Geraldine Strathdee, Consultant Psychiatrist Oxleas NHS FT Associate Medical Director, mental health, NHSL

This talk and some scientific London takeaway facts for you to solve!

• What do we need from clinical leaders

• What do we need from scientists as leaders

• London Scientific problems to take away & solve!

Clinical leadership going forward

• Focus on values

• Vision of care

• Scientific literate

• Informatics literate

• Economics literate

• Communications literate

• Emotional intelligence

• People who nurture leaders

• Courageous

• 70% of healthcare is long term conditions

• Home care & Primary care systems

• Better clinical & economic outcomes by Integration of

– Mind and body– Health and social care

• Implementation science – Using science to reduce inequalities

– Making evidence based care , routine care – New models of training

• Patients leading and self managing care

• Applying science to spend more time with our patients and their families

What’s the same What’s the new focus

A value based, affordable vision of care for people with long term conditions & their families in London

“Because we were able to have home carers… my husband was able to spend the last six years of his life in our own home, where he was very happy, instead of going into residential care, which would have made us all very sad”

(Carer, National Dementia Strategy, 2009)

I was diagnosed early I understand what

decisions I can make for now and for my future

I got the best treatment I need for my condition

& my life

My family are well supported in caring for

me

I am treated with dignity and respect as a person and a sufferer of

my condition

I know what I can do to help myself and my life

I enjoy life among my family

I continue to be part of my community and

contribute to it

I am confident that my end of life wishes will be respected and my death will be a good one for me and my

family

From the patient’s

perspective

Safety “Will I be ok?”

Effectiveness “Will the treatment do

me any good?”

ExperienceWill it be a kind, enabling,

experience & will I learn more about taking care of my health Efficiency

Will it be fast, safe , near home ,Helped me get back to work asap

Patients keep telling us they want from the NHS, whether we care at home or in a hospital……..

Professor Bruce Keogh, Medical Director of the NHS Plus a London efficiency view

What do we need from our scientists?

We need you to continue to lead discovery of new assessments, new medications, new treatments, new service models

We need your scientific brains to analyze & innovate where:

Science is being ignoredThe patient pathway is tortuous and inefficient

We absolutely need you to help us implement evidence based care

Where science is needed ..Care Pathway

• Prevention

• Identification

• Assessment

• Evidence based NICE pathways

• Recovery & social inclusion

• Behaviour change & lifestyles • Self screening, self assessment

• Clinician assessment tools

• Clinician decision support tools• Evidence based service design & delivery

• Risk alert awareness technology• Outreach for the most unwell• eRecords, eCare, ePrescribing,

eInvestigation results, efMRI

• Assistive technology for : – home based care for LTCs, dementia, LD

• Technology to reduce bureaucracy & duplication &meetings!

London Scientific problems to take away & solve

Interactive science : the causes of psychosis Understanding the health & social determinants of mental health conditions

Genetic & biochemical

Organic brain & neurodevelopmental

Societal •

‘What could we do?’ ‘What should we do?’ ‘How should we do it?’

Family history Substance misuse /mental ill health/

chaotic deprivation / abuse: physical, sexual,

emotional

School difficultDyslexia, Dyspraxia,

ADHD, Autistic spectrum,

Bullied

TruantingDrug use & dealing

Petty crime In Care

Mental illness starts Regarded as ‘bad’ or

‘strange’

Institutions career Expensive placements

Youth offendersAcute psychiatric wards

Forensic units

Biochemical ‘causes’Caffeine, nicotine, alcohol, street drugsNeurotransmittersEndocrine disorders

Life cycle times•Unemployment •Redundancy•Long term conditions •Adolescence•PregnancyLife trauma: •Bereavement•Losses & isolation•Migration•War.

The Schizophrenia Commission 2012 Schizophrenia and psychosis costs society

– £11.8 billion a year but this could be less if we invested in prevention and effective care. Increasing numbers of people are having compulsory treatment, acute care needs review Levels of coercion have increased year on year and are up by 5% in the last year.

