Thursday 14 th February 2019 #VCSEEngage

1. GM VCSE Mental Health Forum (including dementia, perinatal, children, young people and adult mental health) Thursday 14th February 2019 #VCSEEngage

2. Welcome and Housekeeping Stewart Lucas, Strategic Lead, Mind in Greater Manchester

3. Mental Health Programme Update Zulfi Jiva, Head of Cross Cutting Programmes, Greater Manchester Health and Social Care Partnership

4. The GM Mental Health programme Implementation Plan

5. The Timeline Devolution deal GM Mental Health investment agreed and GM Commissioning Review GM MH and Wellbeing strategy Five Year Forward View Mental Health GM Mental Health Programme Delivery 2015 2016 2018 2017 Devolution does NOT take away Greater Manchester responsibility to deliver on national mandated priorities, standards and targets

6. How Greater Manchester will Deliver Our Share of the National Five Year Forward View Ambition by 2020/21 … 3,920 more children will access evidence-based mental health care interventions – including better access for ADHD, eating disorders + those with disabilities Intensive all-age home treatment will be available in every part of GM as an alternative to inappropriate hospital admissions No GM acute hospitals without all-age mental health liaison services, and 100% meeting the national ‘core 24’ service RAID standard + RADAR Increased access to evidence-based psychological therapies to reach 25% of need - 33,600 more people helped – primary care and LT condition care pathways At least 1,680 more women each year can access evidence-based specialist perinatal mental health care + additional local parent-infant MH support pathways 30 people fewer or 10% reduction suicides and all areas will have multi-agency suicide prevention plans in place (including acute hospital standards) 1,624 people with SMI who can access evidence-based Individual Placement and Supported Employment will do so - and GM Work & Health model support 15,680 people with SMI will have access to evidence based physical health checks and interventions – targeting smoking and obesity 60% people experiencing a first episode of psychosis will access NICE concordant care within 2 weeks Inappropriate out of area placements will be eliminated for adult acute mental health care - with targeted city-centre action, expanded local GM MH rehab specialist units + GMP/L&D triage New models of care for tertiary MH will deliver quality care close to home,reduced inpatient spend, increased community provision and new crisis care models for children and young people Right number of CAMHS/Eating Disorders/LD/Secure T4 beds in the right place – esp reducing the number of inappropriate out of area placements for children and young people

7. GM Mental Health and Wellbeing strategy vision • Improving child and adult mental health, narrowing their gap in life expectancy, and ensuring parity of esteem with physical health is fundamental to unlocking the power and potential of GM communities. • Shifting the focus of care to prevention, early intervention and resilience and delivering a sustainable mental health system in GM requires simplified and strengthened leadership and accountability across the whole system. • Enabling resilient communities, engaging inclusive employers and working in partnership with the third sector will transform the mental health and well-being of GM residents.

8. Translation into GM Mental Health Programme investment (specific sub-programmes and projects)

9. GM Mental Health Programme Implementation Provider Federation Board Primary Care Advisory Group GM Health & Care Board Joint Commissioning Board (NHS/ LAs) Association of GM CCGs (to be discontinued) GM Commissioning Hub GMCA MH Programme Delivery Board Dementia United Board GMHSCP Performance and Delivery Board Specialised Commissioning Oversight Group Population Health Board Adult MH Board CYP MH Board Health and justice Board GM Mental Health Network MH service user/ carer networks MH VCSE forum and reference group Enabling programmes: business intelligence, finance and contracts, workforce, estates, IM&T

10. Adult MH Board and Supporting Action Programmes/WorkStreams Chief Officer, GMHSCP Locality Assurance meetings Adverse Childhood Experiences (ACE) Themes Adult MH Board (Chairs: Henry Ticehurst/ Chris Daly) Communities of Identity/ Equalities • 2 x Transformation Fund Programmes: • Liaison MH (Core 24) • Suicide Prevention • Mental Wellbeing • 5 x Current FYFVMH Non-Transformation Fund programmes: • Early Intervention in Psychosis (EIP) • Increasing Access to Psychological Therapies (IAPT) • Out of Area Placements (OAPs) and Acute Care Redesign • Physical health of people with Severe Mental Illness (SMI) • Individual Placement Support Growing the voice of service users and families 1 x Transformation Fund Programmes Additional Locality MH investment – IAPT Long-term Conditions and Enhanced Adult Crisis and Urgent Care Working with VCSE and faith sectors • 1 x Additional Non Transformation Fund Projects • Personality Disorders Specialised commissioning (adults, children and young people) MH Workforce (adults, children and young people) Finance, BI and contracts (adults, children and young people) Estates, IM&T and Digital innovation (adults, children and young people)

