Using research to inform commissioning decisions Barbara Herts Director for Commissioning – Mental Health
Some national background In England, we spend a lot of money on mental health, but we often spend it on dealing with the consequences of NOT investing in prevention & early access to treatment (Geraldine Strathdee). • 5 Year Forward View For Mental Health published by NHS England in February 2016. • NHSE - “ the first time there has been a strategic approach to improving mental health outcomes across health and care systems.” • Priorities identified as - 7 day NHS; an integrated mental health and physical health approach; and promoting good mental health and preventing poor mental health. • Over 50 recommendations. The Five Year Forward View concludes that £1 billion on investment will be needed by 2020/21 to deliver its vision and ‘plug critical gaps ’ with the expectation ‘that savings and efficiencies generated by improved mental health care e.g. through a strengthened approach to prevention and early intervention, and through new models of care, will be reinvested in mental health services. 2
Some local background • The Essex health economy spends a total of £c.350mm on MH services . Of this, £242m is commissioned by the 7 local NHS CCGs; £51m by Essex County Council (ECC) and the two Unitary Authorities (UAs) in the south; and £57m by NHS England. In addition, ECC spends an additional £195m social care of older adults, of which approximately £130m is spent on dementia • In 2015, partners commissioned Boston Consultancy Group to undertake a Strategic Review of Mental Health. • Key recommendations included: – Simplification of commissioning landscape – Creation of a common language to clarify needs and expectations – Work more jointly • Underlying point of the report – Continuation of the status quo is not an option! 3
The current evidence base: a critical issue for Essex 1. Everybody in Essex is likely to be affected by mental health problems, either directly or indirectly, and at each stage of their life (and we all ‘have’ wellbeing) . 1 in 5 mothers with peri-natal issues; 1 in 4 adults with a mental health problem each year; half of these problems affecting people by their 14 th birthday; and 1 in 5 older people affected by depression (40% in care homes). 2. Mental illness is linked to other problems, and to poor outcomes. People with severe and prolonged mental illness die on average 15 or 20 years earlier; mental health issues complicate recovery from physical illness; people with serious problems are more likely to be unemployed and less likely to have fulfilling and rewarding work; 9 out of 10 prisoners have mental health issues. 3. Many people in Essex will need some kind of specialist help and support. Nationally, nearly two million adults were in contact with specialist mental health and learning disability services at some point in 2014-15; nine out of 10 are supported in primary care and nine out of 10 of those with severe problems are supported in the community; the number of adult inpatient psychiatric beds reduced by 39% overall between 1998 and 2012. Across the system there is significant unmet need and concern about service availability and quality. 4
The current evidence base: a critical issue for Essex 4. The human, social and economic cost is substantial. The social and economic cost has been estimated at £105 billion a year (roughly the cost of the entire NHS); the cost of dedicated mental health support in England is £34 billion (incl. £14 billion of ‘unpaid care’), excluding dementia and substance misuse; and mental health accounts for approaching a quarter of all NHS activity. The Layard Report (2006) estimated the total loss of output due to depression and chronic anxiety at £12 billion a year, or 1% of national income, with a £7 billion taxpayer cost – including benefits and lost tax. 5. Evidence based approaches are cost effective – they save money (which can potentially fund extension/improvement of mental health provision). The Layard Report concluded that investment in cognitive behavioural therapy targeted at people on benefits would pay for itself and bring significant additional benefits; a report from Rethink, London School of Economics and Centre for Mental Health claims substantial cost benefits for a range of interventions, including many where local authorities have a key role (e.g. supported and crisis housing, peer support, self management, personal budgets and welfare advice). 5
Our need for further research • Need to support system wide transformation; how do we affect change? What will work for people? • Direction of travel towards facilitating the meeting of need rather than direct provision of care • Essex Mental Health Review also recommends; – “Generate and share more data across the system” – “Conduct robust needs assessment” – “Develop and track better outcomes” 6
The ethnographic approach • In partnership with The Public Office, Essex County Council have looked to apply to ethnography as a way of meeting research needs • An immersive approach – what’s really going on? – What’s the difference that makes the difference? • The Public Office have overseen research work looking at 6 mental health related projects across Essex. – The Recovery College, Personal Budgets and Personal Health Budgets, Sociability, Carer-led workforce training, zero-suicide, Intensive Enablement 7
Hope for Better Mental Health • The “ Hope for Better Mental Health ” report was produced by The Public Office as a result of their research work. • Challenging findings; – “ the best way to reduce costs and improve outcomes is for service users to recover – to get better. This is a surprisingly radical concept in mental health . Once diagnosed, service users often stay within the system for years, struggling to envision a future that’s different and better than the difficulties they face in the present” • Key point in the report – Co-production can support recovery . – “When people work with professionals who consistently remind them of their abilities and their potential, and who give them opportunities to demonstrate these things to themselves and others, it builds confidence and strength.” 8
Using the findings • The six emergent initiatives that featured in Hope for Better Mental Health have fundamentally rethought where the agency and power for recovery comes from. • Have commonality in approaches that seek to put citizen agency and capability centre-stage, at every stage – Co-production. • “Co -production means delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and their friends.” Essex are looking to embed the co-production approach into a procurement for Integrated Support, Advice, Recovery and Mentoring Services (ISARMS). This service will join-up mental health and substance misuse provision and will be shaped and run by people who use services 9
Engaging with providers… As part of our work on the ISARMs project, we have used our research to inform engagement with providers and people who use service. Cue video… 10
Questions? Barbara.Herts@essex.gov.uk 11
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