NHS Yorkshire and the Humber QIPP resource pack - YHPHO.ppt by suchufp

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									NHS Yorkshire and the Humber
Monthly QIPP resource pack




August 2010

                               1
Introduction
This is the eighth QIPP monthly resource pack. The pack has three components:


BETTER FOR LESS EXAMPLES: We have worked with you to develop practical examples of schemes
which have been developed locally and have potential to deliver better quality at lower cost. This
month the ‘better for less’ examples focus on mental health.


MENTAL HEALTH ‘HOT TOPIC’: Each month we will produce one ‘hot topic’ briefing which provides
more detailed analysis on a subject relevant to QIPP. This month the hot topic is mental health. The
analyses presented here are designed to offer insight and raise questions about variation in
performance. They need to be interpreted in the local context.


QIPP METRICS: We have developed a set of metrics to help understand system health in the tighter
financial climate. We will publish these metrics monthly although some of the indicators will only be
updated quarterly. The purpose is to offer insight and improve understanding of how the system
delivering with lower growth.


The next resource pack will be published week commencing 6 September. The hot topic will be
cancer. If you have any questions or comments on the pack, please contact Ian Holmes.
(Ian.holmes@yorksandhumber.nhs.uk)



                                                                                                        2
1) Healthy Ambitions




                       3
Out of area placements




                                                                                                   Better for Less – out of area placements
                           A collaborative approach to commissioning for
                           out of area placements can significantly reduce
                           placement costs, improve quality and yield
                           better outcomes for patients.


 Why Out of Area placements?                 However, for the individual, placements
                                             can make family and community contact
 Around 500 people in Yorkshire & the        very difficult, lead to a loss of ties and
 Humber are currently supported through a    connections, and make return very
 variety out of area placements. The cost    unlikely.
 of these placements to the system is
 estimated at £15.6m*.                       How can we provide better for less?

 Out of area placements are necessary in     Working with the Commercial Procurement
 some circumstances due to the level of      Collaborative can help to ensure
 challenge individuals create or the small   consistency of costs, quality and service
 number of people nationally needing         for people placed in out of area
 specific types of care.                     placements.
                                               *Data excludes forensics, acute inpatients & PICU                          4
Out of area placements




                                                                                          Better for Less – out of area placements
A project led by the regional Specialist    Financial benefits
Commissioning Group, is offering a
regional approach to the commissioning      The Yorkshire & Humber Improvement
and procurement of high volume high cost    Partnership (YHIP) are working to
                                            understand the reliance on out of area
out of area placements.                     placements in the region. Using early (and
                                            incomplete) data from our region coupled
Patient benefits                            with national evidence and research a
                                            first estimate of potential savings for the
Studies have demonstrated that caring for   region has been calculated.
individuals through local services rather
than out of area placements helps them to   £15.6m was spent in Yorkshire & the
regain independent living skills.           Humber in 2009/10 to deliver out of area
                                            care for around 500 service users, an
                                            average of £31,000 per placement.
Supporting service users through local
services enables them to maintain family    Data collected by YHIP found that
and community contact, important factors    commissioners with the lowest cost
in mental health wellbeing.                 placements were paying up to 60% less
                                            than those with the highest cost
                                            contracts.



                                                                                                                 5
Out of area placements




                                                                                            Better for Less – out of area placements
At an average cost of £31,000, the           This work to improve procurement has given
potential to save between 30% and 60%        increased value for money, supported by
per placement, results in cost savings of    detailed service specifications, quality
between £9,300 and £18,600 per               measures and stronger market management.
placement.
                                             By moving to a new contract and pricing
Based on the data collected by YHIP, PCTs    structure £2.9m was saved initially (4.5% of
in Yorkshire & the Humber commissioned       the overall total). This will potentially
between 6 and 111 placements in              increase to a saving oh £11 million over the
2009/10. Using the median value, a PCT       term of 4 years.
with 23 placements could save an average     http://www.westmidlands.nhs.uk/LinkClick.
of £320,400 through reviewing their use of   aspx?fileticket=qtm_DHt1SDw%3D&tabid=914
placements.
                                             For further information:
Case Study: West Midlands                    Y&H Commercial Procurement Collaborative:
                                             Vicky.Morton@yorksandhumber.nhs.uk
West Midlands specialised commissioning
team (WMSCT) has worked across the           Y&H Specialist Commissioning Group:
West Midlands to commission secure and       Ged.McCann@BarnsleyPCT.nhs.uk
other specialists placements.

                                                                                                                   6
2) Hot topic: Mental Health




                              7
Contents


Overview

Mental health and employment




                               Mental health - Contents
Out of area placements

Mental health care pathway

Dementia

Annexes

                                               8
Contents


Overview

Mental health care pathway




                               Mental health - Contents
Out of area placements

Mental health and employment

Dementia

Annexes

                                               9
Purpose


 This information pack is the eighth in a series ‘hot topics’ that will be
 produced by the SHA to support organisations in developing their
 understanding of some of the challenges and opportunities presented by
 the QIPP agenda.




                                                                             Mental health - overview
 While recognising that it may raise more questions than answers, we hope
 it will stimulate thought and debate within organisations and health
 communities. Clearly the data presented need to be interpreted in the
 local context.

 We would be delighted to receive comments on the contents together with
 any ideas for further analysis.




                                                                                     10
Foreword from the Mental Health Leadership Board
 Mental wellbeing is central to the solution in terms of how to achieve QIPP efficiencies
 across the whole system. Regardless of the pathway on which a patient is being
 treated, there is strong evidence of the QIPP opportunities through maintaining a focus
 on mental health and wellbeing within every NHS encounter.

 Particularly for acute care pathways, the use of mental health wellbeing assessments
 at the beginning of a spell is shown to improve outcomes for patients: facilitating
 speedier recovery and re-enablement. Mental health wellbeing assessments are also a




                                                                                            Mental health - overview
 key component of self-care and directed care models.

 Contemporary mental healthcare is based on the principles of providing quality
 evidence-based treatment, predominantly in a community setting. The introduction of
 Community Home Treatment teams has led to fewer patients needing hospital
 inpatient care. Treatment at home is preferred by service users for its personalised
 feel, the evidence suggests comparable clinical and social outcomes to inpatient
 settings. In Yorkshire and the Humber there is still wide variation in bed usage.
 Commissioners and providers need to consider how to reduce this variation without
 compromising safe, effective and personalised care.




                                                                                                    11
Overview
Mental illness costs the NHS in our region in excess of £1bn annually. However, it is
estimated that the wider economic burden of mental wellbeing is closer to £10bn.

Times of economic slowdown are particularly challenging for mental health services, with
numerous studies linking joblessness and other economic pressures with poorer mental
health. It is against this backdrop of rising demand for mental health services that the
NHS will have to deliver the biggest programme of efficiency savings in its history. The
scale of the challenge is significant, but we know that there are a number of areas where
better care can cost less by:




                                                                                             Mental health - overview
     • Focusing on earlier identification and preventative services
     • Redesigning pathways to support care in the most appropriate setting
     • Ensuring that when patients with mental health problems require acute care they
         receive care that reflects their more complex needs
     • Recognising that understanding mental health and wellbeing issues is key to all
         care pathways, particularly recovery and rehabilitation

This resource pack focuses on 3 areas where evidence suggests significant gains in quality
and productivity can be achieved:
     • Dementia care - particularly relating to acute episodes
     • Out of area placements
     • Mental health care pathway


                                                                                                     12
Overview - prevalence and future costs
                                             Prevalence of any neurotic disorder (based on 2006 populations)