11. CYP MH Board and Supporting Action Programmes/Work Streams Chief Officer, GMHSCP Locality Assurance meetings Adverse Childhood Experiences (ACE) Themes CYP MH Board (Chair: Sandeep Ranote/ Charlotte Ramsden – DCS Link) Communities of Identity/ Equalities • 4 x Transformation Fund programmes: • CYP MH community-based access and crisis care programme • Perinatal and parent-infant MH programme • THRIVE and CYP workforce development programme • Mental and emotional wellbeing in education settings up to age 18 project • CAMHS (Future in Mind) • Non-Transformation Fund programmes: • ADHD • Eating Disorders • Service transitions • CYP Access and Waiting Times Growing the voice of young people and families • 1 x Additional Non Transformation Fund Projects: • Student MH Working with VCSE and faith sectors Specialised commissioning (adults, children and young people) MH Workforce (adults, children and young people) Finance, BI and contracts (adults, children and young people) Estates, IM&T and Digital innovation (adults, children and young people)

12. MH Programme sub-programmes/ projects summary Slides for Mental Wellbeing, Workforce, CYP MH Quality, Access and Waiting Times and evaluation to follow

13. GM Mentally Healthy Schools Rapid Pilot Launched in March 2018 with exceptional outcomes; this is now being further expanded into Phase 2 to cover 63 schools and colleges across GM – with a view to rolling out to 125 schools & colleges by September 2019. CYP MH Crisis Care programme roll out 1. Assessment Centre: Phase 1: now live Phase 2: April 2020 2. Crisis Beds: April 2019 3. RRTs: Phase 1: May 2019 Extended hours: July 2019 24/7/365: October 2019 4. Safe Zones: Phase 1: April 2019 GM Out of Area Placements (OAPs) Delivery Group Over 50% OAP reduction seen in 2018/19 GM CYP Access & Waiting Time GM achieving over 35% - achieving 2021 target more than 2 years early GM CYP Waiting Times published – first in the UK GM Mental Health Programme - Key Headlines

14. Out of Area Placements Clair Carson, Associate Director of Operations Greater Manchester Mental Health Trust

15. The Greater Manchester Plan to Eliminate Out of Area Placements (OAPs)

16. Objectives of the presentation: • What is the issue? • What has been done so far? • How can the VCSE sector support this agenda? • Way forward and Questions

17. Work so far: • Agreement of definition of an OAP in Greater Manchester • Agreed the trajectory required to meet elimination target by 2021 including 33% reduction in 18-19 • Define standards for care coordination and friends and family contact • Review bed management systems • Undertake baseline of community solutions • Further develop OAP steering group to include acute crisis care • Agreement of the DTOC flow diagram on how to implement the national DTOC definition agreed across the conurbation.

18. Deep Dive Work: • Undertaken to understand the presenting issues and to inform the wider GM plan • Demand in the services across GMMH had risen by between 10-16% • The numbers of service users being admitted for 72 hours or less had increased • The numbers of service users on the in patient wards with a length of stay of over 50 days had also risen • Indicating that more people were coming in because they had a short term crisis that could potentially be managed a different way and more people were ‘stranded’ on the wards awaiting another package of care not readily available. • This created a blockage in flow and as a result demand for out of area beds continued

19. Elimination of all OAPs by 2021: • NHSE announce that all Mental Health Trusts are to eliminate the use of Out of Area Placements by 2021 • This would be based on an agreed trajectory every year that works towards a zero use, for GM in 18-19 this is 33% • GM are now well on the way to meeting this years trajectory target.

20. Elimination of OAPs by 2021: • GM forum developed an agreed definition of an OAP that is in line geographically with other Trusts across England and agreed by NHSE • This was agreed by all CCGs and Providers in GM • Two layers, one reportable OAPs, those placed outside GM and locally monitored OAPs, those placed within GM • The previous table clearly shows that reduction. This is validated by GM moving from 1st on a list of worse performers in England for OAPs in March 2018 to the October 2018 position showing GM as the 22nd best out of 44 Mental Health Trusts.

21. OAPs definition:

22. The 10 Point Plan: • Based on the National 15 point plan, the local GM team developed a 10 point plan that, if delivered, would eliminate the need for the use of any Out of Area Placements • Agreeing the GM definition was the first part of this 10 point plan that was addressed and agreed for implementation from April 2018.

