report to: one sutton author(s) and contact phone...

1 04082014 – N Lang LB Sutton Public Health Version 25

Report to: One Sutton

Commissioning

Collaborative

Date: August 2014

Report of: Director of

Public Health

Author(s) and Contact Phone Number(s):

Dr Nicola Lang - Director of Public Health

X5919

Report title: Mental health needs assessment for adults - Sutton

Summary

Attached is the mental health needs assessment for adults for Sutton

Recommendations

To note the needs assessment which will inform the adult mental health strategy

Background Documents and Previous Decisions

Listed in the report

Signed:

Director of Public Health


Background The mental health needs assessment was requested by both the CCG and council as this is

an area of priority.

Recommendations To note the needs assessment, which contains a list of recommendations with clear

ownership for action.

Impacts and Implications: See needs assessment

Consultation Service users and professionals were consulted for the needs assessment

Timetable for Implementation See the needs assessment


Mental health needs assessment for adults London Borough of Sutton

August 2014

Dr Nicola Lang MBBS, FFPH

Director of Public Health

London Borough of Sutton


List of abbreviations AMHP approved mental health professional

AOT assertive outreach team

CAG mental health commissioning action group (Sutton)

CAMHS child and adolescent mental health services

CCG clinical commissioning group

CMHT community mental health team

CPA care programme approach

CQUIN commissioning for quality and innovation

CRHT crisis resolution home treatment

DH department of health

EIP early intervention in psychosis

FTE full time equivalent

IAPT improving access to psychological therapies

IMD index of multiple deprivation

LTC long term conditions

NSF national service framework

QOF quality and outcomes framework

SEMI severe and enduring mental illness

SMHF Sutton mental health foundation

SMI serious/severe mental illness

SWL StG South West London & St George’s mental health trust


Acknowledgements With thanks for data, qualitative views, service descriptions and advice to:

London Borough of Sutton: Keith Skerman (former Executive Head of Adult

Safeguarding), George Platts (Head of Social Work Mental Health services), Steven Forbes

(Executive Head of Adult Safeguarding).

Sutton CCG: Adrian Davey (Senior commissioner - Mental Health Sutton CCG and LBS),

Susan Roostan (Director of Commissioning, Sutton CCG), Claire Symons (Mental health

practitioner and project manager), Chris Keers (CCG Lead GP for mental health).

South West London and St George’s mental health trust: Mark Clenaghan (Service

Director), Gul Baxter (Analyst), Shan Haydar (analyst), Angela Barst (business

management), Jim Bolton (Lead Psychiatrist for Liaison Psychiatry), Daniel Barrett (service

user involvement manager), Mannish Ladva (Analyst).

Sutton Mental Health Foundation and the mental health Commissioning Action Group

(CAG): Alan Leader, Carol Anne Brennan, and Siobhan Passmore.

Sutton carers’ centre: Rachael MacLeod and Amanda Cummins.


Table of Contents List of abbreviations .............................................................................................................. 4

Acknowledgements ............................................................................................................... 5

Executive summary ............................................................................................................. 10

Prevention ....................................................................................................................... 10

Expected prevalence of mental health issues/illness ....................................................... 11

Primary care .................................................................................................................... 11

Secondary care ............................................................................................................... 12

Inpatient admissions (Ward 3) ......................................................................................... 13

Out of area placements ................................................................................................... 13

Liaison psychiatry ............................................................................................................ 13

Community mental health teams (CMHT) ........................................................................ 13

Early intervention in psychosis ........................................................................................ 13

Home treatment team ..................................................................................................... 14

Assertive outreach team .................................................................................................. 14

Probation needs .............................................................................................................. 14

Qualitative views ............................................................................................................. 14

Recommendations .......................................................................................................... 15

1 Background ................................................................................................................. 18

2 Introduction and scope of needs assessment .............................................................. 18

3 Key policy documents for adult mental health .............................................................. 19

3.1 The National Service Framework (NSF) for mental health (1999) ......................... 19

3.2 The mental health strategy – No health without mental health .............................. 19

3.3 No health without public mental health (Royal College of Psychiatrists) ................ 19

3.4 The recovery model .............................................................................................. 19

4 Methods ...................................................................................................................... 20

5 Service descriptions .................................................................................................... 21

5.1 Primary care ......................................................................................................... 21

5.1.1 GP practices .................................................................................................. 21

5.1.2 Improving access to psychological therapies (IAPT) ...................................... 21


5.2 Secondary care ..................................................................................................... 21

5.2.1 Community mental health teams ................................................................... 21

5.2.2 Specialist community teams .......................................................................... 22

The Henderson Hospital had been commissioned on a London/South East Consortium

basis as a Tier 4 Personality Service until 2009. Tier 4 placements are now made on an

as required basis through individual funding requests. ................................................ 23