In England at any one time, 1 in 6 people               PCT
                                                                    Hull       197.2

will experience a diagnosable mental                            Leeds          190.1


health problem. Mental illness covers a
                                                   Bradford & Airedale         187.1
                                                           Calderdale          182.7

broad spectrum of conditions, and                             Kirklees
                                                     Wakefield District
                                                                               178.2
                                                                               177.8
prevalence varies significantly by PCT.                       Sheffield        171.7
                                                            Doncaster          162.2
                                                              Barnsley         161.9

Psychological therapies are used to treat                  Rotherham           159.2


milder conditions (neurotic disorders). Data
                                                       NE Lincolnshire         159.1
                                                   N Yorkshire & York          135.3




                                                                                                                                                                                   Mental health - overview
about these services demonstrates a range         E Riding of Yorkshire
                                                        N Lincolnshire
                                                                               125.6
                                                                               119.8
of prevalence from less than 120 per 1,000                                 0            20    40         60     80       100      120           140       160        180    200

population to more than 197.                Source: Mental Health Observatory 2008
                                                                                         Prevalence of any neurotic disorder, rate per 1000 population


                                                                                                         Mental Health Prevalence - Percentage of patients on G
                                                 Mental Health Prevalence - Percentage of patients on GP lists that are on
QOF data reflects the prevalence of more
                                                                                     QOF mental health registers 2008-09
                                                 QOF mental health registers 2008-09
                                                                                                                      PCT

severe conditions. The proportion of
                                                              PCT                                                                                    England
                                                                                                                               Leeds          0.86
                                                                      Leeds         0.86
                                                                                                                Bradford & Airedale           0.83
patients on registers varies across the
                                                        Bradford & Airedale         0.83
                                                                                                                            Kirklees          0.78
                                                                    Kirklees        0.78

region, the average for Yorkshire & Humber                       Calderdale                                              Calderdale           0.77
                                                                                    0.77
                                                                           Hull     0.73                                        Hull          0.73

is below England. The ability of QOF to                    Yorks & Humber
                                                                    Sheffield
                                                                                    0.73
                                                                                    0.72
                                                                                                                     Yorks & Humber
                                                                                                                            Sheffield
                                                                                                                                              0.73
                                                                                                                                              0.72
reflect actual prevalence relies on people                  NE Lincolnshire         0.71                             NE Lincolnshire          0.71

with such problems consulting their GP and
                                                                 Rotherham          0.71                                 Rotherham            0.71
                                                              N Lincolnshire        0.69                              N Lincolnshire          0.69

GPs adding their patients to mental health                 Wakefield District
                                                         N Yorkshire & York
                                                                                    0.68
                                                                                    0.66
                                                                                                                  Wakefield District
                                                                                                                 N Yorkshire & York
                                                                                                                                              0.68
                                                                                                                                              0.66
registers.                                                       Doncaster
                                                                    Barnsley
                                                                                    0.65
                                                                                    0.61
                                                                                                                          Doncaster           0.65
                                                                                                                            Barnsley          0.61
                                                       E Riding of Yorkshire        0.53
                                                                                                               E Riding of Yorkshire          0.53
                                                                                  0.0              0.2             0.4                  0.6                0.8               1.0
                                                                                                                                        0.0                    0.2             0.4
                                                                                                              Mental health prevalence (%)
                                                                                                                                                                           Mental health p
                                                 Source: Health and Social Care Information Centre (IC) 2009
                                                                                                         Source: Health and Social Care Information Centre (IC) 2009



                                                                                                                                                                                           13
Overview - variation in expenditure
                                                                         Total Cost of Adult Mental Health per Weighted Population Aged 18 to 64 - 09/10

Average spend on mental health per                                                                                                                   Y&H Average


weighted population in Yorkshire &
                                                                                                                                                     England Average

                                                                      East Yorkshire


the Humber is less than the national                                        Bradford

                                                                          Doncaster

average. The regional average                                            Rotherham


however masks large variation




                                       Local Implementation Team
                                                                                 Hull

                                                                     North Yorkshire

across Local Implementation Teams.                                   NE Lincolnshire

                                                                          Calderdale

                                                                              Leeds

(For more information on the source




                                                                                                                                                                       Mental health - overview
                                                                           Wakefield


of this finance data see Annex B).                                          Barnsley

                                                                            Sheffield

                                                                             Kirklees


To what extent does this variation                                 North Lincolnshire



reflect greater service need or
                                                                                        £0          £50          £100          £150           £200              £250




relate to quality of care?                                                               Source: Y&H LIT Results of Financial Mapping Report’s 2009/10 ,
                                                                                         DH/Mental Health Strategies



                                                                            The 2009/10 data was collected based on LITs, this
                                                                            organisational structure ceased to be in existence
                                                                            earlier this year. Local Implementation Teams (LITs)
                                                                            were coterminous with PCTs, responsible for
                                                                            progressing mental health work streams with
                                                                            responsibility for both NHS and non-NHS spend.



                                                                                                                                                                               14
Contents


Overview

Mental health care pathway




                               Mental health - Contents
Out of area placements

Mental health and employment

Dementia

Annexes

                                         15
                                                                                                                                                Mental health – mental health care pathway
Care pathway – Overview
 National and regional policy
 direction over a number of
                                   Changing mental health investment profiles - £s...
 years has been to increase
 emphasis on prevention and         Investment
                                                   Prevention,
                                                  public mental
                                                                           Primary/
                                                                          social care,
                                                                                           Community
                                                                                             teams -
                                                                                                           Other
                                                                                                        secondary -   Acute in-
                                                                                                                                  Specialised
                                                                                                                                  and Secure
 provision of care in community
                                       Levels                            housing, day         liaison   continuing     Patient
                                                     health                                                                        Services
                                                                           resources        services       care


 settings over acute and other
 secondary care settings.           2010/11           £0.5m                £11m             £10m          £11m        £20m         £8.5m




 The table opposite from the        2015/16           £4.5m                £14m             £11m          £6m         £14m         £5.5m

 National Mental Health
 Development Unit sets out an
 illustrative example of how the
                                        [NB: Values illustrative only]

                                         NMHDU (National Mental Health Development Unit)


 pattern of care may shift over
 the next 5 years.
 The profile of mental health services has already been to reflect these patterns of
 provision – for example, nationally, there are one third less mental health beds now
 compared with 15 years ago. But the rate of change has varied considerably across our
 region, and there is large variation in the way services are currently delivered.




                                                                                                                                                               16
                                                                                                                                                                                          Mental health – Mental health care pathway
Care pathway – psychological therapies
The national Improving Access to Psychological Therapies (IAPT) programme is aimed at improving access
for everybody with common mental health problems of depression and anxiety in primary & other
community settings. The National Institute of Health and Clinical Excellence (NICE) has recognised the
contribution that psychotherapeutic treatments (see annex C for examples) can make to the care of
people with a wide range of debilitating mental and physical illnesses (CSIP, 2007).
                                                    Percentage of people who have completed IAPT treatment and achieved "caseness"
IAPT has been rolled out in 3 waves. The            at initial assessment who are "moving to recovery", Q4 2009/10

variation illustrated in the chart reflects the         East Riding of Yorkshire     85.5%


wave at which IAPT has been implemented. The                            Kirklees

                                                              North Lincolnshire
                                                                                     65.4%

                                                                                     60.0%

higher values for sites with developed IAPT                          Calderdale      55.9%


services demonstrates the effectiveness of the
                                                                     Rotherham       45.6%

                                                                      Doncaster      44.5%

programme in implementing mental health                                   Leeds      39.5%


services in the primary & community settings.
                                                        Yorkshire & the Humber       39.0%
                                                                       Sheffield     38.7%
                                                                       Barnsley      38.5%


Once IAPT is fully implemented and matured it is
                                                         North East Lincolnshire     32.4%
                                                               Wakefield District    9.3%

expected that 50% of people completing                                       Hull

                                                         North Yorkshire & York
                                                                                     3.2%

                                                                                     -
treatment would move to recovery. 4 LITs in our             Bradford & Airedale      -

area already have services exceeding this target.                               0%                    20%                 40%                60%                80%                100%

                                                                                    % of people completing treatment and achieved "caseness" at initial assessment "moving to recovery"

“Caseness” defines the level of mental illness      Source: Omnibus Survey Q4 2009/10 (Health and Social Care Information Centre (IC))

                                                    Completing treatment includes those that dropped out or were sign posted on
at which an individual will benefit from
treatment. It is a threshold for a standardised         Note: Low numbers are likely to reflect later wave
measure of symptoms defined using: the                  adopters of IAPT.
General Anxiety Disorder Assessment (GAD7)
and the Patient Health Questionnaire (PHQ9).

