Coproduction of MH

Wellbeing, Recovery and

Employment Service Review

How to support recovery in Crisis

Physical Health

Review of Long Term 1:1 Support

Meeting 5,14th August

Agenda

• Pathway: how to support recovery in Crisis 3:30

• Golden thread: Physical Health 4:00

• Review: 1:1 support 4:30

• Client Profile: geomapping 5:00

Coproduction and Procurement

1. All members of the coproduction group must declare their interests

2. Membership of the coproduction group will not give any advantage in any future procurement exercise

3. We will publish a ‘Prior Information Notice’ in the Procurement Journal so all providers know our:

• Broad timelines

• Broad scope

• Any dates of engagement events

4. Any local market warming event with CVS must be open to all providers or a 2nd event is needed

5. After the community engagement event in September the coproduction group will sign off the final model. There will then be break between the development of the model and any procurement activity in November.

Part of the Pathway: Crisis

A. Local Data – where are we

now? How are we doing?

B. Local Aspiration – where do

we want to be? What are our

outcomes?

C. Improve – what are our

ideas? Are there Alternative

models of best practice

A Local Data:Numbers in Crisis

Number of People

Number of people under Home Treatment Team 312

Average number of A&E attendances with mental health problems

seen by the RAID team per month in 2017/18

299

Adult Acute Occupied Bed Days 2,242

Adult Acute Unique Patients 171

Adult Acute Direct Admissions 76

PICU Occupied Bed Days 553

PICU Unique Patients 44

PICU Direct Admissions 8

A National Data: A&E

4.2% of all A&E attendances are mental health related

• 1/3 will need admission

• 50% discharged home from the ED (+/- GP follow up)

Day of arrival

• MH attendances: Saturday (15.5%) and Sunday (15.8%)

• All attendances: Monday (16.1%)

Time of arrival: 2/3 arrive out of hours (5pm-9am)

• 9am to 5pm: 32.0% MH attendances vs 50.2% all attendances

• 5pm to Midnight: 38.9% MH attendances vs 31.9% all attendances

• Midnight to 9am: 29.1% MH attendances vs 17.8% all attendances

B Local AspirationCommitment to Crisis Care Concordat

• Access to support before crisis point – making sure people with mental health problems can get help 24 hours a day and that when they ask for help, they are taken seriously.

• Urgent and emergency access to crisis care – making sure that a mental health crisis is treated with the same urgency as a physical health emergency.

• Quality of treatment and care when in crisis – making sure that people are treated with dignity and respect, in a therapeutic environment.

• Recovery and staying well –preventing future crises by making sure people are referred to appropriate services

Commitment to Suicide Prevention: Long term aims

more people to be aware of and have access to appropriate services in the early stages of mental health

need or emotional distress.

more people to be assessed for mental health at the stages of life when people are most at risk of

suicide

more people to have the personal tools to help them cope with social stressors and traumatic life events

We would like more people in Tower Hamlets to feel more in control of their mental health.

We would like more people in Tower Hamlets to be able to recognise when in need of support and how to

access help when they need it

We would like more people in Tower Hamlets to be able to access support in a crisis in an appropriate

setting.

frontline staff feel confident in recognising signs of emotional distress and are able to provide appropriate

support.

frontline staff to have a range of referral options for residents.

frontline staff have the right information to make an effective referral.

Vulnerable groups, such as children and young people, to have support specific to their needs.

People bereaved through suicide to feel well supported.

ensure that suicide prevention is embedded in the wider community.

ensure non-clinical frontline staff who are confident in recognising and assisting those in mental health

crisis are retained.

ensure that training needs for clinical and non-clinical staff are met

ensure that frontline staff have appropriate support in the workplace to protect their personal wellbeing

and mental health.

Put in place a communications strategy that promotes local work and supports relevant national

campaigns.

support responsible reporting of suicide in the media

C: Ideas?

1. Crisis has a personal definition: what does crisis mean

to you?

2. What sort of support do people in crisis need to

achieve recovery and wellbeing?

3. Services such as HTT and RAID exist already – what

are the gaps?

4. What role does the Recovery and Wellbeing Service

have?

Golden Thread: Physical Health

• People living with severe mental illness (SMI) face one of the greatest health inequality gaps in

England. The life expectancy for people with SMI is 15–20 years lower than the general population.

• Smoking is the largest avoidable cause of premature death, with more than 40% of adults with SMI

smoking. Individuals with SMI also have double the risk of obesity and diabetes, three times the risk

of hypertension and metabolic syndrome, and five times the risk of dyslipidaemia (imbalance of

lipids in the bloodstream) than the general population.

