Dr Christopher Hilton, Director of Business and Strategy, West London Mental Health NHS Trust discusses how to evolve a model for integrating physical health, mental health and social care, to include closer collaboration with primary care.
This presentation was recorded at our Integrated Care Summit on 11 October 2016.
Thank you very much for inviting me this afternoon, to talk about some of the work we are doing in North West London and in my organisation trying to evolve a model that integrates all of these things together and I guess, I was going to cover, rather than talk about any one thing in great detail, talk about two or three different areas that we have been looking at in terms of mental health integration with physical health and that, hopefully, will incorporate my kind of elevator pitch in the way that you asked the other speak to do, particularly around the triple aim and that also then translates into kind of how mental health, particularly in North West London is threaded very much through our whole STP plans. The theft that we don’t claim necessarily to have invented all of this, and so we are not re-inventing the wheel, we’re very shamelessly borrowing from friends and colleagues from around the world and following the advice that they’ve given us and then I’m going to talk about these three particular areas.
One is around the kind of quality agenda and our experience in North West London of integrating, in a primary care setting, mental health and psychological practitioners into care planning discussions and the benefit that that had. Something about efficiency, and we talked a bit beforehand about pilots, so I’m going to give you three examples, each of which was a pilot and the fact that we are still piloting the same thing, even though we’ve proven that it works three times, is kind of symptomatic of how the NHS works and then finally I’m going to talk to you about my latest adventure which is doing it’s very best in itself to be triply integrated. So this is an intermediate care service that very explicitly integrates primary care and secondary care, mental health and physical, and health and social care all within one service and we’ve been going for over a year now, how that’s doing.
So this is the kind of elevator pitch and I’ve nicked most of the numbers from North West London’s STP so we’re not supposed to talk about the finance and efficiency gap first, but I will, because this is what everyone’s most alarmed about, the £1.3 billion gap by 2021 in North West London for our two million patients and how are we going to do something more efficiently to resolve this. Then the care and quality gap which looks at the fact that in North West London we have eight CCGs, eight local authorities, four acute trusts which then operate on a number of different sites, so we’re probably going to end up with around about five major hospital and a number of smaller DGHs and this sense that most of the care is concentrated in probably the most expensive setting and how can we shift some of that care to an intermediate space or closer to home, and that applies to a number of different areas. So one of the examples here is around palliative care and in North West London four out of five of us say that we’d rather pass away in our own houses and yet only 20% of us actually are able to. Care that’s very fragmented with number of providers and also increasing waiting times etc.
And then the health and wellbeing gap which looks at increasing trajectory of people who have multiple long term conditions, increasing trajectory of markers of physical ill health amongst our population particularly amongst children and what that might be saving up for us and I guess from my perspective, as a psychiatrist by background, this is the un-met need that we often under emphasise and I know that Chris mentioned a lot of this at the beginning, but you know, it’s always worth remembering the disparity between mental health and physical health.
We say that around 5% of presentations to emergency departments are for mental health but actually you only need to scrape a tiny little bit off the surface to discover that a lot of the behaviours that are driving those A&E attendances are very much psychologically or behaviourally motivated, and there might be secondary diagnoses if you look for them, that are actually related to something that mental health services broadly define, can support, and again self-harm is consistently one of the top five reasons for emergency admission and not a day goes by on a post take ward round when there is a patient with self-harm or a suicide attempt on an acute medical unit. There is all of the data that’s been alluded to already about people with physical illnesses and psychological reactions.
Public health in mental health patients is a significant issue and the stats from a few years ago estimates that 42% of all cigarettes smoked in England and Wales were smoked by people with mental health problems. So again, this is something that is contributing to that life expectancy gap that was alluded to, but more importantly I think for me, it’s about helping patients to access services.