23. GM 10 point plan to eliminating Acute OAPS • Whole System collaboration • A GM definition and trajectory • Patient flow data and monitoring • Standards of ACP Fidelity • A GM Bed Bureau • Responding to crisis • Collaborative community housing options • Learning from others • Evaluation with service users, their family & friends • Costs and systems to reduce these

24. How can the VCSE sector help? • Crisis Pathways and alternatives to admissions • National evidence on the role of peer mentors shows their impact on the quality of experience whilst an inpatient • Support on discharge, sustainable community options • Overall support to families, friends and carers throughout the service user journey

25. Alternatives to admission: • Large numbers of admissions less than 72 hours • Audit showed that if something else was available these admissions need not have taken place • The ‘something else’ could be an offer from the VCSE • Crisis beds, crisis cafes and other models • offer an alternative when someone is in crisis • not needing an in patient admission but • needing more than being sent home • Would want to model such approaches with • the VCSE to look at local need and resources • and develop the solutions in a co-produced • way

26. Peer mentors: • Proven evidence base that such approaches add value to the service users, both those receiving and those undertaking the role of the peer mentor • Can be utilised in all areas of the acute care pathway, from the initial support required in the crisis assessment phase, in Home Based Treatment or In Patient wards. • Ongoing support through links with CMHTs and VCSE service provision to benefit from the ongoing role and value this offers

27. Sustainable Community Solutions: • We would want to work with the VCSE sector to develop • ongoing support when service users are discharged from • services such as in patient wards • These will offer a wide range of support designed to offer sustainable recovery options for the service users in their own communities • VCSE services are best placed to understand the local communities, their needs and support structures and we would welcome a co-produced approach to achieving this element of the 10 point plan.

28. Carers, families and friends support: • The VCSE are ideally located to be able to offer support, help and advice to families, carers and friends at different points on the service user pathway • Can offer support away from hospital based services and in the neighborhoods aiding accessibility and improving support options • Offering a non-health based solution can aid in trust and engagement and develop future links to community assets

29. CONCLUSIONS & ACTIONS

30. The elimination of OAPs is a whole system solution • Whilst some elements are with the CCGs and providers to address the longer term solutions lie in co-produced work with our VCSE colleagues • Welcome discussion and ideas and views on how we could achieve this

32. Delivering the Prevention Focus in the Mental Health Strategy Jan Hopkins, Programme Manager, Greater Manchester Health and Social Care Partnership

33. The Mental Health of Older People in Greater Manchester Dr Kathryn Dykes, Greater Manchester Mental Health NHS Foundation Trust

34. The Mental Health of Older People in Greater ManchesterFact and Fiction Polly Kaiser PCFT Kathryn Dykes GMMH

35. Why is this important ? For older people, carers and families For our communities For our health and social care economy

36. Older peoples’ mental health is NOT just dementia. It is vital that all services are responsive to the needs of older people with mental health needs. This includespublic health and prevention recognition of mental health needs in general health services low-level needs intensive support for high-level and complex needs

37. Commissioners and providers must ensure that people over 65 have equitable access to the full range of age-appropriate and non-discriminatory mental health services required to meet their needs. (Equality Act 2010, Joint Commissioning Panel 2013)

38. Older people do not have access to the range of services available to younger adults in mental health despite having the same, and often greater, need. (Royal College of Psychiatrists Faculty of Old Age Psychiatry, 2007)

39. Older People living in Greater Manchester • By 2039 the number of GM residents aged 65+ will expand by 53% to reach 650,000 • The same period will see a doubling of the number of over 85s in GM, to over 100,000 • Analysis suggests that emergency hospital admissions, length of stay and total bed days are all higher in those aged over 65 than the national average.

40. Fact or Fiction? Depression is a natural part of getting older - “it’s just your age” Older people do not have as many risks as younger people – they don’t harm themselves, do they? Older people do not have personality disorder. Older people don’t experience psychosis Older people do not misuse substances Older people can have the same service as younger people – then everyone gets the same Therapies aren’t effective with older people – “You can’t teach an old dog new tricks” Older people don’t contribute to the economy – it’s not like older people need to get back to work is it? Older people are well off now – poverty is a thing of the past. All older people are lonely aren’t they? Older people are frail so can’t exercise or do much

41. Depression is a natural part of getting older - “it’s just your age” Mental health problems are as common in older people as they are in younger adults and are associated with considerable individual suffering. Depression is both the most common and most treatable mental illness in old age, affecting 20% of older people in the community. This figure doubles in the presence of physical illness and trebles in hospitals and care homes (Mueller et al., 2017).