                                                                                                                                                                                                         17
                                                                                            Mental health – Mental health care pathway
Care pathway - psychological therapies: example

In North Lincolnshire, the IAPT programme has been used to further enhance services
offered. Using IAPT standard data for a sample of 38 patients, a comprehensive “clinical
medication review” was undertaken by an IAPT nurse.

Of the patients included, only one had clinical need for extended use of antidepressant
medication as defined by NICE Guidance. In light of the findings, the others were either
helped to stop, referred on or treatment changed with positive outcomes.

Savings from the project were defined as the reduction in costs (based on current
treatment pricing) as a result of no longer prescribing inappropriate treatments. Through
prescribing in accordance with NICE guidance, this small project produced a cost saving
of £17,500. 6 patients successfully stopped using anti-depressants, and 7 successfully
reduced use.

As a result of the pilot RDASH has seconded a full-time nurse prescriber to continue the
work across the organisation and GP practices to release more cost savings.




                                                                                                           18
                                                                                                                                                                                            Mental health – Mental health care pathway
Care pathway– community vs secondary care
                                                                                         Average Direct Cost per Weighted Adult on the Top 5 Highest spend Adult
                                                                                                         Mental Health Serivces in Y&H, plus IAPT
 The pie chart shows the major sections of
 direct cost for all types of adult mental
 health services across Yorkshire & the
                                                                                              £32.2                             £32.6

                                                                                                                                                    Secure and High Dependency

 Humber.                                                                                                                                            Provision
                                                                                                                                                    Clinical Services

                                                                                                                                                    Continuing Care

 The chart below shows the ratio of spend
                                                                                     £3.2

                                                                                                                                                    Community Mental Health Teams

 on services accessed by people with                                                                                                                Access & Crisis Services

 general mental health needs:                                                         £17.6                                             £22.9

                                                                                                                                                    Psychological Therapy Services (IAPT)

 - clinical (secondary care) services,                                                                                                              Other

 - community mental health teams and,                                                                 £18.6

 - access and crisis services.
                                                                                                                        £20.2


                                                                              Direct cost per weighted population (18-64) on: clinical services,
                                                                              access & crisis services and community mental health teams (2009/10)
 Whilst the ideal pattern of care will differ                                 England Average
 across different localities, reflecting                                    Y & H SHA Average
                                                                                          Leeds
 patient needs and geography, over time we      Local Implementation Team      North Yorkshire
 would anticipate the proportion of care                                    North Lincolnshire
                                                                               NE Lincolnshire
 delivered in secondary care to decline and                                            Barnsley
                                                                                      Sheffield
 be replaced by primary and community                                                       Hull
 services.                                                                           Wakefield
                                                                                   Rotherham
                                                                                     Doncaster
                                                                                      Bradford
 To what extent are PCTs with relatively                                                Kirklees
 high secondary (clinical) care spend                                               Calderdale
                                                                                 East Yorkshire
 assessing the options for shifting care into
                                                                                                       0%         20%             40%            60%               80%             100%
 community settings?
                                                                                     Clinical Services        Access & Crisis Services          Community Mental Health Teams


                                                                                                                                                                                                           19
                                                                                                                                                                       Mental health – Mental health care pathway
Care pathway - Community mental health services
                                          People receiving early intervention services by commissioner, rates per 100,000
Rates of community mental health          weighted adult population, Q4 2009-10
                                                       PCT

services are calculated to take account               North Lincs
                                                        Sheffield
                                                                          79
                                                                          78

of different needs of the local                        Wakefield
                                                      Calderdale
                                                                          78
                                                                          76
populations.                                          Rotherham
                                                        Barnsley
                                                                          75
                                                                          75
                                                       Brad&Aire          74
                                                       Doncaster          73
Early intervention services are for                          Hull
                                                         Kirklees
                                                                          72
                                                                          72
younger adults aged 15-34 who have                Yorks & Humber          64
                                                     N East Lincs

had their first psychotic episode.
                                                                          59
                                                      North Yorks         45
                                                     East Riding          42
                                                           Leeds          41

Home treatments provided by crisis                                    0                 20                40                60                 80               100
                                                                           People receiving early intervention services, rates per 100,000 weighted adult population

resolution teams are for adults with      Source: VSMR data (SHA) 2010


more longstanding mental health             Home treatment episodes by commissioner, rates per 100,000 weighted adult
                                            population, Q4 2009-10

problems.                                                PCT
                                                       Calderdale          454
                                                 Wakefield District        437
                                                          Kirklees         419

There is no apparent correlation                N Yorkshire & York
                                              E Riding of Yorkshire
                                                                           411
                                                                           385
between PCTs providing comparable                  NE Lincolnshire
                                                  Yorks & Humber
                                                                           382
                                                                           365
levels of both types of service. East                   Doncaster
                                                             Leeds
                                                                           358
                                                                           351
Riding for example has one of the                        Sheffield         344


lowest rates of early intervention but
                                                    N Lincolnshire         338
                                                         Barnsley          335

above average home treatment
                                               Bradford & Airedale         333
                                                               Hull        328

episodes.
                                                       Rotherham           311

                                                                      0                  100               200               300               400               500
                                                                                    Home treatment episodes, rates per 100,000 weighted adult population
                                           Source: VSMR data (SHA) 2010
                                                                                                                                                                                 Mental health – Mental health care pathway
Care pathway – acute care services
                                          Admissions to mental health inpatient services by commissioner, rates
                                          per 100,000 weighted population 2008-09
Considerable variation exists across                    PCT
                                                     Wakefield District
                                                                                                                              England

                                                                                  460
the region in the number of                        Brad fo rd & Aired ale
                                                   N Yorkshire & York
                                                                                  448
                                                                                  400
admissions to mental health inpatient                   N Lincolnshire
                                                            Ro th erham
                                                                                  386
                                                                                  352
services.                                              NE Lincolnshire
                                                      Yo rks & Humber
                                                                                  346
                                                                                  298
                                                               Barnsley           277
                                                                Kirklees          255
A reduction in admissions and LOS                            Doncaster
                                                            Calderdale
                                                                                  246
                                                                                  236
could free up substantial resources for                           Leed s
                                                                    Hull
                                                                                  224
                                                                                  223
some PCTs                                                      Sh effield
                                                 E Riding of Yorkshire
                                                                                  174
                                                                                  165

                                                                             0            100              200                 300                   400            500

Early calculations by YHIP indicate                                                     Admission rates per 100,000 weighted population
                                          Source: Health and Social Care Information Centre (IC) 2009

that reducing admissions rates in line    Distribution of average length of stay in a psychiatric hospital, by

with the best performing trusts could
                                          provider, 2008/09                                    Distribution of average length of stay in a psychiatric h
                                                                under 1 month    1-2 months   2-3 months
                                                    Provider
                                                                                                             3months
                                                                                               provider, 2008/09 - 1 year    Over 1 year


free up £25 million across the region.     NE Lincolnshire Care Trust Plus                                                                          under 1 month   1-2 months                            2-3 m
                                                                                                                               Provider
                                                            Barnsley PCT                                          NE Lincolnshire Care Trust Plus