Too much is spent on secure care - £1.2 billion or 19% of the mental health budget

Only 1 in 10 of those who could benefit get access to true CBT (Cognitive Behavioural Therapy) despite it being recommended by NICE (National Institute of Health and Clinical Excellence).

Only 8% of people with schizophrenia are in employment, yet many more could and would like to work. Only 14% of people receiving social care services for a primary mental health need are receiving self-directed support (money to commission their own support to meet identified needs) compared with 43% for all people receiving social care services.

Families who are carers save the public purse £1.24 billion per year but are not receiving support, and are not treated as partners. 87% of service users report experiences of stigma and discrimination. Services for people from African-Caribbean and African backgrounds do not meettheir needs well. In 2010 men from these communities spent twice as long in hospital People with severe mental illness such as schizophrenia still die 15-20 years earlier than other citizens.

What are the emerging scientific facts in London

• Health inequalities in London are stark.

• Between boroughs life expectancy gaps of 9 years Within

borough differences of 17 years

• Across England health inequalities are widening due the social

and economic determinants of health, which shape peoples’

lives and their health

London has more:

• Deprivation:

• Transport hubs that bring people to London • Mobile populations• Asylum seekers , & no recourse to public funds • More crime The impact of the economic downturn on health & health inequalities that may occur in London:

— More suicides and attempted suicides; possibly more homicides and domestic violence

— An increase in mental health problems, including depression, and lower levels of wellbeing

— major increase in dementia

Parity of care & the economic impact

We have very affordable effective treatments

Health care needs to be redesigned to meet the challenge of co-morbidity

• Health services in many countries fail to provide co-ordinated support for patients’ multiple needs.

• Patients frequently experience fragmented care and opportunities to improve quality & efficiency are missed.

• There is a professional, institutional and cultural separation between mental and physical health that must be overcome.

“The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated”. Plato (427–347 BC)

Co-morbidity is the norm

Lancet, Barnett, Mercer et al 2012

Mental health, physical health & deprivation

Barnett, Mercer et al 2012

Mental health raises costs in all sectors

• Overall, international research finds that co-morbid MH problems are associated with a 45-75% increase in service costs per patient(after controlling for severity of physical illness)

• Between 12% and 18% of all expenditure on long-term conditions is linked to poor mental health and wellbeing – at least £1 in every £8 spent on long-term conditions.

Heart F

ailure

Stroke

Heart d

isease

Diabete

s

Hypert

ensio

n

Arthriti

sCOPD

Cancer

Asthma

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

DepressionAnxiety

% in

crea

se in

ann

ual p

er p

atien

t cos

ts

(exc

ludi

ng c

osts

of M

H ca

re)

Mental health drives LTC costsAnnual per patient costs with and without depression(excluding MH treatment costs)

Welch et al 2009

From a GP …………Clare Gerrada

Professor Michael Porter GPs are trying to do everything for everyone, too much of 21st Century care was being provided through 19th century organisational models.Porter is a world authority on strategy in business, & has spent the past decade working in healthcare systems in

dozens of countries.

• I was struck the other day when I saw a patient - who has been off work for 3 months waiting for CBT. He is depressed and was just told to go on sick leave- no medication, just a referral for CBT in the distance future.

• When I saw him , what upset me most was that if he had broken his leg, he would have been treated asap, given rehab, told to go to work on crutches and would not have just been abandoned.

• I want to make it impossible for mental health problems to be treated as second class illnesses - with patients with treatable conditions languishing on waiting lists or worst still with no treatment at all

Poor outcomes of untreated depression comorbidity in physical LTCs

Stroke Heart disease

Diabetes

2012 publication Compendium of examples of cost effective programmes for people with Long term physical illnesses in acute trusts & primary care

settings

Thank you for listening

If you have ideas on how to improve our implementation of scientifically proven care,

please email me on geraldine.strathdee@london.nhs.uk