42. Older people do not have as many risks as younger people – they don’t harm themselves – do they ? Older people who self-harm are at 67 times greater risk of suicide than the general older population and three times greater than the relative risk of suicide among younger people who self-harm (The University of Manchester, 2012) Sudden unexplained deaths on psychiatry in-patient wards are highest among people aged 65-74 (no data for greater ages) being 8 times higher than people under 45 years of age (National Confidential Inquiry into Suicide and Homicide in People with Mental Illness (2009) Annual Report England and Wales. University of Manchester.) There is an elevated risk of suicide in older people who self-harm yet older people do not get access to specialist care; • only 12% of over 65s who self-harm are referred to mental health services within 12 months of their initial self-harm episode. • Referrals are a third less likely for older people in the most deprived areas even though the incidence of self-harm is higher in these areas. • One in seven older people self-harmed again within a year of the initial episode (Morgan et al., 2018)

43. Older people do not have “personality disorder”. There is an incorrect belief that older people do not experience “personality disorder” leading to denial of support and services. The prevalence of “personality disorder” in the general older population is documented to be at around 10% (Beatson et al., 2016; Cruitt & Oltmanns, 2018; Zweig, 2018). For older people in outpatient mental health settings prevalence figures between 5 and 33% have been reported. (Van Alphen et al., 2012) Older people with a “personality disorder” make up 44% of completed suicides (Mattar and Khan, 2017) This group are more likely to have complex and chronic difficulties (van Alphen, 2012; Zweig, 2008). Increased somatization and seeking care from others can lead to difficulties in the provision of care and longer admissions (Beatson et al. 2016).

44. Older people don’t experience psychosis • Psychosis is much more common in older people than younger adults with 20% of people over age 65 developing psychotic symptoms by age 85 and most are not a precursor to dementia (Ostling, Palsson, & Skoog, 2007). • The prevalence of psychotic symptom among the elderly ranges between 2.6% and 10% (Ostling, Palsson, & Skog, 2007; Ostling et al.) • The healthcare costs of late-life schizophrenia are estimated to be as high as the amount spent on teenagers and young people with schizophrenia (Nebhinani, Pareek, Grover, 2014).

45. Older people do not misuse substances The number of older drug users in Europe is predicted to double between 2001 and 2020. (European Monitoring Centre for Drugs and Drug Addiction, 2010) The “baby boomer” population born between 1946–1964 (now aged between 53 and 71 years old) is at the highest risk of substance misuse which is rising within the older population. (The Royal College of Psychiatrists, 2018). Older people with mental disorders such as depression, anxiety, and personality disorder have higher rates of substance misuse than those without mental disorders. Deaths related to poisoning from substances in older people have more than doubled over the past decade. (The Royal College of Psychiatrists, 2018). Older people who misuse substances may not present with the same symptoms as their younger counterparts and, therefore, may be more difficult to identify. (Kuerbis, Sacco, Blazer, & Moore, 2014).

46. Older people can have the same service as everyone else – everyone gets the same • To avoid direct and indirect forms of discrimination via the ‘one size fits all approach’, care services must be age appropriate (Royal College of Psychiatrists, 2011). • As people age they are increasingly likely to have multiple diagnoses which require expertise to manage them alongside the mental illness (Hilton, 2012).

47. Therapies aren’t effective – “You can’t teach an old dog new tricks” • Psychological treatment is as effective for older patients as for younger adults (Karlin et al. 2015; Rodda, Walker and Carter, 2011; Pinquart, Duberstein and Lyness, 2007). • Evidence shows that a range of treatments, including but not limited to CBT, are effective treatments for older people with depression (Gould, Coulson and Howard, 2012; Laidlaw et al., 2008; Scogin et al.,2006).

48. Older people don’t contribute to the economy – it’s not like older people need to get back to work is it? £245 bn per year in lost consumers £230bn in lost workers £5bn from lost volunteers £4bn from lost grandparents • By 2021, NOT meeting the mental health needs of older people could be costing the UK economy(Lishman, 2007) • The consequences of depression in older people are vast, including reduced quality of life and increased medical morbidity and mortality as well as an increased caregiver burden. There is also an increased expenditure of resources to compensate for the individual’s functional decline and consequential needs (Goncalves et al., 2009).

49. Older people are well off now- poverty is a thing of the past • Using the most commonly used definition 1.9 million pensioners (16%) are living in relative poverty. (Age UK 2018) • Percentage living in Poverty (Age UK 2018) • 65-69 = 13% • 80-84 = 19% • 85 + = 17% • White pensioners = 14% • Asian or Asian British = 29% • Black or Black British = 33% • Incomes for pensioner couples have continued to rise whilst incomes for single male and female pensioners have not risen in real terms, or have fallen slightly. (UK Poverty 2017 A comprehensive analysis of poverty trends and figures, 2017). • Pensioners who rent their homes are much more likely to be in poverty than owner occupiers.(UK Poverty 2017 A comprehensive analysis of poverty trends and figures, 2017)

50. All older people are lonely - aren’t they ? • The proportion of older people who say they are often lonely has remained relatively constant since at least 2006/07. But the size of the older population is growing. • The chances of being often lonely do not differ because of age – loneliness is similarly common at all ages, the risk of loneliness is driven by people’s circumstances, which can differ by age (Age UK, 2018). • Loneliness increases the likelihood of mortality by 26% and is as bad for you as smoking 15 cigarettes a day. (Holt-Lunstad, 2015; 2010)