5.2.3 Inpatient services ........................................................................................... 23

5.2.4 Liaison psychiatry ......................................................................................... 23

5.2.5 Section 136 ................................................................................................... 24

5.2.6 Recovery college ........................................................................................... 24

5.3 Social care / social work........................................................................................ 25

5.3.1 Approved mental health professional (AMHP)................................................ 25

5.3.2 Team structure ............................................................................................... 25

5.4 Carers’ support ..................................................................................................... 25

5.5 Support in the community ..................................................................................... 25

5.5.1 Sutton Mental Health Foundation ................................................................... 25

5.5.2 Prosper .......................................................................................................... 26

5.5.3 Sutton wellbeing ............................................................................................ 26

5.5.4 Sutton 1in4.................................................................................................. 26

5.6 Offender health in the community (non forensic) ................................................... 26

7 What is the need? (Epidemiology) ............................................................................... 27

7.1 Risk factors for mental health problems – Sutton .................................................. 27

7.1.1 Community mental health profiles – risk factors ............................................. 27

7.1.2 UCL benchmarking and comparison – risk factors ......................................... 27

7.1.3 Prevention of mental ill-health in Sutton ......................................................... 28

7.2 Best estimates - expected prevalence for mental health problems ........................ 28

7.2.1 Common mental disorders ............................................................................. 28

7.2.2 Psychotic disorder ......................................................................................... 29

7.2.3 Depression .................................................................................................... 31

7.2.4 Bipolar disorder ............................................................................................. 32

7.3 Observed prevalence of mental health problems in primary care .......................... 32

7.3.1 Depression in primary care ........................................................................... 32

7.3.2 Sutton primary care performance indicators .................................................. 33


7.4 Secondary care admissions .................................................................................. 35

7.4.1 Age standardised hospital admissions for schizophrenia ............................... 35

7.4.2 Emergency hospital admissions for schizophrenia ......................................... 36

7.4.3 Proportion of admissions under the mental health act (MHA) ......................... 37

7.4.4 Number of bed days used by mental health secondary care is lower than the

England average ......................................................................................................... 37

7.4.4 Inpatient admissions (Ward 3) ....................................................................... 37

7.4.5 Out of area placements .................................................................................. 38

7.5 Liaison psychiatry St Helier hospital ...................................................................... 41

7.5.1 Diagnosis liaison psychiatry clients ................................................................ 41

7.5.2 Frequent flyers ............................................................................................... 42

7.6 CMHT caseloads .................................................................................................. 43

7.7 Specialist team caseloads ..................................................................................... 44

7.7.1 Early intervention in psychosis (EiP) .............................................................. 45

7.7.2 Home treatment ............................................................................................ 46

7.7.3 Assertive outreach team ............................................................................... 47

7.8 Probation caseload for Sutton - mental health needs ............................................ 48

7.8.1 Breakdown of current caseload by Emotional Wellbeing ................................ 49

7.8.2 Breakdown of current caseload by Current Psychological Problems /

Depression .................................................................................................................. 50

7.8.3 Breakdown of current caseload by social isolation ........................................ 50

7.8.4 Breakdown of current caseload by Self-harm/ Attempted Suicide/ Suicidal

Thoughts ..................................................................................................................... 50

7.8.5 Breakdown of current caseload by Psychiatric Problems .............................. 51

7.8.6 Issues of emotional wellbeing linked to risk of serious harm, risks to the

individual and other risks ............................................................................................. 51

Issues of emotional wellbeing linked to offending behaviour ........................................ 51

8 Suicide in adults .......................................................................................................... 53

9 Measured performance around mental health ............................................................. 53

9.1 Primary care ......................................................................................................... 53

Case finding of mental health problems in people with long term conditions ............... 53

IAPT ............................................................................................................................ 53

9.2 Secondary care ..................................................................................................... 54


9.2.1 Smoking cessation for clients ......................................................................... 54

9.2.2 Care programme approach ............................................................................ 54

9.2.3 Settled accommodation ................................................................................. 55

9.2.4 Employment ................................................................................................... 55

9.2.5 Contact with community psychiatric nurse ..................................................... 55

10 Qualitative views - what do people think about services? ............................................ 56

Professionals .................................................................................................................. 56

Service users .................................................................................................................. 58

The main points arising from the clients views are as follows: ......................................... 59

11 Comparisons with other areas: innovations ................................................................ 60

Annex 1 –Sutton and Merton mental health strategy ........................................................... 63

Annex 2 - Social work structure for mental health LBS ........................................................ 64

Annex 3 – risk factors for mental health Sutton compared with London .............................. 66

Annex 4 – long term conditions Sutton ................................................................................ 67

Annex .................................................................................... Error! Bookmark not defined.

Annex 5 – settled accommodation ...................................................................................... 67

Annex 6 – CPA employment ............................................................................................... 69


Executive summary Mental ill health represents a significant burden of disease nationally, forming ‘23% of the

total burden of ill health in the UK’1. The impact of mental disorder is a 10-20 year reduced

life expectancy2.