So only a quarter of people that need mental health care, are in receipt of services and if you look at other long term conditions such as diabetes, 90% of people with diabetes are getting the care that they need. But there is a significant access problem for people with mental health problems to get the care that they need and this is something that I Aps and other initiatives have helped to tackle but the bottom statistic is that I think really significant, because we can talk about premature mortality and high rates of morbidity but actually if you look in a very holistic way at recovery, patients with amputation, two thirds of them will get back to work. Patients being given a diagnosis as severe and during mental illness, less than 10% of them will ever work again. So actually however you define recovery, whether that’s because the voices have gone away or because you feel able to cope with the symptoms you are experiencing, or because you’re functionally able to live your life, this sort of functional recovery is considerably lower for people with mental illness than people with other seriously, physically disabling illnesses.
So this is my elevator pitch for “the problem” and I guess this is the diagram that we see all the time about how we’ve stacked up our organisations to spend an awful lot of money on huge and residential care and not enough money at all on primary and community care and a minute, miniscule fraction on actually looking at preventative services and proactive early intervention services, and we need to turn the whole thing completely upside down if we’re to try and do an accountable care approach.
This is how we have been doing mental and physical health integration for the last, however long. To the extent that I work on a site, it used to be The First Middlesex County Lunatic Asylum, is the site that I work on and we have a mental health facility on one side of the car park, a general hospital on the other side of the car park and to get a patient from one side to the other we need to call LAS. So what a complete waste of time, money and a terrible patient experience to get patients from one to the other and a totally disintegrated service and clearly in this scenario, this is not a slight against firemen, the patient’s not going to survive. So we need to think in the same way about reintegrating our services.
You can define the triple aim depending on which consultancy you’re speaking to, but there’s going to be something about quality and safety of care and I think we’ve heard from the previous speaker that providing integrated services and greater quality and a safer service, it prevents the unnecessary use of unnecessary interventions. You can get improved patient experience and you’ve also got improved efficiency in the whole system by actually providing this integration.
So, we’ve been trying to work out how to do this in North West London and we went and asked some colleagues around the world. So, we went to Boston, Massachusetts and they talked about this wonderful fully integrated mental health, enriching the medical neighbourhood, you know, curb sides, all of these kind of strange jargon about effectively being able to have these warm hand arse between different professionals and actually what we ascertained is this all about being in the room. This is not about knowing their number, especially not knowing their fax number, it’s about actually being in the same space to have a discussion and share learning. When I asked them “well how far have you got with this?” The advice was “oh well we haven’t actually done this yet, we’re planning to”. And I said “well why not?” and they said “Oh we thought we would do it later” and the real clear message from them was “oh well if you’re starting, if we started again, we would put mental health in right at the beginning, don’t leave it for later”. This was a Baltimore physician who told us that they have wonderful behavioural health integration and they had put it in from the beginning and it was aimed at improving mental health outcomes, treatment adherence and care planning for long term conditions improving self-management, improving quality of life, substance misuse, and it had knock on effects on costs.
And they had this model that’s very similar to what we are all trying to apply which is identifying the patients, screening in some way or other, everybody in the workforce making every contact count, being able to provide brief interventions, basic interventions. They had this unusual acronym which I can’t actually remember it stands for, referring patients into Treatment Pathways and knowing the pathways and which pathways to refer them into and then using specialist services for those patients who needed them.
So in North West London, we’re not a Vanguard site, we were a predecessor to a Vanguard, we’re a pioneer site of integrated working, and one of the initiative that came into place was to try and incentivise GPs to work with secondary care and vice versa.