NHS Ideas for Physical Health and Mental Health:

personalised care planning, engagement and psychosocial

support

• Personalised care planning needed to make the lifestyle and behaviour changes.

• Should address the full needs of the service user, taking steps to combat loneliness, isolation

and promoting wider engagement in self-care, exercise, healthy eating and lifestyle.

• Social prescribing’ supports personalised care planning by working across health and social

care organisations, voluntary sector, community and faith groups.

• Voluntary sector organisations can also play a crucial role in effective care planning and

providing follow up support. For example:

• Peer supporters can help to reduce barriers in engagement, address social isolation and

support behaviour change.

• Care navigators can play a key role in improving the pathway for people with SMI. With

their in-depth knowledge of local services, they can point people in the right direction,

approach services on an individual’s behalf and support people to attend appointments

where appropriate.

Introduction

On the 1st March Inspire and People Participation held a work shop to look at the barriers around physical health for people with a mental health condition. 14 people attended:-

The purpose of this workshop was to gather views, opinions and experiences, around physical health and the barriers that may contribute to this.

This is what people have told us….

Barriers/Challenges to Physical

HealthBarriers:

• Body image

• Pressure on yourself and pressure from other people

• Media

• Time constraints

• Stresses of daily life

• Striving for perfection can lead to a negative effect when perfection is not achieved

Gym/Exercise Barriers

Barriers:

• Someone suffering with mental health issues does not want to exercise in an unwelcoming and unsupportive environment

• Some people with mental health issues are fully aware they want to exercise but their anxiety means there are physically unable to leave the house

• Cost of gyms are very expensive, benefits are not taken into account

Gym/Exercise Barriers

Barriers:

• Gym not inclusive-loud music, anti-social, unfriendly, competitive, instructors pressuring people.

• Expectations can be very high which can be demoralising and zap your motivation

• Gym not friendly, unfriendly name, glass shop front

• Marketing of the gyms is not widely inclusive

• Worries about having a low/crash after an adrenaline high, hypo due to diabetes

Gym/Exercise Solutions

Solutions

• Alternatives to gyms and alternative forms of physical activity. When you think about exercise you think about running, gym etc. but exercise is about movement

• Place emphasis on smaller achievable person centred steps

• Gyms could become a hub for different activities and public sector gym facilities expanded to provide the above

• Mentoring or buddying system to support people in accessing facilities

• Anxiety flagging system – if not feeling like you can talk to people wear something that will tell people

Gym/Exercise Solutions

Solutions

• Chair exercises, walking groups, art tours book tours physical activities that will reach out to all

• Cost of gyms-find a pathway for people with limited income

• Staff at gyms need awareness and more training

• Publicly fund free gym/sauna and other activities for people with disabilities eg – Ability Bow

• Educate people about physical health and moving away from the gym concept-e.g. 10/15 min walk a day is very beneficial to everyone

Gym/Exercise Solutions

Solutions

• Seated exercises in a group session and safe environment-group support

• More benches in parks

• More public toilets

• Training gym staff on realistic goals

• Targeted plan involving health professionals

• CBT/DBT goals physical exercise related

• Realistic person centred goals – a little step toward physical activity

Gym/Exercise Solutions

Solutions

• Targeted plan involving health professionals eg diabetic nurse

• Sugary sports drinks, energy bars etc full of sugar what can you eat and drink – vending machine with healthier alternatives

• Well ventilated, open spaces with windows – especially for panic/anxiety

• Gym at mile end hospital only used until 4 and not at weekends could we tap into this

• Directory of what is available

Integrating Mental Health and Physical

Health-Challenges

Barriers

• How do people find out if they’re physically ok?

• Understanding that if the average person is at 1 in terms of wellbeing, people with mental health conditions are starting below the baseline which means they have a huge barrier before reaching it and therefore a longer journey

• Language barrier-English is not the first language of many people in the borough. People lack confidence in asking for help

Integrating Mental Health and Physical

Health-Challenges

Barriers

• Weight/blood pressure/diabetes/cancer tests-people

struggle to engage

• Fear of going to GP

• Difficulty with accessing check-ups at doctors

• Pressures on GP-don’t have time or resources

Integrating Mental Health and Physical

Health-Solutions

Solutions

• Have a local hub (e.g. MIND) to relieve pressure on GP

• Opt in health checks

• More practice nurses

Integrating Mental Health and Physical

Health-Solutions

Solutions

• Psychological support is offered to someone who has

kidney failure for example; why not the other way

around?