In terms of risk factors for mental health problems, Sutton has an older and less ethnically

diverse population than the rest of London which would lower the risk of mental health

issues. There are, however, risk factors in Sutton that may increase the likelihood of mental

health problems, such as – working age unemployment, lower levels of physical activity in

adults, and lower numbers in substance misuse treatment.

This needs assessment sets out the epidemiological data on mental health in the borough,

qualitative views of service users and professionals, comparison of innovations and best

practice in other areas, and describes services locally - to build a picture of adult mental

health, with recommendations for action.

Prevention

Summaries of ‘what works’ for prevention of mental illness for London can be applied to

Sutton. Although child health is outside the scope of this report, the interventions that would

prevent mental illness in Sutton in later life would be:

Support for looked after children as they have high levels of mental disorder (46%,

Ford et al 2007)

Support for new mothers (to reduce perinatal depression)

Support for parents and infants

School based mental health interventions/prevention e.g. targeted mental health in

schools (TAMHS)

Prevention of child abuse, and intervention when detected

Treatment of self harm in children and adolescents3

Support for people with a long term limiting illness to reduce depression

1 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf: 10.

2 UCL partners London document Campion et al 2013. Powerpoint presentation.

3 Sutton has the third highest levels in London - again this is an adult needs assessment but this is very important and worthy of

note. Rate is 88.20 admissions in children and adolescents per 100,000

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf


Expected prevalence of mental health issues/illness

Using national estimates of prevalence projected onto Sutton for persons aged 16 to 64

years, we estimate the following numbers of persons with expected mental health issues:

Mental health problem Numbers estimated for Sutton using national data

Common mental disorders 16000 persons

Psychosis in last year 500 persons

Depression 2800 to 4000 persons

Bipolar disorder 1600 persons

Primary care

UCL partners has analysed four key primary care mental health indicators from different

data sources so that Sutton primary care performance can be compared with the rest of

London.

Proportion on primary care depression register – Sutton compared with London

Sutton’s proportion of adults on the primary care depression register is 9.6% which is

within the London range of 4.8% in Barking and Dagenham and 12.6% in Islington. When

we compare Sutton with our statistical London comparator boroughs of Barnet and Harrow4

this is better than Barnet (8.5%) or Harrow (7.3%). However, a more detailed practice level

analysis above shows there is still individual improvement to be made.

Proportion of new cases of depression receiving further assessment between 4-12 weeks –

Sutton/London

The Sutton proportion is 70% which falls between the London lowest - Bromley at 55% and

highest - Kingston at 83%. Barnet is at 66% and Harrow at 80%. The best performing

London borough was Kingston, so lessons could be learned to see how re-assessment and

recording is flagged within primary care in that borough.

Proportion referred for psychological therapies – Sutton/London

The proportion of the population referred is 4.8%, which is higher than both comparator

boroughs of Barnet (2.5%) and Harrow (2.7%), but broadly similar to Richmond and

Kingston (both at 4.8%).

Emergency admissions for neurotic disorder – Sutton/London

In terms of emergency admissions in Sutton adults, this is 10.2 per 100,000 population. This

contrasts with Hackney at 28.5 per 100,000 (highest) and Tower Hamlets at 6.9 per 100,000

(lowest). A fairer comparison is with Barnet 11.0 per 100,000 and Harrow at 8.2 per 100,000

- so Sutton’s figure lies midway between the two comparator local authorities.

4 http://longerlives.phe.org.uk/area-details#are/E09000029/par/IMD10-UTLA-D8 last accessed 31 Dec

2013.

http://longerlives.phe.org.uk/area-details#are/E09000029/par/IMD10-UTLA-D8


Secondary care

Age standardised hospital admissions for schizophrenia

These hospital admissions are variable across London and are often linked to deprivation.

However Sutton at a rate of 56.2/100000 falls between Barnet (32.5) and Harrow (74.1)

which is difficult to explain, as we would expect similar admission rates across similar

comparator boroughs. Comparing Sutton with the other South West London boroughs using

the same provider of services, we see that Merton and Wandsworth admission rates are

lower than Sutton, and conversely Kingston and Richmond admissions are higher. This

goes against predictions that admission rates are linked to deprivation.

Source: UCL partners academic health science partnership public mental health briefing presentation

2013.


Inpatient admissions (Ward 3)

Data for 2012/13 were analysed and showed 265 admissions to Ward 3 over the course of

that year.

Out of area placements

The King’s Fund has noted the costs of out of area placements at £34,000 per year

compared with £21,000 ‘for an equivalent local placement’5. A snapshot picture of the

Sutton out of area placements was obtained on 1st November 2013 of 38 persons on 1

November 2013. The average age for the working aged adults (i.e. 18 to 64 years and 364

days) was 43 years. The numbers are small in most diagnosis categories, but the majority

of patients (61%, 23/38) had a primary diagnosis of schizophrenia. The largest proportion

of ‘out of area’ placements were in London (17 placements out of 38).

