1. Being Sad makes me ill
Dr Geraldine Strathdee, National Clinical Director for Mental Health.
Stadium of Light
15 October 2014

2. 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

3. Culture change! Reversing the damage of the separation of physical & mental health practice
Chris Manning, extraordinary thinker

4. This used to be the prevalence in general population 30 years ago!
1. Premature mortality in people with psychosis People with mental ill health are more likely to have poor physical health
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
This used to be the prevalence in general population 30 years ago!
Thousands of people with psychosis are at high risk of dying of physical health problems in their twenties and thirties, at an age when primary care would not usually consider active primary or secondary prevention.
People with schizophrenia & bipolar disorder die on average years earlier than the general population.
More Premature deaths are due to treatable cardiovascular, pulmonary and infectious diseases (66%) than from suicide and injury (33%). And Ministers are conducting a Deaths Review
The differential mortality gap has worsened in recent decades particularly from heart disease in younger people: those aged 25 to 44 now experience 6 x higher cardiovascular mortality than an age-matched general population.
Medication: evidence implicates some or all antipsychotics in causing or worsening weight gain, dyslipidemia, and diabetes, but what is ethical prescribing
Metabolic syndrome is 2-4 times higher in people with schizophrenia receiving antipsychotics than in an appropriate reference population
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.

5. 2. Premature deaths due to untreated depression & anxiety In long term condition-
Those with long term physical health conditions are at higher risk of experiencing mental health problems…especially depression / anxiety
27%
Diabetes
29%
Hypertension
% of people affected by depression
31%
Stroke
People who experience persistent pain are four times as likely to have an anxiety or depressive order as the general population
33%
Cancer
44%
HIV / AIDS

6. Integrated 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.

7. 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

8. 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

9. 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 smoking
89%
88%
Monitoring of BMI
52%
51%
Range across Trusts for monitoring of BMI
5 – 92%
27 – 87%
Monitoring of glucose control
57%
50%
Range across Trusts for monitoring glucose control
16 – 99%
25 – 83%
Monitoring of lipids
47%
Monitoring of blood pressure
61%
56%
Monitoring of five risk factors in those with established cardiovascular disease
37%
Monitoring of alcohol consumption
70%
69%

10. This outlines practical actions for
Board
Executive team
Learning and development dept.
Operational management
Clinical team
Every clinician

11. 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 Hardy’s 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

12. 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 % 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.

13. The availability of treatment & the costs of effective treatment

14. NICE guidelines for the treatment of depression in LTCs show stepped care model

15. 2012 publication Compendium of examples of cost effective programmes for people with physical illnesses in acute trust, primary care settings

16. Additional slides with details if asked to show

17. What does every clinical team need to do & what support do they need to do it
Template Letter to GP to get the summary record with Reed/ICD codes, medications, physical blood etc results
Mental health & Lester plus cardiometabolic physical assessments
Coproduced formulation with service user
ICD physical & MH codes recorded on ECR
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

18. NAS 2 (blue) v NAS – Physical Health - interventions
Standard 5 – intervention offered for identified physical health risks
Intervention for BMI > or = 25kg/m2
71%
76%
Intervention for abnormal glucose control
36%
53%
Intervention for elevated blood pressure
25%
Intervention for alcohol misuse
74%
72%

19. NAS 2 (blue) v NAS Antipsychotic prescribing

20. 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. 

21. 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.

22. 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 3rd 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

23. 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