So I was seconded effectively, for a few hours a month to go and work in primary care, and the liaison psychiatrist like myself, all said “we need to be there”. The message from the integrated care people was “yeah, sure you can come if you want, sounds fine”. And I think they thought that having a psychiatrist there, particularly for discussions around diabetes would be really useful, because all of the patients who are on antipsychotic, horrible psychiatric medications are all diabetic so if we’re in the room, we can be told off for the medications that are prescribed. And we thought “okay, well we’ll face up to that and we’ll go into the meetings with that as our cover”. We would then have a multidisciplinary discussion about all of these patients and what we found, there was 34 case conferences in the first few months, we discussed 205 different cases, 167 of those cases, using our very unscientific tally chart, had relevant mental health issues that we were actively contributing to, you can’t quite see the text but a lot of it was around motivation, self-management, depression undiagnosed, adjustment disorders undiagnosed, anxiety, a lot of undiagnosed dementia, capacity issues. “The patient said I wasn’t going to take the medication so we haven’t prescribed any”. And it was like, “well hang on have you thought about why they made that decision, have you actually asked them why?” There were a few more serious mental disorders in there that were contributing, but the idea that we were there to be told off about antipsychotics went away very quickly and all of the discussions became about motivation and other behavioural factors.
So most of these patients weren’t on any case load. These patients were picked by the GPs because their HbA1C was bad and most of them didn’t have any diagnosis of mental illness at all, or they might have had primary care treatment but we were sort of wading into their management, in the same way that the diabetologist sat next to me, was wading into their diabetes management, so it wasn’t just a mental health thing, it was very much around advising primary care other approaches to take to manage some of these patients, in primary care. So it wasn’t about “oh refer them to me and I’ll sort it out”. If anything it was kind of “please don’t refer them to me until you’ve tried this, this and this first”. A sort of referral avoidance approach if possible, but also empowering the GPs to do stuff.
So I guess this was our way of trying to upskill the different professionals we were working with. I learnt so much more about how you manage diabetes than I ever thought I would ever need, in fact, in those meetings, but also how primary care works was very valuable. We think it benefited patient wellbeing, we instigated some additional processes so actually my job became much, much harder. Year three of this programme, I found these sessions much more exhausting. Year one, I was like “hmm have you screened them for depression, have you screened them for anxiety, have you screened them for cognition, have you asked why they’re not taking their medicine?” and I would say that for everybody. In year three, the GPs would come in and say “Well I’ve screened them for depression and I’ve treated it, and I’ve screened them for anxiety and I’ve treated it, and I’ve screened them for dementia and they’re fine, now what do I do?” Which actually made it a really stimulating discussion but often the answer was “Well I don’t know either” so in some cases it’s still not helpful to refer into secondary care but we could actually share that learning together, and it was certainly an upskilling in how the GPs worked.
So we’re doing this across mental health in lots of different areas, so even in our high secure service, as we run Broadmoor Hospital we now have a liaison physician who works in the hospital who’s an employed salaried GP working for the organisation and we have multidisciplinary discussions for our forensic inpatients so they’re under our care for years in many cases, and physicians come into the hospital and have these same kind of multidisciplinary care planning discussions as part of their physical health care and we’re trying to the same for dementia and primary care and various other things.
I just wanted to skip on slightly to, this is the kind of model of care that almost everybody in the whole country is vaguely working on, it’s sort of concentric layer upon layer of care. Almost all of these models of care have a little old lady smiling in the middle and mine is no different. This idea that there is an individual, their family, their lay support surrounded by an enhanced primary care team that might include mental health workers, might include district nurses that sort of thing, social workers and third sector. Beyond that you’ve got intermediate care and outside, at the end, you’ve got that peak of need for the acute hospitals and long term residential care. The idea is that we’re trying to keep patients at the centre of everything but, also in the kind of lowest concentric ring if possible.
On the back of lots of discussions similar to the previous speaker, we had lots of discussions trying to plan how in North West London are we going to deliver this bit, the care coordination care team, and the informal community support, and I kept saying you need to have mental health in the room. And I’m pleased to say that our patients, we call them in North West London, we call them lay partners, the lay partners very strongly endorse this and there is this assumption no in North West London that every whole systems integration team should include a mental health professional. Not a doctor, could be a psychologist, it could be a mental health OT or a nurse, who is a core team member. This is not about ‘phone a friend’, this is about they’re in the room and their role is to identify undiagnosed mental health and psychological needs, and to reduce the need for referring to somebody else. And we also identify that all members of integrated teams should be trained and supported to do all this stuff, as I’ve alluded. So this is now embedded in what North West London, in every single CCG patch is trying to do.
