Item 5 - London Clinical Senate Council 29 November 2016 Improving physical health for individuals living with serious mental illness The Stolen Years Project Dr Mary Docherty 1
Lo Lond ndon on an and Na d Nati tion onal c al con onte text xt • The London Health Commission identified the need to care for the most mentally ill in London so they live longer, healthier lives. Despite knowing that people with mental illness are less likely to access physical healthcare little had been done to proactively address it. • To improve the care of those living with serious mental illness (SMI), the Better Health for London report (2014) set the goal with the leaders of all the mental health trusts in London to reduce the gap in life expectancy between adults with SMI and the rest of the population by 10% within 10 years. Improving the mortality gap is also a key focus nationally, recent national reports and strategies outlining this include: • The coalition government’s No health without mental health (2011), the annual report of the Chief Medical Officer (2013), the BMA’s report on achieving parity of outcomes (2014), The Kings Fund’s Bringing together physical and mental health (2016), The Academy of Medical Royal Colleges’ Working across medicine to improve the physical health of people with severe mental illness (2016). • The NHS Five Year Forward View (2014) outlined the need for NHS to break down the barriers in how care is provided between physical and mental health and for patients with mental illness to have their physical health addressed at the same time . • The Five Year Forward View for Mental Health (2015) outlined the requirement for 280,000 more people living with severe mental illness to have their physical health needs met by 2020/21 by increasing early detection and expanding access to evidence-based physical care assessment and intervention. 2
The he ca case se for or cha hang nge Prevention Gaps- Inequality and the Health and Well being Gap • In the UK men with SMI are estimated to die 8 – 15 years and women 7 – 18 years earlier than those without mental disorders. The overall life expectancy or mortality gap has been estimated at between 10-25 years. This is a three-fold risk of premature mortality compared with the general population. • The vast majority of preventable deaths are due to chronic physical health conditions such as cardiovascular, respiratory and metabolic disease. Individuals living with SMI relative to the general population have double the risk of obesity and diabetes, three times the risk of smoking, hypertension and metabolic syndrome and five times the risk for dyslipidemia. Diagnosis and Treatment Gaps- Inequity in healthcare utilisation and the Care and Quality Gap Nearly half (46%) of people with SMI will have a long-term physical condition yet the evidence base for treatment inequalities extends across a range of conditions: hyperlipidaemia, cancer, diabetes, arthritis, stroke, surgical procedures including lower rates of surgical procedures for cardiovascular disease. Individuals living with mental health have three times more accident and emergency attendances and five times more unplanned inpatient admissions the the general population with significantly higher length of stays. Health outcomes gaps- Inefficiency and the Cost and Efficiency gap The estimated economic cost of smoking among people with mental ill health was £2.34 billion in 2009/10. From emerging London based analysis, costs of physical health co-morbidity for those living with SMI between doubled and quadruple care costs. This mirrors international data where co-morbidity with physical health conditions added between 20% to 90% to costs. When further co-morbidity with substance misuse is added, costs have been estimated to escalate dramatically with up to a further tripling of costs. 5 year survival rates for some LTCs are lower in individuals living with SMI than the general population - 22% of people with coronary heart disease and SMI had died compared to 8% of people without, 19% of people with diabetes and SMI had died compared to 12% of people without, 28% of people who had suffered a stroke and had SMI had died compared to 12% of people without SMI. 3
The Stolen Years programme summary • A large component of the mortality gap is due to preventable and treatable physical health conditions. Individuals living with SMI experience gaps in prevention, diagnosis, treatment and treatment outcomes for physical health risk factors and conditions. They fail to benefit equally from current configurations of health care services providing primary, secondary or tertiary disease prevention. • Progress in achieving change has been slow due to the complexity of the determinants of excess mortality and morbidity and lack of a systematic cross sector approach targeting the primary drivers. Lack of clarity about roles and responsibilities and system related barriers that inhibit joint accountability perpetuate the challenge. • There is significant variation in care available to support the physical health of those living with SMI but where pockets of excellent practice exist there is an absence of a co-ordinated effort to sustain and scale up this progress. • Despite consistent service user and carer feedback , the request for personalisation, holistic care and responsive services that flex according to individual preferences and optimise both health and non health based community approaches has not been met. • In late 2015 the Stolen Years programme engaged with key stakeholders from across mental health, social care and physical health sectors to identify priorities and understand the key challenges in addressing the mortality gap in London . A comprehensive scoping exercise and literature review was conducted to identify gaps and opportunities. Hundreds of service users contributed to identifying priorities and recommendations. A mapping exercise of all current sector challenges was conducted. It was evident that despite the existence of high quality reports with robust recommendations there was a lack of guidance on how to deliver these changes. • Where improvements in outcomes are contingent on multiple different activities in and between different sectors it was agreed that strategic guidance on commissioning and implementation were needed . • A programme of work was agreed to support closure of the implementation gap . A support tool would be developed to deliver evidence based or consensus activities in different sectors and settings addressing the key drivers of premature mortality . Building on current progress and system assets, a systematic approach would be taken that supported evaluation, scale up and iterative closure of evidence gaps whilst tracking the impact on key outcomes over time. Key clinical leadership networks have been created and linked up across sectors to support delivery. • The programme is now commencing consultation on the draft tool kit. Feedback on its format and content is being sought 4 alongside identification and clarification of roles, responsibilities and opportunities to support delivery and implementation.
The Stolen Years Strategy Development of a whole system quality improvement framework to close the mortality gap A cross sector strategy was developed to address the current variable, uncoordinated and frequently unevaluated efforts to close the mortality gap and to optimise key existing policy and other system levers and enablers. Priority, evidence based activities to address the key drivers of the mortality gap were identified from the literature review and whole system consultation. These were broadly grouped into efforts or interventions that target key drivers of the mortality gap namely health risks and behaviours, healthcare utilisation and treatment outcomes. The recommended activities and guidance on how to complete them are ambitious in raising standards but compatible with economic constraints and responsive to concurrent system wide work to develop STPs and deliver the Five Year Forward View. These activities were then mapped to their intended outcomes and potential indicators to enable tracking of progress in short, medium and longer-term goals towards closure of the mortality gap. e.g. changes in smoking rates, changes in smoking related disease burden, changes in premature deaths from smoking related conditions. The strategy serves as a quality improvement framework for commissioning and provision to deliver multi level improvements in care for those living with SMI. It can be used as a whole system map to enable planners and providers in different parts of the health and care system to see how small changes and improved pathways and relationships across sectors can fit together on aggregate to accelerate efforts to close the mortality gap. The early strategy outline was delivered to STP planners in March 2016 to facilitate forward planning and accommodation of these service improvements in each London region’s 5 year plan. 5
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