• Offering a physical health check to someone who is

struggling with mental health issues

• Nurse led health checks – these can be at third sector

organisations.

Medication-Challenges

Barriers

• Lack of information about medication and its effects on

physical health

• Potential for weight gain on certain mental health

medication

• Packaging-small font-people struggling to read instructions

• Day night reversal effects, balance, strength, drowsiness,

co-ordination

Medication-Challenges

Barriers

• Lack of genuine/honest conversations with GP A nurse available for support with GP apt

• GP solution culture change – training

• GPs don’t have the specialist training and knowledge around side affects for medication like secondary mental health professionals

Medication-Solutions

Solutions

• Accessible timely advice and information given to people

on negative side effects of medication and managing them.

• Traffic light label put on medication, similar to food labelling.

• Develop a positive framework for consultants ensuring right

advice is given at the right time

• Flagging GP Appt on the system to tell them if someone

with a mental health condition is attending – offer/book

double appointment

Medication-SolutionsSolutions

• Resources to help people understand computers and social media; maybe students could help us with this.

• We need more funded, accredited training, to learn new skills.

• There is the Prince’s Trust available for people up to the age of 25. Similar provision is needed for older people.

• Ensure people are aware of what is meant by a reasonable adjustment and how to access this.

Many people from all different

walks of life can benefit from the

solutions presented

Break

Review: Long Term 1:1 support

A. Local Aspiration –what are

our outcomes? Have they

changed?

B. Local Data – where are we

now? How are we doing?

C. Improve – what are our

ideas? Are there Alternative

models of best practice

31

Key outcomes

Specific outcomes

People have improved mental health People have improved mental state including reduced anxiety and

distress

Improved access and increased use of support services

Service users feel more informed about their health and wellbeing

Reduced admissions to hospital or need to seek medical help

Reduced mental health inequalities between different groups

People are better able to manage their mental health and lead

a full life

Increased numbers of people are able to manage their mental

health problems.

Service users have increased self-esteem.

Service users increase their skills and gain appropriate

qualifications.

Increased numbers of service users enter employment

Service users have improved social networks

Service users become more active citizens.

Service users are better able to manage their finances.

Increased numbers of service users feel in control of their lives

A. Local Aspiration: 1:1 support

B Local Data: how are we doing?

Aim Q4 Q1

Number of clients that have received long term 1:1 support 300 296 (including 12 in crisis

& 27 in group support)

304 (including 245 one to one

caseload, 35 one to ones from

groups and 24 crisis)

Capacity of team (based on caseload of 35) 265 272

1:1 face to face appointment hours 1210 hours 2012

Number of new referrals during quarter 43 32

Number of clients during quarter who are under CPA/EPC/social

care

51

17%

142

51%

Number of clients who have a support plan in place 80% 257

86%

224

(91%)

Numbers of clients discharged 28 27

Number of crisis clients (not current referrals) 12 18

Number of clients that have been in the service over 2 years 54 27

C: Ideas for future 1:1 support?

What does good support look like for very unwell people living in the community?

1. What should be included?

2. Where is it delivered?

3. Who delivers it?

4. What else should we think about?

Case study: X has been referred for support due to relapse in mental health problems. He feels unable to leave his Mum’s house. What would good support look like?

User Profile: Geodata

35

Population Map for Inspire Users

Source: INSPIRE list of patient postcodes, matched to LSOA level

The left shows a map of Inspire users

standardised by LSOA population size. Red areas

correspond to higher relative density of Inspire

users per 1,000 population.

Of the 1,388 matched LSOAs to Inspire users’

postcodes, 1,334 users live in Tower Hamlets.

The most number of users per LSOA is 12.