                                                      Sheffield Care Trust                                                         Barnsley PCT


There is wide variation in the length         Bradford District Care Trust
                                               Rotherham, Doncaster & S
                                                                                                                             Sheffield Care Trust

                                                                                                                     Bradford District Care Trust
of stay profile of providers in the              Humber MH NHS FT
                                                  N Yorkshire & York PCT
                                                                                                                      Rotherham, Doncaster & S
                                                                                                                        Humber MH NHS FT

region however, average performance       Humber MH Teaching NHS Trust                                                   N Yorkshire & York PCT


is in line with England.                                 Yorks & Humber                                          Humber MH Teaching NHS Trust

                                          SW Yorkshire Partnership NHS FT                                                       Yorks & Humber

                                                               ENGLAND                                           SW Yorkshire Partnership NHS FT

                                               Leeds Partnerships NHS FT                                                              ENGLAND

                                                                                                                      Leeds Partnerships NHS FT
                                                                             0%           20%               40%                  60%                   80%           100%
                                                                                                Percentage of records in Mental Health Minimum Data Set 20%
                                                                                                                                          0%                                              40%
                                          Source: Health and Social Care Information Centre (IC) 2009                                                               Percentage of record
                                                                                                                 Source: Health and Social Care Information Centre (IC) 2009

                                                                                                                                                                                                21
                                                                                          Mental health – Mental health care pathway
Care pathway – personality disorders
Personality disorders are common conditions, between 5% and 13% of people living in
the community suffer with such problems and between 50% and 70% of the prison
population are affected.

The psychological, social and economic consequences of personality disorder affect not
only the individual but families, friends, communities and society in general. Some
people survive asking little of public or voluntary services; others use a range of
services of varying benefit. Although sufferers may access A&E departments and
primary care services, these contacts are not able to respond to the real needs of such
patients.

The Personality Disorder Development Programme was established in 2003 and is based
in the Department of Health and Ministry of Justice. This programme has overseen
investment in national pilot services to test ways of developing new local responses.
The outcomes of the pilot based in Leeds suggest:

-investment in dedicated multi agency personality disorder services substantially
 improve outcomes for the population
- investment significantly reduces the impact on wider mental health services and the
 wider health care, social care and criminal justice systems


                                                                                                         22
                                                                                   Mental health – Mental health care pathway
Care pathway – personality disorders (2)
Following the pilot scheme in Leeds, an audit project has been undertaken to
determine the effectiveness of a dedicated personality disorder resource.
Data for a cohort of individuals that access the Leeds Managed Clinical
Network for personality disorder has been compared with a relative cohort
from Sheffield.

In a sample of 22 patients (typically 75 cases will access services at any given
time) the following outcomes were observed:
- 60% reduction in acute mental health service admissions
- 100% reduction in PICU admission
- 20% reduction in A&E attendances

The reduction in health care service usage resulted in net savings of £104k,
service users reported improved satisfaction and clinical outcomes.




                                                                                                  23
Contents


Overview

Mental health care pathway




                               Mental health - Contents
Out of area placements

Mental health and employment

Dementia

Annexes

                                         24
Out of area placements - overview




                                                                                               Mental health - Out of area placements
Out of area placements include long term placements in hospital or residential & nursing
homes.
The challenge of placements results from the need for PCTs to commission from multiple,
often independent sector providers creating variation in costs and quality to meet
additional demand. These arrangements lack consistent service specifications and
performance monitoring arrangements and usually are much more expensive than services
that are provided through normal contracting routes.

Out of area placements are necessary in some circumstances due to the level of challenge
individuals create or the small number of people nationally needing specific types of
care. However, for the individual, placements can make family and community contact
very difficult, lead to a loss of ties and connections, and make return very unlikely.

The Royal College of psychiatrists estimates that 22% of all people in placements are in out
of area treatments. A recent survey by the Royal College showed that out of area
treatments are 65% more expensive than in-borough placements (£34,000 vs £21,000).

In 2009/10 Yorkshire & the Humber had approximately 500 episodes of out of area
placements. PCTs in Yorkshire & the Humber commission services from 11 NHS providers
across the country and 17 private provider organisations.


                                                                                                             25
Out of area placements – expenditure




                                                                                                                           Mental health - Out of area placements
                                                                      Estimated total cost of placements by type 2009/10
The following information for Yorkshire & the Humber
is based on initial and incomplete data returns from     £7,000,000
commissioners in the region.                             £6,000,000
                                                         £5,000,000
Scaling up the data submitted to account for missing
                                                         £4,000,000
data points, commissioners in Yorkshire & the Humber
spend approximately £15.6m on out of area specialist     £3,000,000
mental health placements.                                £2,000,000
                                                         £1,000,000
The available data indicates wide variation in the              £0
types of OAP being utilised by each commissioner
group. Whilst the data is not sensitive to the
complexities of individual cases, high level
comparisons suggest more than 2 fold variation in the
costs of placements.

Eating disorders and locked rehabilitation account for
the highest volume and highest cost out of area
placements* – over £10m in regional spend. There is
                                                                                              Placement type
also wide variation in the associated costs across the                              Eating disorder Rehabilitation
region, commissioners should consider both as areas            Bed day cost Min                  332             410
for high potential savings.
                                                                   (£)      Max                  850             920
While eating disorders are the highest area of spend,
the mental health board believe that locked rehab               * The survey excluded accurate data collections
offers the greatest potential for savings - A high              relating to acute and PICU placements, these
volume of spot contracts are used for these
placements in area which are not reflected in the               are the highest cost & volume placements in
data.                                                           the region.

                                                                                                                                         26
Out of area placements - opportunity




                                                                                                           Mental health - Out of area placements
Nationally, around £330m is spent annually on out of area treatments at a net additional cost of £134m
relative to local services. The majority of oats are thought to be replaceable, reducing the net cost by
half would generate savings in the region of £6.7m per SHA. The lack of local services is a significant
obstacle to realising savings.

In the shorter term, the high cost of oats can be reduced through improved commissioning. The
potential for localities in the Yorkshire and Humber region to realise cost efficiencies and improved
quality outcomes as a result of reviewing their utilisation of out of area placements is variable and is
dependent upon their:
- unique circumstances,
- resource provision and,
- service configuration.
(http://www.rcpsych.ac.uk/press/pressreleases2010/oats.aspx)

Working with the Commercial & procurement Collaborative can help to ensure consistency of costs,
quality and service for people placed in out of area placements. A project, led by the regional
Specialist Commissioning Group, is offering a regional approach to the commissioning and procurement
of high volume high cost out of area placements.

The model seeks to generate competitive markets where appropriate to incentivise competition
amongst providers to improve patient outcomes and deliver improved value for money. Experiences in
East & West Midlands have successfully reduced costs and generated savings for the commissioners
involved.



                                                                                                                         27
Contents


Overview

Mental health care pathway




                               Mental health - Contents
Out of area placements

              & employment
Mental health and employment

Dementia

Annexes

                                         28
                                                                                                   Mental health – Mental health & employment
Mental health and employment - Overview
The Yorkshire and Humber Improvement
Partnership (YHIP) have estimated the cost
of mental illness across our region to be
£9.3bn; this estimate is based on total
system costs for services and employers
spend.

Projections by the Kings Fund suggest an
increased pull on the mental health system
as a consequence of rising unemployment
occurring in times of fiscal prudence. Access                                Evans, Francis 2009

to employment and meaningful activity is as
such, highly relevant in this respect.
Where people recover from mental illness and return to work, evidence shows that there are
savings not only in lower welfare spending, but also that individuals make less use of public
services, including mental health services (Sainsbury Centre for Mental Health, 2009b).