Liaison psychiatry

An audit of patients classified as ‘frequent flyers’ was also carried out by the mental health

trust in collaboration between Sutton and Merton primary care trust6, Epsom-St Helier NHS

Trust and SWL StG. Of 57 patients whose notes were reviewed - 19/57 (33%) had current

contact with mental health services, 16/57 (28%) had no contact, and 22/57 (39%) had

previous contact with mental health services. This indicates a high level (72%) of persons

with a mental health history within the frequent flyer group, even though the sample size is

small.

Community mental health teams (CMHT)

The Community Mental Health Service consists of a single point of access borough based

assessment service, with three locality based Recovery and Support Services for those

people with ongoing treatment needs.. A snapshot of patients aged 18 to 64 years seen

within the service shows that 1307 clients were under its care in 2013/14. The majority of

clients on the adult CMHT caseload have either schizophrenia (26%), mood disorders (13%)

or bipolar conditions (10%).

Early intervention in psychosis

From 2010/11 to 2013/14 there were almost 400 clients seen by the early intervention in

psychosis (EiP) team in Sutton, and 59% were male (in line with national findings). For the

snapshot of 2013/14 clients we see that although the majority of clients were White there is

an overrepresentation in Black ethnic groups (14%) and mixed groups (9%) - when the

Sutton population overall has only small proportions of persons from black (5%) and mixed

(4%) ethnic groups. This is in line with expected national findings, with an increased risk

of schizophrenia in Black African and Caribbean groups7.

5 Kings Fund mental health and the productivity challenge: 12.

6 As it was before April 1

st 2013. Sutton and Merton PCT.

7 Psychiatry at a glance – Katona et al 2005.


Home treatment team

A snapshot view of the home treatment team for Sutton in 2013/14 showed a caseload of

338 persons.

Assertive outreach team

The assertive outreach function is embedded within the Recovery and Support teams using

a Flexible Assertive Community Treatment (FACT) model. From 2012/13 to 2013/14, 157

clients were supported under assertive outreach which equates to approximately 80 patients

per year. From 2012/13 to 2013/14 the Sutton assertive outreach team saw 157 clients

which equates to approximately 80 patients per year.

Probation needs

A snapshot audit of the probation caseload showed that 12% had a record of psychiatric

problems. This is likely to be an underestimate given that Brooker et al in Lincolnshire

probation estimated the need at 39% of clients.

Qualitative views

Service user and professional views are found in detail in the main document, but key

themes emerged around continuity of care, in particular around physical health, medication

continuity and advice, and issues with professionals in primary and mental health services

not communicating effectively. Issues in primary care mental health awareness and stop

smoking were also described.


Recommendations

Key recommendations with suggested ownership are found below, linked to Closing the

Gap – priorities for essential change in mental health8 (2014).

Recommendation Suggested ownership

Timelines Link to closing the gap recommendations

Primary care

1 Ensure increased recording of depression in primary care

Primary care 2014/15

2 Ensure improved levels of 4-12 week reassessment for depression to move towards the levels achieved in Kingston (83%

Primary care 2014/15

3 Ensure that clients with long term conditions are assessed in primary care and offered appropriate psychological support

CCG 2014/15 13 - Mental health care and physical health care will be better integrated at every level

4 Review primary care training needs to ensure that GPs feel confident and skilled to address mental health issues, and that they can

check for mental health conditions in patients with LTCs and

ensure good physical health checks are made for their clients under secondary mental health services

Primary care 2014/15 19 - People with mental health problems will live healthier lives and longer lives

5 Address issues with IAPT recovery and pathways performance

CCG commissioner

2014/15 5 - 0ver 900,000 people will benefit from psychological therapies every year

6 Support a wider consideration of new innovations in primary mental health care

CCG 2014/15 1 -High-quality mental health services with an emphasis on recovery should be commissioned in all areas, reflecting local need

7 Ensure stop smoking and health checks are offered to CMHT clients as well as improved physical health checks and healthy weight

Public health, with CCG and SWL StG

2014/15

Probation

8 Ensure that all clients under probation care have their suicide and self harm risk documented with onward support available.

probation 2014/15

9 Ensure that the high risk cohort has access to secondary mental health services with clear referral pathways from probation to mental health assessment teams.

probation 2014/15

8

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/281250/Closing_the_gap_V2_-_17_Feb_2014.pdf


10 Commission a forensic mental health practitioner to both correctly identify and then work with this group in probation clients, including persons with emotional needs and also the higher risk cohort with suicide risk/self harm risk (approx 20%).

public health with probation

2014/15 4 - We will tackle inequalities around access to mental health services 21We will introduce a national liaison and diversion service so that the mental health needs of offenders will be identified sooner and appropriate support provided

