New approaches to implementing mental health programs in primary care

1. New approaches to implementing mental health programs in primary care Professor Helen Lester Academy Health, Orlando, June 2007

2. What I’m going to talk about • Background to UK Mental Health issues • Two stories of programme implementation • Stepped care models for depression and Access to Psychological Therapies (IAPT) schemes • Health checks in primary care for people with serious mental illness

3. NHS budget for 2006–07 is $190 billion • 1.33 million employees • Services are free at the point delivery • Primary care has a gate keeping role

4. Primary care policy context • Primary care has been viewed as increasingly important in mental health policy terms since 1999 • NSF (1999) and 5 year review (2004) • National Plan (2000) • Tackling Health Inequalities (2003/6)

5. Self care 1-2 million Primary care 3.75 million Shared care 300,000 Specialist services 600,000

6. Treatment of depression: the problem • Prevalence of 2.1-9.8%(NICE, 2004) • 40% of people have a chronic relapsing illness (Lloyd, 1996) • 5,000 deaths p.a. • Economic costs particularly in terms of unemployment and state benefits

7. Incapacity Benefit recipients by medical condition in the UK (2004)

8. The evidence base: NICE guidance on depression (2004) • Uses a stepped care framework • Recognises that depression can be a chronic illness and therefore borrows from chronic disease management models of physical health problems (Wagner, 2004)

9. Over view of the stepped care system Step 5: Inpatient care, crisis team Risk to life, severe self-neglect Medication, combined treatments, ECT Treatment-resistant, recurrent, atypical and psychotic depression, and those at significant risk Medication, complex psychological interventions, Case management and collaborative care Step 4: Mental health specialists including crisis team Step 3: Primary care team, primary care mental health worker Medication, psychological interventions, Case management and collaborative care Moderate or severe depression Watchful waiting, guided self-help, computerised CBT, exercise, brief psychological interventions Step 2: Primary care team, primary care mental health worker Mild depression Recognition Step 1: GP, practice nurse Assessment

10. The implementation gap? • The NICE guidance has few ‘teeth’ in terms of implementation • Lack of therapists so 6-9m waiting lists for people from step 2 onwards…

11. Recent implementation levers • Bad publicity - ‘NHS failing to act on talking therapies clinical guidance, says new report’ • ‘Depression: the great happiness pill betrayal’ • Pledge to IAPT as part of the 2005 Labour election manifesto

12. The vision: Lord Layard and the LSE’s ‘New Deal’ • High profile media coverage • 10,000 more therapists by 2013 • Cost of $120 million • Working in teams in 250 centres • Centrally funded and commissioned • Providing 16 weekly sessions lasting 1 hour • ‘Should more than pay for itself’ • Focused on return to work issues

13. The practical strategy: IAPT programme • 2 very different demonstration sites • Some new monies but mainly service reconfiguration • Cooperation between sectors • Mental health champions • Doncaster is using a high volume low intensity model with case managers as part of a stepped care framework • Newham is using specialist CBT providers • 10 new sites this Summer recognising the advent of different funding mechanisms for commissioning within the NHS

14. Early findings Doncaster: • Need: 2,000 people referred in 5m • Referral pathways: 95% from GPs • Workload: Mean number of sessions = 3 (2-11) • Stepped care model: 10% of people stepped up to CBT • Outcomes: access (including waiting times) and inclusion (including employment) • Waiting times: 1 week

15. Serious mental illness in primary care: the problem • Lifetime prevalence of 3.48% (Perala et al, 2007) • Often starts at a young age so a lifetime of consequences • Societal exclusion including 4% employment rates • Higher morbidity and standardised mortality rates (151) than the general population (Social Exclusion Unit, 2004)

16. Serious mental illness in primary care: the evidence base • Variable/poor health promotion and health prevention in primary care (Brown 1997; DRC 2005) • SMR of 156 (Harris and Barraclough, 1998) • GPs’ view that the work is too specialised • Patients’ view that primary care is the cornerstone of care (Lester et al, 2005)

17. Implementation gap • NICE guidance (2002/7) includes roles for primary care but has few teeth • Educational gaps (only 2% of practice nurses and 30% of GPs have postgraduate mental health experience) • Primary care practitioners can be as narrow minded as the rest of the world

18. Implementation levers • Networked grass roots support for change led by local and national mental health champions • Financial incentives in primary care through the Quality and Outcomes Framework (2004)

19. The vision: Quality and Outcomes Framework 25% of GPs’ income relates to a set of evidence based quality indicators that apply to primary care • Chronic disease management (18 areas- 4% of the overall points/money focused on SMI) • Practice organisation (5 areas) • Additional services (4 areas) • Patient experience (consultation length and patient surveys)

20. The practical strategy: reorganisation of care for people with SMI • Register of patents with a psychosis • Lithium levels monitored and therapeutic • Annual relevant physical health check up and medication review • Liaison with secondary care e.g. • Follow up if the patient doesn’t attend • Care plan to include social networks, early warning signs and crisis plans

21. Early findings: points achievement in 2005/6

22. Generalisable lessons • Alignment of an agreed problem + evidence base + policy levers + a clear vision + practical strategy • Variable amounts of new monies • Reconfiguration and co-operation e.g. across the interface has occurred with some new but mainly existing staff rather than whole new systems

23. “Although vision is important for initiating change, it is not enough to organise and maintain a system of care. Vision must be translated into practical strategies.”(Alan Rosen,The mental health matrix.1999)