As a result of work commissioned by YHIP, a tool to support the evaluation and costing of
potential savings through employment strategies that will encourage better decision making
will be available next year. The work will also determine the most effective employment
based on cost benefit analysis.

                                                                                                                  29
                                                                                                                         Mental health – Mental health & employment
Mental health & employment - settled employment
                                         Percentage of adults receiving secondary mental health services
                                         known to be in paid employment at time of most recent assessment,
There is strong evidence on the          formal review or multi-disciplinary care planning meeting 2008-09
therapeutic benefits of paid              North East…   8.7
                                                                       England

employment and the likely long            Calderdale    8.0
                                             Sheffield  7.5
term savings to the health                      Leeds   5.2

system (Drake 2009). Work
                                    Wakerfield District 3.4
                                       Yorkshire & the… 3.2

provides protection against                 Doncaster   2.4
                                    North Yorkshire &… 2.0

mental illness( Foresight) and                Kirklees  1.9
                                        East Riding of… 1.8
has a strong therapeutic value,            Rotherham    1.4
                                   Bradford & Airedale  0.8
especially for people with                   Barnsley   0.8

severe and enduring mental                              0.0
                                    North Lincolnshire
                                                  Hull  -
health conditions (NICE,                             0           2           4            6           8           10

McLean & Carmona 2005).                                         % of adults receiving secondary MHS in paid employment

                                                    Source: Health and Social Care Information Centre (IC) 2010

There is wide variation in the proportion of adults using secondary mental
health services known to be in paid employment. The local economy and labour
market conditions will have a significant role in determining employment levels
in conjunction with services offered to individuals. The average for the region is
below the national average.

                                                                                                                                        30
                                                                                                     Mental health – Mental health & employment
Mental health & employment - example
 The Individual Placement Support (IPS) model helps people with mental health
                     problems into paid competitive work.

A multi-site European trial found that individual placement support clients had fewer and
shorter hospital stays than clients in traditional services (Burns et al, 2007), which contributed
to significant savings in in-patient costs over an 18-month period. A US study recently
corroborated these findings: mental health service costs over a 10-year period were 50% lower
for people supported into regular employment than among other groups (Bush et al, 2009).

The annual cost of implementing IPS in line with government commissioning guidance on
vocational services is estimated at around £6.7 million per SHA, £440,000 per average PCT. In
comparison, current spending on day and employment services is around £18.4 million a year.

There are a range of tools to help with this including:
- Vocational Guidance for Commissioners (DH/DWP) and;
- Implementing Recovery, a Model for Organisational Change (Sainsbury Centre for Mental Health
2010).

There is a strong argument for recovery focussed delivery within mental health, with investment
in effective vocational rehabilitation at it’s core.




                                                                                                                    31
Contents


Overview

Mental health care pathway




                               Mental health - Contents
Out of area placements

Mental health and employment

Dementia

Annexes

                                         32
Dementia - overview
The National Dementia Strategy (NDS) published by The Department of Health in 2009 has
brought a long overdue focus to the types of services and supports offered to the estimated
820,000 people directly affected in the UK.

“Dementia describes a group of symptoms associated with a progressive decline of brain
functions, such as memory, understanding, judgement, language and thinking. The most
common form of dementia is Alzheimer’s disease.”




                                                                                                     Mental health - Dementia
“People with dementia become increasingly dependent on health and social care services and on
other people. Dementia has a significant economic impact: the total cost of dementia in terms
of care and lost productivity is estimated at £23 billion across the UK. (The Alzheimer’s Research
Trust)

The scale of resources required to support dementia sufferers each year is almost 5 times more
than other cancer:
                               Dementia            £27,647
                               Cancer              £5,999
                               Stroke              £4,770
                               Heart Disease       £3,445

Dementia diagnoses are often made at the time of crises that could have potentially been
avoided. Dementia patients often also have a much poorer experience and worse outcomes
associated with other pathways, especially urgent care.

                                                                                                             33
Dementia - Overview
                                                Observed cases of dementia on GP disease registers, 2008/09, as a percentage of

Around 60,000 people in Yorkshire and the
                                                estimated dementia cases aged 65 and over, 2008, Yorkshire and Humber PCTs


Humber suffer from dementia.                                                                      100%




                                                Cases of dementia - observed as a % of expected
                                                                                                  80%

At present there is significant under-
diagnosis of dementia across our region and                                                       60%


it is estimated that approximately 60% of                                                                England

cases in our region are undiagnosed. East                                                         40%



Riding of Yorkshire having the highest                                                                                                                                                                                                                                                                    50.9%




                                                                                                                                                                                                                                                                                                                                 Mental health - Dementia
                                                                                                                                                                                                                                                    44.4%         45.2%         45.4%        46.3%
                                                                                                  20%                                                                  39.6%               39.6%         42.2%                 42.3%    42.3%
                                                                                                                                                 37.1%

estimated level of under-reporting (27% of
                                                                                                                          33.8%   35.5%
                                                                                                         27.0%



cases identified) and Bradford and Airedale                                                        0%




                                                                                                                                                                                                                                                                                              Rotherham
                                                                                                                                                                                                          Yorkshire & Humber
                                                                                                                           Hull




                                                                                                                                                                       North Yorkshire &



                                                                                                                                                                                            Calderdale
                                                                                                         East Riding of




                                                                                                                                                  North Lincolnshire




                                                                                                                                                                                                                                                                                 Doncaster
                                                                                                                                                                                                                                                     Kirklees



                                                                                                                                                                                                                                                                    Wakefield
                                                                                                                                  Lincolnshire




                                                                                                                                                                                                                                Leeds



                                                                                                                                                                                                                                         Barnsley
                                                                                                                                   North East




                                                                                                                                                                                                                                                                                                           Bradford & Airedale
having the lowest levels of under-reporting




                                                                                                           Yorkshire




                                                                                                                                                                             York
(51% of cases identified).
                                                Source:Observed - The Information Centre; Expected - Mental Health Observatory                                                                                                                                  Produced by Yorkshire & Humber PHO



Across the UK, healthcare costs for dementia
are £1.3bn (where dementia is the primary
diagnosis), of which 44% is spent on hospital
inpatient stays.

63% of all spend on dementia is on care home
costs. This includes both self funders and
social services monies.

                                                                                                          Source: Adapted from Knapp et al (2007) Dementia UK and the King's Fund (2008) Paying the Price
                                                                                                          NOTE Direct costs of dementia exclude informal care costs of £5.8 billion borne by families. Two-thirds of
                                                                                                          the direct costs, £6.42 billion, relate to the provision of care home places for people with dementia and are
                                                                                                          split

                                                                                                                                                                                                                                                                                                                                         34
Dementia – future trends
Dementia incidence and prevalence increases as the population ages. Between 2008 and
2025, prevalence is forecast to rise by 51% across Yorkshire and the Humber. The LA
area expected to experience the highest growth is East Riding (78%) and the lowest
growth is expected in Sheffield (33%).
                                                                                      Chart 5: Number Predicted to have Late On-set Dementia
                                                                                                       Yorkshire & Humber 2008 & 2025 by Local Authority District
                                  20,000
                                                  68%




                                                                                                                                                                                                                                                                                                                               Mental health - Dementia
                                                                                                                                                                 57%                            57%
                                                                                                                              78%                                                                                                   54%
                                                                                                                                             50%                               51%                                                                                                             70%              52%
                                                                                                                                                                                                                                                        47%                47%
                                                                          35%                            41%
                                  16,000
                                                                                        33%
                                                        13,876




                                                                                                                                                                                                                  31%
    Number Aged 65 Years & Over




                                                                             10,872




                                  12,000
                                                8,264




                                                                                                                                 8,130




                                                                                                                                                                                              2008                               2025                                    % Change
                                                                                               8,108
                                                                     8,047