Dual diagnosis

11 Ensure that the alcohol pathways for identification and onward referral by St Helier are clarified and made effective.

public health, SWL StG and liaison psychiatry with A&E St Helier

2014/15

12 Ensure that persons presenting to St Helier hospital already under the care of mental health services or substance misuse services are flagged with their provider and effectively gripped by that service in order to reduce continued A&E use

LBS, CCG and mental health trust with Liaison Psychiatry

2014/15

13 Clarify arrangements for dual diagnosis and ensure that all specialist teams are skilled to care for such clients. Ensure that clients under assertive outreach /all mental health teams have access to all the psychosocial support that clients with solely substance misuse needs have access to

SWL StG with public health as commissioners and CCG

2014/15

Pathways including social care and specialist placements

14 Look at clear referrals to NHS dentists who understand mental health clients’ needs

PHE, NHSE and public health with SWL StG

2014/15

15 Review discharge processes from Ward 3, as well as social care processes in the discharge system.

LBS with SWL StG

2014/15

16 Ensuring secondary care services check with clients’ GPs what medications they are on in the community, and communicate with one another in secondary care to reduce clients’ perception of telling their story again and again, with better continuity of case managers.

CCG and mental health trust with pharmacy leads in SWL StG and CCG pharmacy lead

2014/15

17 Review the specialist placements offer (that is not available in secondary care) to see whether greater efficiencies could be achieved. Review the services for personality disorder in the borough, in particular after residential placements

CCG 2014/15

18 Request staffing size and complement from the trust to build an improved picture of activity.

CCG 2014/15

Suicide prevention

19 Explore potential for evidence based ‘Postcards from the Edge’ interventions in persons who self harm, c.f. Australian model based on randomised controlled trial using liaison psychiatry to pilot this approach.

Liasion psychiatry together with CCG and public health

2014/15 14 - We will change the way frontline health services respond to self-harm


Holistic care and wider determinants of health

20 Ensure that explanation of psychiatric medications is done sensitively by Psychiatry and ideally with a pharmacist also, with clear guidance on what side effects may occur, and advice so that clients can make decisions about their lives.

SWL StG 2014/15

21 Review wider support in the community and the availability of complementary therapies. Improve performance around employment for persons with mental health illness in Sutton.

LBS and Our Place!

2014/15-15/16 23 - We will support employers to help more people with mental health problems to remain in or move into work 24 We will develop new approaches to help people with mental health problems who are unemployed to move into work and seek to support them during periods when they are unable to work


1 Background Mental ill health represents a significant burden of disease nationally, forming ‘23% of the

total burden of ill health in the UK’9. In terms of costs, it also represents 11% of the NHS’

secondary care budget. Other issues that underscore its importance are the overlap with

long term conditions (LTCs); it is estimated that ‘between 12 per cent and 18 per cent of all

NHS expenditure on long-term conditions is linked to poor mental health and wellbeing’10.

Mental health issues are also relevant for community safety, with national statistics

showing that 90% of persons in prison have a mental health need11 and 40% of call outs to

the Metropolitan police having a mental health underlying issue. Most fundamentally, we

know that the impact of mental disorder is a 10-20 year reduced life expectancy12.

2 Introduction and scope of needs assessment Mental health is a priority area for Sutton Clinical Commissioning Group (CCG) and the

London Borough of Sutton. Two areas that relate to mental health – improving access to

psychological therapies, and crisis intervention are noted in the CCG’s commissioning

intentions for 2014/1513, and mental health is highlighted as an area for change in the Joint

Health and Wellbeing Strategy (2013).

As of 1 April 2013, Public Health within Sutton council became responsible for mental

health promotion and suicide prevention, so this needs assessment will also inform work

in these areas. This needs assessment relates to adult mental health, and does not include

child and adolescent mental health. Substance misuse forms a separate needs

assessment, as does older people’s mental health (cognitive impairment and dementia).

A ‘core’ mental health needs assessment for Sutton & Merton primary care trust (PCT)

was completed in 201014. This was then followed by the Mental Health Joint

Commissioning Strategy 2010-201515, which identified priority areas and aspirations

(Annex 1).

9 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf: 10.

10 The Kings Fund/Centre for Mental Health – Long term conditions and mental health. The cost of co-morbidities. Naylor et al

(Feb 2012). 11

Singleton and Meltzer 12

UCL partners London document Campion et al 2013. Powerpoint presentation. 13

http://www.suttonccg.nhs.uk/website/SUTPBC/files/4SCCG_GB_04.09.13_COMIMISS_CYCLE.pdf. 14

This looked at demographics and mental health risk factors only. 15

Adrian Davey, Joint Mental Health commissioner Sutton CCG, personal communication, strategy dated March 2010.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf

http://www.suttonccg.nhs.uk/website/SUTPBC/files/4SCCG_GB_04.09.13_COMIMISS_CYCLE.pdf


3 Key policy documents for adult mental health 3.1 The National Service Framework (NSF) for mental health (1999)

This addresses the mental health of adults up to the age of 65 years and described six key

standards:

Mental health promotion, primary care and access to services, effective services for people

with severe mental illness, carers, and suicide prevention – NSF 1999.

