can be met in a co-ordinated way This is all complicated by the fact that there is a history of exclusion from services for our beneficiaries and diversity of experience of services and effective ways of meeting needs. But critically geography plays a part – Leeds has a good provision of services in a relatively compact area with good public transport. Calderdale being a larger area with a smaller population and less well resourced LA for example has fewer individual services, a potential 13 mile journey each way to access a service on a “rural” bus service Geography of West Yorkshire: 2.2 million people, 783 square miles, 5 local authority districts, 3 of the 10 largest cities in England; 3 mental health trusts, 8 A&E departments, one police force/ ambulance service, 2 prisons, the only formal mechanisms for co-ordination across all of them are the Police and Crime Commissioner, and the West Yorkshire Combined Authority including WY Metro (transport) . The figures, based on the September 2018 workforce stats from NHS Digital and the latest ONS population data for all clinical commissioning groups, showed there were just 15.2 psychiatrists per 100,000 population in the north-west, 12.7 in Yorkshire and Humber, 15.4 in the West Midlands and 15 in the east Midlands. Bottom of the table was Wessex, with 12.5. London (north, central and east) has the most psychiatrists per 100,000 population (27.7), closely followed by the rest of the capital. https://www.theguardian.com/uk-news/2019/may/06/most-depressed-english-communities-in-north-and-midlands?CMP=Share_iOSApp_Other Mark Crowe

Access to services before WY-FI 12/06/2019 Access to services before WY-FI WY-FI Mental Health – Current Key Statistics: Of the 813 beneficiaries that WY-FI has worked with so far, 760 experience mental ill health of some description and 97% of those experience both mental ill-health and addiction (dual diagnosis). 77% have a homelessness need and 81% have a reoffending need. Female beneficiaries are slightly more likely to have the mental ill health need, as shown in previous work People with a mental health need are not getting the treatment that they need, few people are receiving the specialist help during their first three months on the project: Only 4% of the beneficiaries received counselling or psychotherapy. Only 9% had any contact with a community mental health team. Only 4% attended a mental health outpatient appointment. Early work suggests that less than half (45%) of WY-FI beneficiaries who have a mental health need receive services from a mental health provider, either in hospital or in the community. The most common treatments are provided by hospitals (as in-patients) and community health teams, followed by psychotherapists, CBT practitioners and counsellors Three quarters of those beneficiaries that do receive a service have all four needs (Homelessness, Addiction, Re-offending, Mental Ill-Health, HARM) although there is not much difference in the proportion that don’t receive a service. The big difference is that those who do not receive treatment have a much higher risk of having an unplanned exit from WY-FI, they are also not as likely to remain on the programme for as long as beneficiaries who do receive treatment Mark Crowe

Access to services whilst on WY-FI 12/06/2019 Access to services whilst on WY-FI WY-FI and Mental Health Services Since the development phase of WY-FI West Yorkshire has acknowledged the challenges in working with mental health services. This was initially at all levels, and although we have to accept some of the responsibility in this the way mental health services are delivered and managed is so opaque that even to the informed lay person working out where to go to collaborate on behalf of people with multiple needs is nigh on impossible. We are covered by three major mental health trusts all of whom also work outside West Yorkshire. We produced a paper entitled WY-FI and Mental Health 15 Months On, which summarised the work done to date. One aspect of this was to understand beneficiaries’ experience of mental ill-health through drama workshops which were really powerful and exposed some of the unexpected power imbalances in the mental health system. The persistence of Navigators in working with individual professionals on a case by case basis has, over the years, created relationships were trusted joint working can take place. In some districts prior professional connections also helped (Bradford, Wakefield) and although it is suggested that each MARB has representation from mental health services this has not always been the case (Calderdale, Kirklees). Joint working relationships have got representatives from MH services onto the MARBS. Through this process we learned that the people of interest to WY-FI were likely to be the ones that had been struck off services’ patient lists because they did not attend appointments. We did find extraordinary examples of MH services only communicating by letter (because that was what they always did) to someone with no fixed abode. It took a while to get both clinical and administrative staff on board with the idea that someone who was NFA could be contacted through a navigator. Through these MH representatives on MARBs we have been able to unpick some of the barriers to engaging more strategic managers in WY-FI but there is still a strong disconnect between the operational management/ deployment of mental health staff and the proscribed limits of their professional practices. Nowhere is this clearer than in their attitude to patients that experience substance addiction in addition to either chronic/ enduring mental health conditions or psychotic episodes brought on by substance use. One of the critical factors at play here is the presentation of the patient. This is often with low level MH or emotional well-being needs; or substance related psychosis. The person is also self-medicating with substances to deal with deeper psychological issues (over 60% of people with multiple needs have had some sort of childhood trauma, much of which has not been effectively treated, if treated at all. HOS baseline reading for those with mental health need: Physical health on average is poor for the beneficiaries, they received an average score of 3.16. They struggle severely with finding meaningful uses of time (2.26) Emotional and mental health is very low (2.26) NDTA baseline for those with a mental health need: High drug and alcohol use, average score of 3.48. A score of 4 indicates daily abuse of alcohol that can cause significant impairment. High stress and anxiety (3.44) In one district (Calderdale) the Locality Group identified a particular problem of WY-FI beneficiaries being excluded from access to mental healthcare. This was based on a reluctance to assess and if assessed a reluctance to diagnose or treat (often citing dual diagnosis). Unsurprisingly, neither the beneficiaries’ mental health nor emotional wellbeing improved. The district WY-FI Locality Group (including the local authority commissioner for mental health services) ran a pilot project with an independent mental healthcare provider which would operate more flexibly in terms of thresholds, attendance, length of engagement, joint working with the Navigator Team and approaches to treatment. The attached Project Report summarises the practical challenges and successes of running such a project and includes a suggested model for future adoption. Mark Crowe