I’m going to change tact slightly, and talk about a couple of other initiatives. So a piece of work that we did across the North West London sector was around frequent users of emergency services. These are sometimes rather pejoratively referred to as ‘frequent flyers’, we don’t use that term. Frequent attenders is quite unhelpful. With the latest name for them is ‘familiar faces’, but the idea is identifying people who are regular users of the emergency departments. We looked at 105 patients from eight A&E departments across North West London and found they were, most of them fitted into four themes; substance misuse, long term conditions, deteriorating frailty and psychiatric primary diagnosis.
By identifying these patients, irrespective of their diagnosis, and working with them intensively, care planning with them and involving all of the professionals involved in their care and their attendances, we were able to reduce the attendance rate of these 105 patients from over 3000 attendances in the year prior between them, to around 2000 attendances in the year afterwards. So there was a saving of 1075 attendances per year for these patients. Through a coordinated care planning approach.
We did the same thing in Ealing, and the only bit I’m going to highlight to you on this slide, is that the patients liked it, because for the first time, people were asking them about all of their problems and their whole life and what was driving the attendances, and the GPs liked it because it was about trying to resolve a problem. There’s always this thing in the papers, you know “this patient’s been to hospital 100 times”. What the paper doesn’t say is that 99 times then the care plan was wrong, because the patient came back again. And actually this time, it’s about trying to identify the right care plan that puts the care in place that makes the patient feel supported and not need to access unscheduled care.
So we had a structured template that looked at their most common physical presenting complaints and symptoms and the, you know the most likely treatments that were needed. We had a physician contribute to say “well actually this patient often does come in with whatever it might be, and this is a typical treatment plan for it”. We also looked at the mental health components and is it driven by anxiety or cognitive impairment and that sort of thing. Substance misuse played a role, and is it helpful or not to actually instigate an inpatient detox and admit the patient or actually is there another plan in place, and then the social aspects. So a lot of it was kind of like getting the patient’s permission. If you turn up in A&E am I allowed to phone your mum and tell her you’re here again, that sort of stuff. It was all very much what the patients needed. Most of the patients engaged with us and helped us co-design it with them. Those that didn’t, we planned anyway and that box was blank.
We’re doing the same thing in Hammersmith & Fulham which is what I was going to say there, but I do think there is something really valuable. The evidence base isn’t brilliant for this sort of care planning but three times we’ve piloted it and three times we’ve demonstrated a patient experience, a safety and quality and a financial benefit. So that triple aim is there, and it’s just trying to embed it into regular practice.
And finally, I’m just want to talk a bit about intermediate care. One of the things that I’m really interested in, and passionate about, is that we’re trying to move patients from acute hospital settings into the community and we’re now trying to do, there’s different names to it, but effectively hospital at home type services for patients with physical illnesses.
Now over the last five years we’ve put liaison psychiatry into nearly every hospital in the country. We’re saying that by 2020, every acute trust must have liaison psychiatry and 50% of them must have enhanced core 24 liaison psychiatry in every hospital. At the same time we’re trying to move the patients out, so what I’m also saying is who looks after the patients’ mental health needs with the liaison psychiatry approach if they’re not in hospital anymore? Because community mental health teams won’t do it. So we looked at our intermediate care service and asked the AHPs, the physios, the nurses and the OTs etc. about their mental health and they were consistently not confident identifying the mental health needs of their patients. They had no idea how referrals worked, they said they’d had no training or the training they’d had was poor and a lot of the services said that if you were in anyway mad or had a mental health problem or cognitively impaired, you weren’t allowed to come here. So they talk about parity of esteem, most of these patients were explicitly excluded like a red flag from accessing these services.