3.2 The mental health strategy – No health without mental health

This emphasized six high level objectives:

More people will have good mental health

More people with mental health problems will recover

More people with mental health problems will have good physical health

More people will have a positive experience of care and support

Fewer people will suffer avoidable harm

Fewer people will experience stigma and discrimination

3.3 No health without public mental health (Royal College of Psychiatrists)16

This policy document (2012) made 14 high level statements which brought together

different areas including minimum pricing for alcohol, smoking cessation for mental health

clients, and the need for targeted health promotion work with mental health clients.

3.4 The recovery model

Key documents have also followed which describe what is known as the recovery model -

defined by the Social Care Institute for Excellence as ‘a way of growing with or despite

continuing disability’17. The model includes ideas such as ‘a shift of emphasis from pathology

and morbidity to health and strengths…social inclusion (housing, work, education,

leisure)…empowerment through information’18. This includes key initiatives such as peer

support, employment and supported housing.

16

http://www.rcpsych.ac.uk/PDF/Position%20Statement%204%20website.pdf 17

CSIP, RCPsych, SCIE. Joint Position Paper 08. A common purpose: Recovery in future mental

health services: vi.

18 CSIP, RCPsych, SCIE. Joint Position Paper 08. A common purpose: Recovery in future mental

health services: vi.

http://www.rcpsych.ac.uk/PDF/Position%20Statement%204%20website.pdf


4 Methods Review of policy Summary of key national

documents around mental health

Notes

Service descriptions Request made to SWL StG Liaison psychiatry service description was obtained, but detailed staffing breakdown was not available from SWL StG

Epidemiology (needs) UCL partners document for commissioning benchmarking and prevalence

Actual service use data provided by SWL StG as well as NHSE, mental health minimum dataset and other sources e.g. NCHOD

What do people think (corporate/qualitative work)

Individual 1-1 interviews (semi structured) with professionals – social work, commissioners

Semi structured focus group held with 8 service users on 13/11/13

Best practice examples (comparative)

Evidence reviewed from Cochrane reviews and other signposted service by expert professionals

Wider determinants of mental health

Information sought from housing and Job centre plus

No data available from JCP on clients with mental health issues.


5 Service descriptions

5.1 Primary care

5.1.1 GP practices

There are 27 GP practices in Sutton, and all deliver primary care for mental health, with

onward referrals to secondary care where needed. SWL StG has provided training around

mental health for practice nurses.

5.1.2 Improving access to psychological therapies (IAPT)

The IAPT service is based at Jubilee East, and is provided by SWL StG following a

competitive tender in 2009. There are 25 staff who see clients in Sutton.

5.2 Secondary care

South West London and St George’s (SWL StG) is the main provider of secondary mental

health services for Sutton’s residents. Sutton is one of five boroughs with SWL StG as the

main provider: these boroughs are Richmond, Kingston, Sutton, Merton and Wandsworth,

and Kingston is the lead overall commissioner for the contract but there is a joint Sutton

CCG/LBS commissioner.

Out of area placements for specialist input for clients with personality disorder or

other needs are commissioned by the CCG from a variety of (mainly private)

providers.

Forensic mental health falls under specialist commissioning (NHSE).

Substance misuse services are provided by SWL StG in partnership with

Community Drug Services South London CDSSL.

Staffing levels were not available from the mental health trust.

Recommendation: request staffing size and complement from the trust to build an improved picture of activity.

5.2.1 Community mental health teams

The Sutton CMHT is entirely based at Jubilee East in Wallington with a single point of

access.

Assessment team

The Sutton community mental health service is based at Jubilee East Local Care Centre in

Wallington and consists of:

A borough based assessment service which provides one point of access for all

referrals into the service. The assessment team receives all referrals for adult

services across the borough via an open system. After assessment 50% of people

are signposted onwards or sent to their GP for support, some are referred to IAPT

some to inpatient care and some to the recovery and support teams. The


assessment team works with all three recovery and support teams. If there are

social care needs that cannot be met by SWL StG then a referral is made to the LBS

social work team and where possible a joint assessment is made19. The Sutton

assessment team received 759 referrals in 2012/13 and 544 in 2013/14 (to date) –

which gives an average for 2013 of 64 referrals per month20.

Recovery and Support (based at Jubilee East) - three (Cheam, Wallington and

Carshalton) Recovery and Support Teams which provide treatment and recovery

based services for those people with ongoing severe and enduring mental health

needs. There will be approximately 800 people receiving treatment at any one time in

the recovery and support teams

5.2.2 Specialist community teams

Early intervention in psychosis

There is one early intervention in psychosis (EIP) team which works across Sutton and

Merton. This service is based at the Wilson Hospital but supports people in their own homes

and offers outpatient clinics at Jubilee East.