WY-FI & Insight Healthcare Project in Calderdale 12/06/2019 WY-FI & Insight Healthcare Project in Calderdale Process Gathered the lived experience from service user groups and beneficiaries to identify the problems they had in accessing services. Presented those findings to the WY-FI Locality Group in Calderdale along with some recommendations as to how to put a pilot project forward. Lengthy discussions followed with two models emerging: 1) invest in support from a service user group; 2) resource the expansion of current provision to include WY-FI beneficiaries Neither of these came to fruition, partly because of the readiness of the beneficiaries to engage in a self–run service user group and because the resource was inadequate to extend clinical provision. So we tried to find a mental health services provider who could work with us to create a pilot Mark Crowe

12/06/2019 Pilot Design Insight Healthcare is a not-for-profit organisation specialising in the delivery of primary care psychological therapies services. Insight delivers the elements of the CYP mental health services in Calderdale. Project Objectives Provide 30 Beneficiaries with a full assessment of MH needs delivered by qualified High Intensity Therapists Support beneficiaries to access treatment, either within Insight Healthcare or supported referral to secondary care and/or other services that would better meet their needs For those offered treatment within Insight, support 40% (12) to move to recovery or achieve significant clinical improvement as measured by appropriate psychometrics (such as the PHQ-9, GAD- 7 and others) Provide evidence-based recommendations to improve mental health pathways for adults with multiple needs in Calderdale, including supporting people with a dual diagnosis Agreement Insight were happy to work flexibly to accommodate the needs of the group. They were happy to develop a partnership approach to person-centred working around someone’s mental health needs Targets Assessments within 5 days of referral from Navigator (appointment booked) Treatment offered within 10 days of assessment (appointment booked). Insight will provide up to 25 1.5hr treatment sessions of CBT/EMDR/Counselling as appropriate 40% recovery rate expected from those in treatment (either complete or significant improvement) shown by PHQ-9/GAD-7/other measures If a beneficiary is not contactable or is having difficulty engaging with assessment/treatment, they will be put on the ‘paused’ list, and reviewed every 6 weeks in conjunction with their recovery navigator. Mark Crowe

12/06/2019 What we found Close joint working between Insight practitioners and the Navigator Team, which could be further enhanced by co-locating services. Reducing cancellations and non-attendance of sessions by developing individualised plans which focus on giving the beneficiary the best possible opportunities to engage, including focusing on joint-working with other services, particularly the alcohol and drug team. Working on practical day to issues to support beneficiaries to manage unwanted or unhelpful behaviours, improve confidence and self-esteem. Insight practitioners provided training to the Navigation Team and other staff/ managers who are likely to come into contact with similar clients on areas and issues that will be helpful to them in their work Mark Crowe

Outcomes for 35 beneficiaries 12/06/2019 Outcomes for 35 beneficiaries Assessment only 21 beneficiaries 13 dropped out 1 in prison 1 deceased 1 relocated 5 already open to Secondary Care Services Engaged with treatment 14 beneficiaries 5 dropped out during treatment 3 started treatment and then relocated 6 completed treatment The DNA rate was 32% which is lower than originally expected considering the engagement challenges that are apparent with the beneficiaries. The attendance rate was 59% and the remaining 9% were cancellations Of the 14 beneficiaries who engaged in treatment, the recovery rate was 43%. Mark Crowe

12/06/2019 Co-evaluation The WY-FI Network conducted a piece of research among a sample of 6 beneficiaries who had been referred to the Insight service as part of the project. All 6 found the local mental health services difficult to navigate. Despite this 5 had a formal mental health diagnosis and 4 had begun treatment and were subsequently discharged. 5 had experienced exclusion from services because they were deemed “ineligible”. Between 4 and 6 of the 6 beneficiaries reported that they felt the service was person-centred, offered a range of therapies and locations and worked in a co-ordinated way with their navigators. Half of the beneficiaries had a supported referral into subsequent or alternative provision. These findings are not as paradoxical as they may appear as it is quite possible that individuals will have had to approach (or even been signposted) to multiple services at different times. Mark Crowe

