1. Mental Health and how it impacts on your Business The role of the GP Dr John Hague Governing Body GP Ipswich and East Suffolk CCG

2. What am I going to discuss? How big the problem is What my problems are What your problems are Some solutions from a commissioners viewpoint 2

3. How it all fits together 3

4. The Area 4 Around 72,000 people aged 16-74 with anxiety, depression or both. (Higher than expected) Around 9,500 children in Suffolk have a mental health disorder, of which some 5,800 have a conduct disorder Self harm prevalence for 15-16 year olds is 10% of girls and 3% of boys. Up to 1500 women in Suffolk per year experience depression and anxiety during and after pregnancy. Prevalence of personality disorder is around 24,000 people aged 16 to 74 66 GP practices 450 GPs 2 acute hospitals 4 community hospitals A recently retendered community health provider A single mental health trust Children’s universal health services delivered by the local authority

5. The Burden Only around a quarter of those with mental health conditions are in treatment Only 13 per cent of the NHS budget goes on such treatments yet mental illness ….. Accounts for almost a quarter of the total burden of disease. Suicide in teenagers has risen by 12% since the start of the 2007 recession Anti-depressant prescriptions have almost doubled since 2002 and is now over 40 million items per year in England alone 5

6. The causes? (in no order) Economic downturn Bullying (at work) Poor HR practice Debt & Poverty Perceptions of Job Centre / DWP Bereavement / relationship issues / physical health Family History 6

7. The impact, for you Poor performance Reduced profit Disciplinary issues Presenteeism Bullying Unemployment Bankruptcy 7

8. The reality, for me There is no more money There are no more clinicians (today, or tomorrow – recruitment is very, very hard) There are always more patients There is always more illness Acute hospitals always take the money from the system Around 14 unfilled GP vacancies in East Suffolk today ½ of GP training places locally unfilled Hard to recruit practice nurses 8

9. The reality, for me A GP will have up to 110 patient contacts a day 40-60 is absolutely normal After that there is 20-40 letters, 20-40 repeat prescriptions, and 20-40 laboratory results (each consisting of up to 40 individual results) Do the maths! 9

10. The reality, for me That is our environment We are where we are We would like to be more efficient, offer more, offer more time etc – but this depends on national solutions, that will take years to implement Of course we can do better ourselves Constant improvement is a given As is workforce innovation 10

11. The reality GP’s do not provide an occupational health service, as the taxpayer does not pay for it Employers need to do this themselves You could start at NHS Health at work (Other providers are available) 11

12. The reality Mental illness represents 1/3 of an average GP’s workload In my case it’s more like 60% I am very keen to explore system wide solutions 12

13. What People Tell Us 13 There are gaps between existing services Services need to be more personalised People should not need to navigate pathways. Services should be accessible The wider workforce needs better understanding of mental health The 1 st person you speak to should be skilled enough to get you to the right service at the right time I don’t want secondary care services if I don’t need them More join up with physical health services Should be easy to go back to services and ask for help Services should listen and not label It is helpful to talk to people with similar experiences Services should not keep discharging me and making it hard to re-refer More support earlier in schools Debt, housing and other social issues effect mental health

14. The reality Most medication comes from a GP prescription Most ‘fit notes’ are signed by GP’s Talking treatment via Suffolk Wellbeing service (and its partners) 14

15. 15 The wellbeing service sees over 15% of those with anxiety and depression in Suffolk every year Around ½ of patients will recover (about as good as medication) This is performance as expected People can self refer by phone or web No need to take medication as well Over 80 languages available on website Free workplace workshops (Other providers are available)

16. Primary care & the CCG The CCG now co-commissions primary care Patch wide ‘investors in people’ Work on recruitment and retention with HEE, NHSE, SCC Monthly education sessions Regular feedback – example below Contract query line Support of CCG for system wide reform Genuine involvement of 14 GP’s in commissioining, with good relationship with officers and NHS England 16

17. Primary Care Mental Health: Our Commissioning Approach Joined up commissioning Co-production Innovation Developmental Evolutionary Outcomes focus GP’s will continue to do what they do 17

18. What We Want to Achieve 18 Our Vision – From mid 2016 A stepped care primary care mental health service NICE requirements and exceeding national IAPT targets An all age pathway with a strong family based approach Delivering evidence based interventions Offering integrated physical and mental health pathways Promoting recovery and peer support No gaps between primary and secondary care - integrated delivery As accessible as general primary care Partnership based delivery Developing the universal workforce

19. Vision for Common Mental Health Problems Huppert Ch.12 in Huppert et al. The Science of Well-being 19 FlourishingModerate mental health LanguishingMental disorder Signs Symptoms and Risks

20. Who is it for 20 An age inclusive psychologically focused service for: Adults with mild to severe common mental health problems (with secondary care providing care coordination and risk management when there is high risk) Children and Young People with mild to moderate common mental health problems and those with conduct disorders or behavioural problems Step down from secondary care

21. Outcomes 21 Service Level Outcome  Exceeding all national IAPT targets  Timely access to all services  An increased proportion of people in PBR cluster four managed in primary care Patient Level Outcomes  Sustained recovery and improve functioning  A meaningful role (including employment and learning)  Satisfaction with the service  Carers feel supported in their caring role  Improved physical health e.g. healthy weight, stop smoking, achieve responsible drinking levels  Family mental health and wellbeing is improved  Right step, first time System Impact  A more empowered, knowledgeable and confident system-wide workforce  Joined up pathways with other health, care and support services  Integrated pathways for people with long term conditions  Integrated care pathways for common mental health disorders Impact on Secondary Mental Health Care  Reducing length of stay in secondary care for people with complex needs  Reducing referrals to secondary care  No-one falls in a gap between primary and secondary care

22. Why is this different? A strong family focus A complete pathway for all common mental health problems, no gaps Integrated working between all providers A strong focus on outcomes and recovery Good relationships with primary care and services for children and young people 22

23. Early Intervention: But Not Prevention Relationship with 5 steps to mental wellbeing, Action for Happiness, “Happy City” This is all a Public Health responsibility 23

24. Workplace well-being programmes TargetWorking-age adult population accessed through their place of employment Inter- vention Multi-component health promoting programme, including a health risk appraisal and information and advice tailored to the employee’s readiness to change health-related behaviours. Cost = £80 per year employee per year Outcome evidence Quasi-experimental evaluation in UK company reported significantly reduced stress levels, reduced absenteeism and improved productivity (Mills et al 2007). Economic pay-offs Reductions in sickness absence and presenteeism; reduced costs of avoidable mental health problems to NHS FindingsTotal savings = £9.69 for every £1 invested (Slide from Paul McKrone, LSE)

25. You could Read… 25

26. You could… Pay well Be an Investor in People Tackle bullying at work Practice superb HR practice Offer debt & poverty advice Offer help with bereavement / relationship issues / physical health / stress Take a long view 26

27. Thank you Any Questions? johnhague@nhs.net 27