Crisis home treatment team

This service is based at Jubilee East. Patients presenting in crisis at night to St Helier are

seen by the Psychiatric liaison team there.

Assertive outreach team

The assertive outreach function is embedded within the Recovery and Support teams using

a Flexible Assertive Community Treatment (FACT) model.

Personality disorder

Personality disorder – complex needs service Tier 3

The Complex Needs Service operates as a Tier 3 personality disorder service

offering both dialectic behaviour therapy (DBT) and Mentalisation Behavioral therapy

(MBT) in both 1-1 and group settings.

The Service User Network (SUN) project - This DH pilot started in 2005, and the

central funding will stop in September 2014, when the five CCGs in the sector have

committed to commissioning a modified model. There are open referrals and this is a

group therapy model, co-produced with clients. There is a staff facilitator and a

number of groups in the borough.

19

Gill Moore personal communication email 3 Jan 2014. 20

Data from Mannish Ladva via email Jan 2014 SWL StG.


The Henderson Hospital had been commissioned on a London/South East Consortium basis

as a Tier 4 Personality Service until 2009. Tier 4 placements are now made on an as

required basis through individual funding requests.

5.2.3 Inpatient services

In 2003 there were six wards originally available for inpatients in Sutton Hospital, but service

provision has gradually moved to a more community based focus, resulting in more people

being supported in the community and fewer persons requiring inpatient treatment. In 2009,

this therefore reduced to three wards – an adult acute ward, and older persons ward and a

rehabilitation ward. A health protection issue caused the temporary movement of these

services in 2009, and the service models were reviewed. The rehabilitation ward was

replaced by individual funded placements and the adult and older person’s provision moved

to Springfield Hospital. These arrangements were confirmed in a consultation by NHS Sutton

& Merton in 2012. The Sutton working age adult inpatient provision is located on Ward 3 at

Springfield Hospital in Wandsworth. The ward has ensuite bedrooms for 20 patients – and

men and women are separated.

There are also 11 beds in the Hexagon project located in Sutton itself. This house is

primarily for patients in recovery and has 24 hour cover by a registered mental health nurse

(RMN). This forms part of the block contract arrangement with Sutton CCG and is provided

by Hexagon Housing Association.

5.2.4 Liaison psychiatry

The liaison psychiatry service is based at St Helier Hospital and is led by Dr Jim Bolton,

Consultant Psychiatrist. This team sees all hospital mental health, A&E and outpatient

referrals where there is a mental health need. Team members also provide training for

hospital staff in the recognition and management of mental illness in the general hospital

setting. The service operates as a type of community mental health team, in the hospital.

From 9am to 5pm on weekdays the liaison team sees patients, outside these hours

emergency psychiatric cover is provided by a rota of junior doctors based in the hospital,

with senior medical cover available. After 11pm the community psychiatric nurse on the

home treatment team rota is also based in the hospital and is available to conduct joint

assessments with the junior doctor on-call.


Team structure

Role Full time equivalent

Banding Funding source Added note

Consultant Psychiatrist 1FTE Consultant CCG block

Nurse team leader 1FTE Band 7 CCG block

Nurse (community psychiatric nurse)

1FTE Band 6 CCG block

Senior House Officer (specialist trainee)

1FTE Specialist trainee

deanery

Foundation Year doctor 1FTE Foundation year 1 doctor

deanery

Higher specialist trainee doctor

1FTE (depends on placements)

ST4-6 deanery

Administrator 1FTE CCG block

Older adult psychiatric liaison nurse

1FTE Band 7 LBS funded Managed by CMHT Dr Stinson

Occupational therapist 0.5FTE LBS funded Managed by CMHT Dr Stinson

Accident and Emergency (A&E) is covered 9-5 on weekdays by the liaison psychiatry

service. Out of hours, patients are assessed by the duty doctor, accompanied by a home

treatment team nurse when they are available. Referrals are made by telephone21.

Nationally, estimates point to ‘an overall prevalence of physical/mental health co-morbidities

in the inpatient population of nearly 50%’22. Additionally, co-morbid mental health issues

in patients with long term conditions increases the risk of mortality and also is ‘typically

associated with increases of 45-75% in the costs of physical health care for long-term

conditions’23.

5.2.5 Section 136

The police have the power to arrest people who they assess as suffering from a mental

disorder in a public place and transferring them to a place of safety, under Section 136

clients of the Mental Health Act. The designated place of safety is two dedicated Section

136 suites adjacent to Ward 1 at Springfield Hospital – this provision covers the five

boroughs covered by SWL StG.

5.2.6 Recovery college

The SWL StG recovery college was the first mental health recovery college in the country and started in 2009. In 2011/12 a total of 1057 individual service users (students) attended

21 Frail elderly persons are either admitted to medical wards after assessment in A&E, or admitted

to Ward 3 if the primary issue is cognitive impairment/dementia.