So we stuck a liaison nurse there, just one, and in a winter period, with winter resilience funding there was 600 referrals to the intermediate care team and the nurse was inputting into about 100 of these patients and went out and did face to face assessments with about 30 or 40. So she was going out every day and seeing patients. The following year we increased that to a seven day service and again it was about 48% of the patients we were inputting into, and it was a similar approach to our MDT meetings. We weren’t necessarily going and doing the work for the team, we were helping the team to do the work. So this patient appears a bit confuses, “well have you done a MOCA, have you done a cognitive assessment, have you asked the patient why they’re not taking their medication rather than just saying they’re not, ask them why, have a conversation” and that helps the care plan.
So we thought we were quite good at this and decided in the end that we should ask the patients what their experience was and they said that they felt that their care had improved as a result of the HPs enquiring about their emotional wellbeing. They said that people took time to ask them about their whole life, they were interested in them as a person rather than a broken bone. Relatives liked it and referrers in the team felt that there was a benefit of having a psychiatric nurse involved.
So with my director of strategy hat on, rather than just integrated into this service, we decided they’re not doing it very well, let’s take it over. And when it came up for procurement last year, we put together a new partnership, and so this is my organisation down here West London Mental Health Trust, we are now the lead provider for what we’ve branded Homeward and we’ve come together with a neighbouring trust who provide community services, an acute trust, a local authority and this is a primary care federation that provides all of the out of hours care in Ealing. So we now have put together a partnership under a lead provider model that delivers integrated physical and mental health, mental health, physical health and social care and has secondary care, intermediate care and primary care in its core structure.
In the first year we’ve had just over 5000 referrals into the service. We’ve got a workforce of just over 100 staff, all of the patients under the care of the rapid response hospital at home team, we accept full clinical responsibility for them. So just as if you were in a hospital, you’re under our care in a hospital at home service and patients get a comprehensive multidisciplinary by a psychosocial assessment and a care plan.
And the final thing, is we’re now trying to hand these patients, when they’re discharged, over to the joint care team and the Ealing CCG has commissioned care coordinators and the care coordinators now sit with my team, they’re not part of my service, but they come and they integrate with my team, in some cases every day but definitely every week to identify the patients that are being stepped down back into the community so that those who have enhanced needs can be handed over more smoothly to primary care with a plan from our psychiatrist, our specialist nurses, our AHPs and our physician, and our social workers. So it’s trying to be as integrated as possible.
This is not my diagram, I nicked this from Devon I think, they’re doing something similar, but I like the idea. This is the image that we’re trying to sell to patients. That we will come to you.
And the final thought before I finish, is we’re all trying to do the same thing, so we are care planning, care coordinating, providing care closer to home, we’re setting up virtual wards, all of this integrated care stuff that we’re hearing about all day, and we’re extending the roles of practitioners, we’re risk stratifying people, co-producing stuff and you know, when I was starting to think about all of this and getting interested in how health is evolving through integrated care working, accountable care partnerships and the STPs, I thought “hang on a minute, we’ve done all this before” and actually one of the things about mental health is that we’ve had no money for decades and as a result of having no money for decades, we’ve had to test all of these “financial efficiencies”, and new ways of working and actually care planning is what the care programme approach legally mandates mental health services to do.
We’ve got care coordinators coming out of our ears, we’ve got care in the community whether you like it or not, it’s existed, it’s been and gone, we’ve rebranded it in different ways, but since the national service framework in the early 90s you have not been allowed to admit a patient to a mental health bed unless you have gate kept them for an out of hospital alternative. Nobody’s yet suggesting that for physical health treatments but intermediate care is very much the core of mental health services.
What I would say is, physical mental health integration is really important but actually one of the things that mental health services can do is teach the rest of the system the stuff that we’re currently trying to do. What’s worked, what hasn’t worked and let’s learn together from the things that haven’t worked in mental health and not just forget it and pretend it’s different.