                                                                                                                6,861




                                   8,000
                                                                                                                                                    6,245
                                                                                       6,084




                                                                                                                                                                     5,641



                                                                                                                                                                                      5,059
                                                                                                        4,873



                                                                                                                         4,563




                                                                                                                                                                                                       4,397
                                                                                                                                            4,170




                                                                                                                                                                                                                                           3,850
                                                                                                                                                             3,587




                                                                                                                                                                                                                                                                3,461
                                                                                                                                                                             3,347




                                                                                                                                                                                                                         3,304




                                                                                                                                                                                                                                                                                                     3,308
                                                                                                                                                                                                                                                                                  3,274




                                                                                                                                                                                                                                                                                                                       2,928
                                                                                                                                                                                               2,795
                                   4,000




                                                                                                                                                                                                                 2,523



                                                                                                                                                                                                                                   2,493



                                                                                                                                                                                                                                                       2,360



                                                                                                                                                                                                                                                                          2,222



                                                                                                                                                                                                                                                                                             1,947



                                                                                                                                                                                                                                                                                                               1,932
                                         0
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                                                                                                                                                                                                                                                                         or
                                                                                                                                                                                                                                                                        N
                                                                                                                                                                                     Source: Using Projecting Older People Population Information System - Crown Copyright 2007




                                                                                                                                                                                                                                                                                                                                       35
Dementia – medication and prescribing                                                                                                                        Figure 1: Yorkshire & The Humber PCTs: Weighted Prescribing of Low dos
                                                                                                                                                             (2.5mg & 5mg), Risperidone (500 micrograms & 1mg), Haloperidol (500 micr
                                                                                                                                                                              1.5mg), Quetiapine (25mg) and Aripiprazole (5mg &10mg)
                                                                                                                                                               Weighted prescribing costs (per 100 dementia patients) of
                                                                                                                                                                                              April 2007 - March 2010

A Department of Health commissioned                                                                                                                  4500           all relevant low dose anti-psychotics (2009/10)
                               prescribing
review of anti-psychotic drugsFigure 1: Yorkshire & The Humber PCTs: Weighted Prescribing of Low doses of Olanzapine
for dementia found an unacceptable level 1.5mg), Quetiapine (25mg) and Aripiprazole (5mg &10mg)
                              (2.5mg & 5mg), Risperidone (500 micrograms & 1mg), Haloperidol (500 micrograms & 1mg &                                 4000


of elderly people dying with dementia as a                     April 2007 - March 2010
                                                                                                                                                                                                                                                                       Ba
                                                                                                                                                                                                                                                                       Bra

result of their prescribed medication.




                                                                                                                         DDD/100 dementia patients
                                                                                                                                                     3500                                                                                                              Ca
                                                                                                                                                                                                                                                                       Do
                                                                                       4500                                                                                                                                                                            Ea
                                                                                                                                                                                                                                                                       Hu
                                         Figure 1: Yorkshire & The Humber PCTs: Weighted Prescribing of Low doses of Olanzapine
There                                is little evidence of benefit from the 1mg), Haloperidol (500 micrograms & 1mg &
                                                                                             3000                                                                                                                                                                      Kir
                                         (2.5mg & 5mg), Risperidone (500 micrograms &                                                                                                                                                                                  Le

use of                               antipsychotics in elderly patients and Aripiprazole (5mg &10mg)
                                                                                                                                                                                                                                                                       No
                                                          1.5mg), Quetiapine (25mg)
                                                             4000                                                                                                                                                                                                      No
                                                                                             2010
                                                                          April 2007 - March 2500
with dementia, yet there is evidence of an




                                                                                                                                                                                                                                                     Mental health - Dementia
                                                                                                                                                                                                                                                                       No
                                                                                                                                                                                                           Barnsley                                                    Ro

increased incidence of stroke in the short                                                                                                                                                                 Bradford & Airedale                                         Wa
    4500
                                                           DDD/100 dementia patients




                                                                                                                                                     2000                                                  Calderdale
                        3500
term, and increased mortality in the short                                                                                                                                                                 Doncaster

     longer term. The level of increased
and4000
                                                                                                                                                                                                           East Riding of Yorkshire
                                                                                                                                                     1500
                                                                                                                                                                                                           Hull Teaching
mortality was found to be 10 for every
                                                                                                                                                            0809Q1   0809Q2    0809Q3      0809Q4      0910Q1     0910Q2      0910Q3      0910Q4
                        3000                                                                                                                                                                               Kirklees
                                                                                                                                                                        Barnsley
1000 patients over 12 weeks.
                                                                                                                                                                                                           Leeds
                                                                                                                                                                        Bradford & Airedale                North East Lincolnshire Care Trust Plus
  DDD/100 dementia patients




                              3500                                                                                                                                      Calderdale                         North Lincolnshire
                                                                                       2500                                                                             Doncaster                          North Yorkshire & York
The government’s response to the report                                                                                                                                 East Riding of Yorkshire           Rotherham
stated that “people with dementia should
                                                                                                                                                                        Hull Teaching                      Wakefield District
    3000                                                                                                                                                                Kirklees
only be offered anti-psychotics if they are
                         2000                                                                                                                                           Leeds

severely distressed or there is an
                                                                                                                                                                        North East Lincolnshire Care Trust Plus
                                                                                                                                                         DDD (Defined Daily Dose system): Value assigned to
                                                                                                                                                                        North Lincolnshire
immediate risk of harm to the person or
    2500
                         1500
                                                                                                                                                                        North Yorkshire & York
                                                                                                                                                         each drug representing assumed average
                                                                                                                                                                        Rotherham
others. The NHS locally should be following
                              0809Q1 0809Q2 0809Q3                                                                                                   0809Q4  0910Q1   0910Q2     0910Q3     0910Q4
                                                                                                                                                         maintenance dose/day when used for its main
                                                                                                                                                                        Wakefield District
NICE guidance and PCTs have a
    2000
                                                                                                                                                         indication in adults.
responsibility to ensure that this happens.”
                              1500
                                       0809Q1   0809Q2   0809Q3                               0809Q4   0910Q1   0910Q2                   0910Q3             0910Q4


                                                                                                                                                                                                                                                             36
                                      (2.5mg & 5mg), Risperidone (500 micrograms & 1mg), Haloperidol (500 micrograms & 1mg &
                                                   40001.5mg), Quetiapine (25mg) and Aripiprazole (5mg &10mg)
                                                                       April 2007 - March 2010
                                                                                                                                                                Barnsley


Dementia – medication and prescribing
                                                                                                                                                                Bradford & Airedale
                               4500




                                                DDD/100 dementia patients
                                                                            3500                                                                                Calderdale
                                                                                                                                                                Doncaster
                                                                                                  Quarterly low-dose risperidone prescribing as a percentage of all
                                                                                                                                                                East Riding of Yorkshire

The harms and limited benefits of using
                               4000                                                                               risperidone prescribing 2009/10               Hull Teaching
                   3000                                                                                                                                         Kirklees
                                                                                                                                  Figure 2: Yorkshire & The Humber PCTs: Low Dose Risperidone (500 micrograms an
antipsychotic drugs both first generation                                                                                          Barnsley
                                                                                                                                   Bradford & Airedale
                                                                                                                                                                 Percentage of All Risperidone Prescribing
                                                                                                                                                            as aLeeds


typical and second generation (atypical)                                                                                                                        North East Lincolnshire Care Trust Plus
   DDD/100 dementia patients