12/06/2019 Beneficiary progress 5 beneficiaries found their work with Insight helpful in reducing their offending behaviour and 4 found it helped with managing personal relationships. “This has been the first time that I been able to access focussed psychological therapy, due to previously being told I cannot access treatment whilst still using drugs/alcohol.” “If I had been able to access CBT sooner, it could have prevented me developing severe addiction issues and associated difficulties (ruptures with family, forensic services etc).” Beneficiaries who were supported by Insight in Calderdale were roughly twice as likely to show improvements in the areas below when compared to the WY-FI population as a whole who hadn’t had access to mental health services. Self-Caring and Living Skills Emotional and Mental Health Meaningful Uses Of Time Intentional Self Harm Stress and Anxiety Social Effectiveness Mark Crowe

Case Study - W Case Study of Beneficiary W (a female aged 40-50). 12/06/2019 Case Study - W Case Study of Beneficiary W (a female aged 40-50). Presenting Mental Health difficulty: W presented with severe post-traumatic stress disorder, due to a complex history of childhood sexual, physical and emotional abuse. W also had comorbid severe anxiety and depression, triggered by deteriorating physical health, chronic pain and decreased mobility. Presenting Substance difficulty: W began using pain killers to cope with sustained sexual abuse in childhood, from the age of 8. W then progressed to cannabis, and became dependant on alcohol in her teenage years. W states she abstained from alcohol in her 30’s, but still heavily relied on a variety of pain killers and cannabis to help block her symptoms of PTSD. Treatment plan using CBT: After initially engaging W through a home visit with one of the WYFI navigators to establish a rapport and build confidence in engaging with CBT, she agreed she would like to engage. Mark Crowe

Outcomes for W Resilience – combatting isolation 12/06/2019 Outcomes for W Resilience – combatting isolation Finding and sustaining more suitable accommodation Undertaking social activities – reconnecting with son and grandchild; finding healthy and stable friendships Accessing the right benefits – reducing anxiety about money Reducing anxiety (in general) and panic More hopeful for the future, mood and anxiety had improved and moving towards more functional independent living The outcomes are both social and clinical and cannot be isolated from each other W displayed high levels of resilience and stated she would like to work primarily on her depression. We identified much of W’s depressive symptoms were triggered by high levels of social isolation, due to experiencing numerous physical health conditions and severe chronic pain, leading to restricted mobility. Working in conjunction with the navigators-who were integral throughout W’s treatment, we targeted social isolation as a primary goal, as this was the key contributor to client’s depression. W’s navigators helped find more appropriate accommodation for her restricted mobility, so she could then visit the local town and increase social activity. We then worked on engaging W in more valued and meaningful activities to target her depression, and she re-established relationships with her son and grandchild, which gave her a sense of achievement. W also recognised in sessions some unhealthy relationships she had established through previous alcohol use, and she disengaged with them in order to engage in other stable and healthy friendships. We then targeted W’s anxiety about the future, due to her chronic pain and deteriorating health. One of the navigators and myself attended a benefits tribunal with W to support her with an application for support, which was fortunately successful. We were then able to work on client’s chronic worry, pacing, and panic in sessions, which helped further engage her in more social activity. At the end of sessions-W was waiting for the final move in date to her new flat, she was actively engaging with supportive friends, her son and grandchild, and had begun visiting the local town again to run errands. W’s mood had improved, she was hopeful for the future, and her anxiety was at a level she could now function more independently. W fully engaged in all sessions, and is testament to how much progress can be achieved through team work. Mark Crowe

12/06/2019 Percentage of Calderdale Beneficiaries Accessing MH Services Over the Life of WY-FI Legend: CMHT – Community Mental Health Team Appointments; COUN – Counselling (general); MHOPA – Mental Health Out-Patient Attendance; MHINP – Mental Health In-Patient Admission (days); SUPP 10 – Counselling/ therapies; SUPP11- Cognitive Behavioural Therapy (CBT); SUPP12 – Psychotherapy; SUPP36 – CMHT Accessed service yes/ no Does it work? Well yes, here’s the last quarter’s operation of the pilot and at this point there is a peak in access to almost all forms of mental health service. Would it have worked without being co-designed? No, because we got information about both problems and solutions Mark Crowe

Improved Outcomes and Cost Savings 12/06/2019 Improved Outcomes and Cost Savings Mental health in patient is one of largest cost savings. Overall in WY-FI - Beneficiaries with a mental health need are more likely to improve their emotional and mental health the longer they stay on the project. Around 50% improve their emotional and mental health in their second score around 70% improve on their first score by their fourth score. Similarly stress and anxiety score improve over time, around 32% improve on their second score. Around 60% improve on their fourth score. 53% improve their physical health, 33% maintain and only 13% decrease their physical health when they exit. Overall 60% show an improvement in the first 18 months in their housing and 65% show an improvement in their chaos scores. After 18 months 82% show an improved NDTA score and 73% show an improved HOS score. After 30 months on the project 88% improve their NDTA and 83% improve their HOS. Highlighting the importance of a multi-year offer of service. By comparing each users service use in the first year of the project against the second year of the project we find that beneficiaries show an average saving of £5,230 overall in the 18 service user areas per beneficiary on the second year of beneficiaries journey. A large proportion of the cost savings come in the form of £2,002 from the reduction in mental health service in patient services when compared to a beneficiaries first year on the project, when we compare the average service use in the first year against the second year for each beneficiary. Mark Crowe