Rhiannon England/David Maher April 2014 Developing a Primary Care Mental Wellbeing Network

Whole System Review – A case for change 1)System re-design is required with a shift towards primary care based provision 2) A prevention strategy will reap short and long term benefits Social resilience and primary prevention improve individual and population mental well being Secondary prevention interventions, including employment, housing and social networking, improve the quality of life and recovery prospects for people with mental health problems 3)Pathways and access routes must be clear – a real single point of entry With information about the range of services readily available to users, carers and professionals 4)Quality improvement is vital 5) Outcome measurements need development Successful implementation will: improve and simplify access to specialist services increase access to universal services Increase independence, choice and control support individuals to live ordinary, independent lives in their local communities focus on both the social, health and employment requirements of patients at all steps of their care experience promote resilience and staying well 2

Effective & Innovative Commissioning Least Intensive First Time Mental health services to work with community services, local organisations and primary care to enable people to access the right services as early as possible Care Closer to Home Continue the emphasis on preventing hospital admission & extending the options for out of hospital care through the use of Serious Mental Illness Local Enhanced Services Building resilience Commitment to the recovery model, promote the ability to live ‘ordinary’ independent lives & support people to use Recovery Plans to map their success and keep positive Customer Service Safe services of excellent and effective quality, choice and control and outcomes focused GPs as patient advocates in commissioning planning Building collaborative care networks Working with Local Authorities and other partners in building truly integrated support pathways for people

Why Primary Care?  GPs are trusted  nine out of ten patients were satisfied with the care they received at their surgery and over half of patients were ‘very satisfied’ (54 per cent). Only four per cent of patients were dissatisfied with the care they received. This suggests that the current doctor-patient relationship is highly valued and that the public place a significant degree of trust in doctors as professionals.  GPs know their communities, know their patients, and are best placed to apply a local and patient centred evidence base to designing future MH services  Primary Care have developed skills in managing Long Term Conditions  GPs understand the bio-psycho-social aspects of mental illhealth and are able to take a more holistic view of ‘what works’

Local Context – A Primary Care model of Mental Health 5 A primary care model of mental health requires building (The City and Hackney 3 Cs): -Capacity within primary care to care for repatriated CMHT patients as part of commissioning intentions to deliver increased care closer to home -Confidence within primary care by increasing liaison and shared care management of patient groups -Competence within primary care to develop the skills and motivations to effectively and safely treat more patients with mental health conditions as part of core primary care An effective model will ensure: -Working partnerships with community mental health services, third sector organisations, and service users -Co-production of pathways to a range of evidence-based & risk-assured, well-being and preventative interventions -Promotion of the principles of recovery and social inclusion -Raised awareness of the mental health needs within GP practice registered populations -Raised level of skill and knowledge available within primary care in the recognition, assessment and treatment of mental illness -Increased capacity within primary care to manage the needs and treatment of people with serious mental illness -Evidence based Primary Care mental health interventions integrated across clinical networks -Improved communication between mental health services and Primary Care

6 City and Hackney MH Enhanced Primary Care Model Secondary Care Primary Care Liaison (Clusters 3,11) 1x WTE Primary Care (44 Practices working in 6 Consortia) Primary Care Mental Health Guides Primary Care Dementia Advisors 1x WTE Primary Care Dementia Advisors 1x WTE Primary Care Liaison (Clusters 3,11) 1 x WTE Primary Care Liaison (Clusters 3,11) 1 x WTE Primary Care Liaison (Clusters 3,11) 1 x WTE Primary Care Liaison (Clusters 3,11) 1 x WTE Primary Care Clinical Support Primary Care Dementia Advisors 1x WTE Primary Care Dementia Advisors 1x WTE Primary Care Dementia Advisors 1x WTE Primary Care Mental Health Guides Primary Care Ancillary Support/ Guides Primary Care Liaison (Functional Older Adults, Cluster 18) 1XWTE Primary Care Liaison (Functional Older Adults, Cluster 18) 1XWTE Primary Care Liaison (Functional Older Adults, Cluster 18) 1XWTE Primary Care Liaison (Functional Older Adults, Cluster 18) 1XWTE Primary Care Liaison (Functional Older Adults, Cluster 18) 1XWTE Funded through SMI shifted activity Funding required (from shifted FOA and dementia cluster 18) Funded through dementia bed centralisation Funded non- recurrently Primary Care Dementia Advisors 1x WTE Primary Care Liaison (Clusters 3,11) 1 x WTE Primary Care Mental Health Guides Primary Care Liaison (Functional Older Adults, Cluster 18) 1XWTE