    3500                                                                                                  50                       Calderdale
                                                                                                                                                                North Lincolnshire
for the treatment of people with
                   2500                                                                                                            Doncaster
                                                                                                                                   East Riding of Yorkshire
                                                                                                                                                                North Yorkshire & York

dementia, who exhibit challenging
    3000                                                                                                  45
                                                                                                                                   Hull Teaching
                                                                                                                                   Kirklees
                                                                                                                                                                Rotherham
                                                                                                                                                                Wakefield District
                   recognised.
behaviours is well 2000                                                                                                             Leeds
                                                                                                                                                                                                                                                  Barn
                                                                                                                                                                                                                                                  Brad
                                                                                                                                    North East Lincolnshire Care Trust Plus                                                                       Cald
                                                                                                                                    North Lincolnshire                                                                                            Donc

Prescribers should continue to follow NICE-
                                                                                                          40




                                                                                         ADQ percentage
    2500                                                                                                                            North Yorkshire & York
                                                                                                                                                                                                                                                  East
                                                                                                                                                                                                                                                  Hull

SCIE guidelines on dementia which advises
                      1500                                                                                                          Rotherham                                                                                                     Kirkle
                                                                                                                                    Wakefield District                                                                                            Leed
                           0809Q1 0809Q2 0809Q3 0809Q4 0910Q1 0910Q2                                                                 0910Q3      0910Q4
avoiding the use of any antipsychotics for




                                                                                                                                                                                                                                     Mental health - Dementia
                                                                                                                                                                                                                                                  North
                                                                                                          35
    2000                                                                                                                                                                                                                                          North


non-cognitive symptoms or challenging
                                                                                                                                                                                                                                                  North
                                                                                                                                                                                                                                                  Roth
                                                                                                                                                                                                                                                  Wak

behaviour of dementia unless the patient is
    1500
                                                                                                          30


         distressed 0809Q3 0809Q4 0910Q1 0910Q2
severely0809Q1 0809Q2 or where there is a risk 0910Q3 0910Q4
of immediate harm to them or others.                                                                      25
                                                                                                               0708Q1 0708Q2 0708Q3 0708Q4 0809Q1 0809Q2 0809Q3 0809Q4 0910Q1 0910Q2 0910Q3 0910Q4



PCTs should review their prescribing of low                                                                                     Figure 3: Yorkshire & The Humber PCTs: Weighted Prescribing of Risperidone
                                                                                                                                                            January - March 2010

dose antipsychotics using practice registers                                                                                       Hull Teaching

and where appropriate work with clinical                                                                  North East Lincolnshire Care Trust Plus


colleagues to revise prescribing at local                                                                                                Kirklees



level.
                                                                                                                                          Leeds

                                                                                                                             Bradford & Airedale

                                                                                                                                      Calderdale

                                                                                                                                      Rotherham

                                                                                                                                        Barnsley


ADQ: Average Daily Quantity. This represents the assumed
                                                                                                                         East Riding of Yorkshire

                                                                                                                                      Doncaster
average maintenance dose per day for a drug used for its                                                                       Wakefield District

main indication in adults. It is based upon prescribing                                                                        North Lincolnshire

behaviour within England, and is an analytical unit used to                                                               North Yorkshire & York


compare treatment activity, not a recommended dose.                                                                                                 0    500           1000             1500              2000         2500   3000
                                                                                                                                                                              ADQ/100 dementia patients


                                                                                                                                                            Risperidone_Tab 1mg    Risperidone_Tab 500 micrograms   Others

                                                                                                                                                                                                                                             37
Dementia - acute health care needs
An analysis of recent admissions of people
with dementia to an acute hospital bed over
a 12 month period 08/09 identified 3 key
groups:
-Those with a primary diagnosis of dementia
-Those with a secondary diagnosis of
dementia
-Those with a diagnosis of senility of which




                                                                                                                                                  Mental health - dementia
95% also have dementia

Across the 3 groupings an average of 95%                      Admission Method of Patients in Yorkshire & Humber Acute
of admissions of people with dementia                          Trusts with a Secondary Diagnosis of Dementia 2008/09

were emergencies. This can reflect the              Emergency - via A & E     69.1%


relatively chaotic way patients receive                Emergency - via GP     16.4%

care and the poor management of their         Emergency - via Bed Bureau      5.5%
condition.
                                                                   Elective   4.3%


Given the low rate of diagnosis on page 1     Emergency - via other means     2.8%

it is likely that many of these do not have    Transfer from other hospital
                                                                              1.2%
effective community case management                      provider



arrangements in place which result in
                                               Emergency - via consultant
                                                    outpatient clinic
                                                                              0.7%


admission to hospital beds in crisis                                        0%        10%   20%      30%     40%      50%      60%    70%   80%
                                                                                            Percentage of total episodes in 2008/09
situations.

                                                                                                                                                          38
Dementia - acute health care needs
A high percentage of admissions are to                                        Treatment Specialty in Yorkshire & Humber Acute Trusts for
                                                                              Episodes with a Secondary Diagnosis of Dementia 2008/09
medical wards with chest infections                                 Geriatric Medicine      42.7%


and urinary tract infections as primary
                                                                     General Medicine       26.9%

                                          Trauma & Orthopaedics                             5.8%

reasons for admission. The latter                                    Other specialties      5.8%

diagnosis is consistent with a                Respiratory Medicine                          4.2%

                                                                         General Surgery    3.8%
breakdown in carer support as a                                      Gastroenterology       3.1%

critical trigger to admission to          Accident & Emergency                              2.6%


hospital beds.




                                                                                                                                                                                      Mental health - Dementia
                                                                    Diabetic Medicine       1.9%

                                                                                 Urology    1.8%

                                                                              Cardiology    1.3%

                                                                                           0%       5%      10%     15%       20%      25%     30%      35%       40%           45%

Although there is variation in length                                                                        Percentage of total episodes in 2008/09

of stay across the 3 groups, overall it                                     Median Length of Stay, with interquartile range, of Patients in Yorkshire &
was lower than what was expected.                                   35
                                                                                  Humber Acute Trusts with a Diagnosis of Dementia 2008/09


The findings were consistent with the                               30

recent Nuffield Trust report 2010
which identified an 11.8% rise in
                                                                    25
                                            Length of stay (days)




emergency admissions over the last 5                                20




years and a noticeable increase in                                  15



short stay admissions.                                              10



                                                                    5



                                                                    0
                                                                            Primary diagnosis of dementia    Secondary diagnosis of dementia    Primary diagnosis of senility




                                                                                                                                                                                              39
Dementia - acute health care needs
                                                                       Destination of Patients Discharged frrom Yorkshire & Humber
The chart opposite confirms the national evidence                      Acute Trusts with a Secondary Diagnosis of Dementia 2008/09

that an admission to an acute hospital bed for a           Usual place of residence     70.3%

patient with dementia is associated with an                                   Death     14.9%
increased risk of admission to a care home and
increase risk of mortality. Overall, the physical
                                                            Non-NHS run care home       6.1%


health and psychological outcomes for people with        NHS other hospital provider    2.9%


dementia in acute hospitals are poor.                            NHS run care home      2.8%


                                                                              Other     1.8%




                                                                                                                                                                        Mental health - Dementia
The report looked at over 24,000 admissions across     Temporary place of residence     1.3%
the 3 groups which accounted for over 338,000                                          0%       10%   20%      30%     40%       50%      60%         70%       80%
Occupied Bed Days (OBDs) at a cost of £70m. This                                                      Percentage of total episodes in 2008/09

represented an average of 9% of all acute hospital                                                                             Total        OBDs
                                                                                                                                                                %

beds.
                                                         Acute Trusts                                                                                       Dementia
                                                                                                                              Beddays      Dementia
                                                                                                                                                            -v- Total

                                                         AIREDALE NHS TRUST                                                   104,622       10,169             10

                                                         BARNSLEY HOSPITAL NHS FOUNDATION TRUST                               143,097       11,838             8
A recent NHS Confederation Report “Acute                 BRADFORD TEACHING HOSPITALS NHS FOUNDATION TRUST                     230,093       17,024             7