CCG of Postcode Count

Tower Hamlets 1328

Newham 17

Hackney 16

City of London 9

Redbridge 10

Bexley 2

Harrow 1

Waltham Forest 1

Enfield 1

Barnet 1

Westminster 1

Havering 1

Inspire Mental

Health Consortium

36

Depression - Tower Hamlets Patients Diagnosed with Depression Residence Map

2017/18 (based on GP record)

1

2

4

3

5

Area NameDepression

patients

% of all Depression

patients 17/18

1 Weavers / Spitalfields and

Banglatown

3,446 12%

2 Bow East 1,844 6%

3 Poplar 1,609 5%

4 Bromley South 1,596 5%

5 Stepney Green 1,538 5%

Source: THT/ELHCP Data Repository

37

Anxiety - Tower Hamlets Patients Diagnosed with Anxiety Residence Map 2017/18

(based on GP record)

4

31

2

Area NameDepression

patients

% of all Anxiety

patients 17/18

1 Weavers / Spitalfields and

Banglatown

3,488 11%

2 Blackwall and Cubitt Town

/ Island Gardens

2,071 6%

4 Bromley South 1,640 5%

3 Poplar 1,322 4%

Source: THT/ELHCP Data Repository

38

Serious Mental Illness - Tower Hamlets Patients Diagnosed with SMI Residence Map

2017/18 (based on GP record)

13

2

4Area Name

SMI

patients

% of all SMI

patients 17/18

1 Weavers / Spitalfields and

Banglatown

385 9%

2 Stepney Green 333 8%

3 Bromley South 272 6%

4 Shadwell / St. Katherine’s

and Wapping

169 4%

Source: THT/ELHCP Data Repository

Tower Hamlets Map

39

Meeting Area of recovery path Golden Thread Review

3rd July How to support recovery within Primary Care

• Prevention

• Integration with Primary Care

• Ways into the service – transition/Young People

•Psychology

• Barriers to the service eg multiple needs, geography

•Integration of services with other key services such as

homelessness services, schools, probation

Stigma Short Term

1:1

17th July How to support recovery in secondary care

•Inhouse services

• User Led Grants

Personalisation/car

e planning

Group Work

14th August How to support recovery in Crisis

•Relationship with A&E and crisis services

•Suicide prevention

•24/7 Safe Place

Physical Health Long term

1:1

20th August 2pm Recovery College

28th August How to support Post ward recovery

• Relationship with wards and post-discharge support

Coproduction/Peer

work

Employment

40

Coproduction 5

Notes

41

Part of the Pathway: Crisis

Notes

• What sort of support do people in crisis need to achieve recovery and wellbeing?• Immediate place of safety (suggestion of café in Royal London)

• Phone/video phone/text

• Outreach come to you – CPNs on motorbikes

• Right training – relatable experience/skills for assessment

• Integration – lots of people get referred from A&E to GP – why cant they book an appointment and share notes? Handover

between services?

Recommendations for the future Recovery and Wellbeing Service:• Safe place to “just be” (ideally out of hours)

• Discussion around being present in a busy drop in café when not wanting to engage with anyone – could indicate this with

a subtle code ex/ wearing a yellow scarf

• Someone to listen/talk to (peers with right training – relatable experience/skills for assessment?)

• Practical support around the causes of the crisis which are often not MH related, eg eviction, benefits

• Out-of-hours support that linked in with other services eg. Triage fast track pathways into ‘held’ next day appointments in usual

services such as GPs/

42

Physical Health

Notes:

• need sustainable long term approach • Health trainers were great but everything stopped when they did

• initial intensive input then scale down

• Specialists such as Mile End Gym physio should be path to universal offer by building confidence

• Technology could be used more innovatively, example, to deliver activities on webcam to 20 different people within their homes

• Need the universal offer such as local gyms to work better with people with mental health• Special space and time for people within community offer

• Different formats work for different people:• Some people like groups which help with social isolation

• Some work better with 1:1

• Evenings as well as afternoons

• Helpful activities include:• Physical health checks

• Cooking classes

• Buddy system to go to the gym which picks people up from their house “most important thing is to come and grab me by my hand” “having someone there with me gave me energy to carry on”

1:1 Support

What does good support look like for very unwell people living in the community?

1. What should be included?• Outreach

• Model good functional behaviour

• Working out balance between what person can do and gaps – then delivering these gaps

• Help people facilitate own behaviours whilst allowing for bad decisions and knowing when to walk away

2. Where is it delivered?• In the community – wherever people need the support worker to enable them to facilitate their recovery plan.

3. Who delivers it?• Understanding

• Lived experience

• Good communication

• Listening skills

• Know how to cope in a crisis

• Consistent

• Reliable

• Human

• Patient

• calm

4. What else should we think about?• Peer support required additional organisation input. Essential to have training, supervision, right infrastructure, support networks of best practice ex need

carefully thought out hub for privacy/debrief – need to be sensitive to triggers/their own recovery needs.

• Challenges of operationalising peer support when there is potential of workers becoming unwell.

Recommendations

• Community based delivery of recovery plans

• More peer support workers but they need to be properly supported and resourced