7 Secondary Care to Local Enhanced Service Local Enhanced Service into Primary Care GMS Currently under the care of secondary care and a: Non-CPA Patient in Cluster 3 Non-CPA Patient in Cluster 11 Non-CPA Patient in Cluster 1,2,18 who meet criteria for Local Enhanced Service (ie Depot provision) Non-CPA Patient on SMI Register who meet criteria for Local Enhanced Service GP as RMO coordinates decision following a formal multi-disciplinary review with the prescribing GP, practice staff and the Mental Health Liaison Function Managing well in settled accommodation and able to meet basic living needs Patient is stable and has no significant clinical, social or risk management issues Requires minimal assistance with medication concordance and is stable on medication, but will require review and monitoring No outstanding care-plan actions Patient is able to exercise choiceNo additional needs above those provided under QOF Identified relapse Management PlanAgreement of patient and MDT LES Team Less than 3 contacts in preceding 12 monthsNot requiring depot medication Acceptance Criteria

Primary Care Secondary Care SMI Local Enhanced Service SMI QOF Key Roles Enhanced Primary Care Liaison Function Determine the appropriateness of referrals according to selection criteria guidelines. Prepare and write the transfer summary, then co-ordinate the transfer process. Collate risk assessments and medication management plan. Co-ordinates transfer of patient to GP care including Information Governance authorisation from patient. Enables development of rapport between the patient, any carer, secondary care and the GP. The transfer process offers the opportunity to clarify and model the monitoring process with the GP. Monitoring includes ensuring case notes are updated across management systems Transferred patients are reviewed clinically initially six monthly to ensure appropriate care and appropriate stepping up or down. Intervene to provide interventions for brief periods to re-establish clinical relationships that show signs of breaking down. A patient registration and tracking system maintained by liaison function supports the GP in maintaining continuity of care and provides information about satisfaction and other quality assurance metrics. Coordinates quarterly Consultant-Led clinics for case discussion and professional development. Supports the delivery of a Development Curriculum to upskill primary care in managing mental health conditions. Supports the clinical assurance process for moving SMI patients onto a Local Enhanced Service provision. Provide pre-assessment support for those patients who may need stepping up into secondary care.

Stepped Care Cost & Monitoring Framework 9 LES costs due to the shift of patients *£100 per patient discharged into primary care NHS ELC Wide £137,600 LIAISON FUNCTION COSTMONITORING Quarterly consultant-led clinics & development sessions operating at practice, cluster and/or network level. £100,000 Cluster and network level engagement with Effective Shared Care Arrangements agreed and implemented. Liaison Nurse 12 x Band 6 12 x Band 5 £700,000Responsible to secondary care clinical governance but with accountability to primary care. Shared care agreements at practice level 4 LOCAL ENHANCED SERVICE PAYMENTMONITORING Patients on depot medication.£80 per quarter (i.e. £320 per year) Lithium – 3 monthly blood monitoring. Depot or other antipsychotic medication – 6 monthly GASS. SMI patients discharged into primary care not on depot. This pays for the second of the bi-annual clinical reviews conducted by the practice for SMI patients (the first review is covered under QOF payments). 1 £100 per yearComprehensive care plan review including holistic health review – 2 per annum by Liaison Nurse, PN and GP. 2 Initial year 1 payment for SMI register data matching with ELFT. £250.00

Transforming health services – Case Examples  Primary Care based mental health provision through Serious Mental Illness Local Enhanced Service- (EPC- Enhanced Primary Care)  Primary care based psychological therapies support for:  medically unexplained symptoms where significant psychological features are present  Personality disorders, experiencing crisis or difficulty engaging in services and where secondary or tertiary care is not appropriate  People with mental health problems who have been discharged from services and do not meet referral thresholds for current primary or secondary services  “Frequent attenders” for GP consultations in primary care  Difficult or poor engagement in services  A&E based psychotherapy support for frequent attendees, MUS and difficult to manage patients  Rapid Assessment Interface & Discharge service:  Psychiatric liaison service reducing admissions, reducing length of stay and rapidly coordinating care  Providing holistic support for acute in and outpatients  Streamlining care pathways for those with co-morbidities