Awareness” (2010) suggested that up to 50% of all        CALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST                     288,504       28,562             10


dementia on acute and general hospital wards was         DONCASTER & BASSET LAW HOSPITALS                                     217,280       34,073             16



undiagnosed.
                                                         HARROGATE & DISTRICT NHS FOUNDATION TRUST                            103,629       10,362             10

                                                         HULL & EAST YORKSHIRE HOSPITALS NHS TRUST                            415,438       22,977             6

                                                         LEEDS TEACHING HOSPITALS NHS TRUST                                   627,056       47,736             8

A local clinical audit and national prevalence rates     MID YORKSHIRE HOSPITALS NHS TRUST                                    378,272       33,641             9


would suggest that it is likely that the true            SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST                    555,358       66,533             12



incidence in acute hospitals is in excess of 900,000
                                                         NORTHERN LINCOLNSHIRE AND GOOLE HOSPITALS NHS FOUNDATION
                                                                                                                              222,159       10,200             5
                                                         TRUST


OBDs at a cost of up to £196m in Yorkshire &             SCARBOROUGH AND NORTH EAST YORKSHIRE HEALTH CARE NHS TRUST           112,842        6,162             5

                                                         THE ROTHERHAM NHS FOUNDATION TRUST                                   170,785       18,423             11
Humber.                                                  YORK HOSPITALS NHS TRUST HQ                                          215,127       20,883             10

                                                         Grand Total                                                          3,784,262     338,583            9



                                                                                                                                                                                40
Dementia – health & social care costs
                                                                           Percentage of total spend on older people in residential homes
It is estimated that £567m per annum is spent in                                                      2008/09
the region on residential care accounting for 57%      80.0%


of the total budget for social care for older          70.0%


people compared to 52% nationally.                     60.0%


                                                       50.0%

It is estimated that at least two thirds of all
residential care placements have dementia.
                                                       40.0%



There is local evidence to suggest that a              30.0%



significant number of admissions to acute beds         20.0%




                                                                                                                                                                                                                                                                          Mental health - Dementia
and residential care are avoidable with the            10.0%


development of crisis services, intermediate care        0.0%

and liaison services. In Bradford it has been




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estimated that £13,000 per person, per year can




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be saved for a person with dementia. The



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                                                                                  Total Costs in Yorkshire & Humber Acute Trusts for
current national average spend on a person with                                   Patients with Dementia 2008/09
dementia is £27,000 per person per year.                  York
                                                         SNEY
The National Audit Office suggests that £284m         Sheffield
nationally could be saved immediately through       Rotherham
                                                         NLAG
the adoption of best practice (or £6m per            Mid Yorks
average general hospital).                               Leeds
                                                     Hull & EY
                                                     Harrogate
‘Improving Services to People with Dementia’:       Donc & Bass
http://www.yhip.org.uk/silo/files/improvingserv     Cald & Hudd
                                                                                                                                                                                                               Senility
ices-to-people-with-dementia-and-acute-health-        Bradford
                                                                                                                                                                                                               Sec Diag Dementia
                                                      Barnsley
care-needs.pdf.                                        Airedale                                                                                                                                                Prim Diag Dementia
                                                                0                                   10                     20                   30                40            50            60              70                80                  90              100
                                                                                                                                                        Total costs in 2008/09 (£100,000s)
                                                                                                                                                                                                                                                                                  41
Contents


Overview

Mental health care pathway




                               Mental health - Contents
Out of area placements

Mental health and employment

Dementia

Annexes

                                         42
Annex A – key contacts
Heather Raistrick – Adult Services Care Manager, NHS Y&H
(Heather.Raistrick@yorksandhumber.nhs.uk)

Sue Baughan – Assistant Director (Knowledge Transfer), YHPHO
(seb509@york.ac.uk)




                                                                            Mental Health - Annexes
Dr Stephen Stericker – Service Improvement Lead, YHIP
(stephen.stericker@yhip.org.uk)

Michele Cossey – Pharmacy & prescribing lead, NHS Y&H
(Michele.Cossey@yorksandhumber.nhs.uk)

Ian Holmes – Associate Director, Economics and System Management, NHS Y&H
(Ian.Holmes@Yorksandhumber.nhs.uk)

Helen Mercer – Economist, Strategy and System Reform Directorate, NHS Y&H
(Helen.Mercer@yorksandhumber.nhs.uk)



                                                                                    43
Annex B - Finance Mapping Data
Each year Mental Health Strategies compile a summary for each Local Implementation Team (LIT) of the mental
health financial mapping data. Each LIT corresponds roughly to a PCT region but includes services
commissioned by the non NHS bodies for that region as well.
It is essential that this financial information is not considered alone, but is interpreted along side outcome and
performance measures for each LIT to decide if value for money is being achieved. We have compared data for
the following:
      - Total Adult Mental Health Spend per weighted Adult Population 09/10 (plus the percentage
      increase/decrease in spend from previous period 08/09)
      - Total Indirect costs per weighted Adult & weighted Old Person for 09/10 (plus a graph showing what




                                                                                                                                    Mental Health - Annexes
        percentage of a LITs total adult and old person costs are spent on non direct costs).
      - A comparison of how much each LIT in Yorkshire and Humber spent in 09/10 on the top five highest
        spending services in England in 09/10
      - A comparison of how much each LIT spent on IAPT services in 09/10

Data Issues
The data is based on an overall picture of reported investment in adult and older people’s mental health
services, including delivery of services from all providers to, and all commissioners for the LIT, not just NHS
organisations.

The overall quality of the data nationally supplied from organisations inevitably varies but has been validated
by the supplying organisations, LITs and Mental Health Strategies. However, 2009/10 is only the fourth year that
local authorities have collected Old Persons Mental Health (OPMH) finance mapping figures and thus overall,
their figures are unlikely yet, to equal the quality or coverage, of the now well established adult finance
mapping data.
The OPMH analyses should therefore be considered, to a degree, to be provisional, and can be expected to
improve in future
                                                                  Source: Y&H LIT Results of Financial Mapping Report’s 2009/10 ,
                                                                  DH/Mental Health Strategies
Annex C - Psychological therapies
Examples of psychological therapies:

•   Cognitive–behavioural therapy – a structured problem-focused, goal-orientated
    approach aimed at modifying thoughts, assumptions, beliefs and behaviours in order to
    influence disturbing emotions and habits.
•   Psychodynamic therapy – a relatively intensive therapeutic approach aimed at reducing
    inner tensions and relational conflicts through the exploration of unconscious meanings
    and motivations, often with reference to past formative experiences and current care




                                                                                                 Mental Health - Annexes
    relationships.
•   Systemic therapy – a distinctive approach that aims to study, understand and treat
    disorders of the interactional whole (rather than an individual person), for example the
    family or a group of individuals.
•   Integrative therapies – recently developed treatments created from a combination of
    elements from one or more other treatments.
•   Counselling – typically brief interventions that help people cope with challenging
    circumstances by providing space for reflection and by restoring their capacity to resolve
    problems.




                                                                                                         45
Annex D - Useful resources
The YHIP Mental Health programme provides development support to mental
health and social care providers and commissioners in relation to key
government priorities, sharing best practice and development of services in
relation to policy requirements.
http://www.yhip.org.uk/mental-health/

The HUB is structured to provide information and dedicated links to




                                                                               Mental Health - Annexes
resources, and also a communication tool for people to discuss mental health
in the workplace.
http://www.workplacementalhealth.co.uk/




                                                                                       46
3) QIPP metrics




                  47
QIPP metrics (1)




                   48
QIPP metrics (2)




                   49
QIPP metrics (3)




                   50
QIPP metrics (4)




                   51
QIPP metrics (5)




                   52
QIPP metrics (6)




                   53
QIPP metrics – definitions and sources




                                         54

								
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