22 Liaison psychiatry in the modern NHS – Parsonage et al Centre for mental health: 10.

23 Liaison psychiatry in the modern NHS – Parsonage et al Centre for mental health: 10. Last

accessed 19 November 2013.


courses at the Recovery College. A further 72 family and carers and 131 staff attended courses, and a total of 431 courses were delivered to all students24.

5.3 Social care / social work

5.3.1 Approved mental health professional (AMHP)

This service is based at the Jubilee Centre and comprises 2-3 staff each day, one of these is

the senior practitioner, and the others cover on a rota basis.

There is funding for two social workers with an interest in substance misuse (with currently

one vacant post).

5.3.2 Team structure

The social work team is managed by the Head of Mental Health and Community Social

Services at LBS. The full team structure is found at Annex 2.

Team manager 1FTE

Senior practitioner 2FTE

Social workers 13FTE (includes 1 vacancy)

5.4 Carers’ support

There are four whole time equivalent posts within the Sutton Carers’ centre, supporting the

carers of Sutton in a staged approach from general advice up to psycho-educational

specialist work to support families.

There are 600 persons identified as mental health carers in Sutton. An additional 400 young

people are supported by the ‘ACES’ programme which is a Big Lottery funded project for

young carers of adults with substance misuse needs. A range of complementary therapies

are available for carers of mental health clients in Sutton, via the Sutton carers’ Centre such

as yoga, counselling and also improving access to psychological therapies (IAPT) via two

days per week from a SWL StG worker located in the carers’ centre in Sutton.

5.5 Support in the community

There are several advocacy / support groups for mental health in Sutton, which include:

5.5.1 Sutton Mental Health Foundation

Sutton Mental Health Foundation (SMHF) has three bases: Belmont Connect, Cheam

Connect and Sunday Connect (based at Robin Hood Lane in Sutton). SMHF helps people

with mental health issues learn, provides support, and connects them to others. The two

main bases are open Mondays to Fridays (apart from Wednesdays), with structured

sessions or classes, peer support, stop smoking support and advice.

There is also a representative and supporter linked to the National Hearing Voices network.

24

Recovery college – personal communication Mark Clenaghan SWL StG.


5.5.2 Prosper

This is a new support group for Sutton clients with mental illness.

5.5.3 Sutton wellbeing

Sutton Wellbeing Network is an alliance of organisations and individuals in Sutton

committed to promoting wellbeing. The network holds a variety of events and activities that

are open to Sutton residents.

5.5.4 Sutton 1in4

This network is a community based user led organisation that aims to ensure that people

who have a lived experience of mental and emotional distress have a voice and can

influence the commissioning of local mental health services. It also supports the

establishment of peer led support groups and activities across the borough and holds a

programme of ‘Signpost Sutton’ events that are open forums on mental

health related issues.

5.6 Offender health in the community (non forensic)

NHS England commissions both inpatient and community forensic services for those people

whose mental health needs has resulted in, or has the risk of leading to offending behaviour.

NHSE is commissioning Together for mental wellbeing (a national charity) to discuss with

SWL StG to progress this issue in a phased approach for custody suites and courts only,

starting with Kingston and Wandsworth and then Sutton and Merton to follow25.

A Senior Specialist Registrar in Psychiatry (SWL StG) meets with teams at Sutton and

Merton probation on a monthly basis for a complex case discussion group, similar to a

Balint group model, that focuses predominantly on ‘difficult to work with’ offenders. There is

no formal link for patients with mental disorder other than the usual referral pathways to

South West London & St. George's26.

Oxleas Foundation Trust has forensic psychology input into Sutton and Merton as part

of the personality disorder offender pathway. The probation office (Sutton and Merton) has a

Probation officer for both Merton and Sutton separately on PD. These probation officers

work with Oxleas mental health Psychologist Dr Wayne Stockton to review PD complex

cases and then see where they can be referred in the community27. The pathways are

dependent on the provision in the community.

25

The project is taking a phased approach. In Phase 1 the FMHPs will work in the custody suites at Wandsworth

and Kingston Police stations. Initially they will be scoping the needs as regards service users with mental health

or learning disability problems. In particular they will consider demand times so that we can tailor the service

where possible. Phase 2 is focused on Sutton and Merton custody suites. The demand at these suites will be

scoped and a service model will be developed. Initially this may involve telephone support from the FMHPs to

provide advice and consultation to custody managers and staff - Colin Burgess Together via email.

26 Personal communication Dr Guy Hillman 2.10.13 via email.

27 Dr Stockton also covers the approved premises in Wandsworth.


7 What is the need? (Epidemiology) Prevalence modelling may be easier for some diseases - for mental health this can be

difficult28 as they may not be captured by national prevalence surveys, cases may not be

identified or the course of illness may be complex.

7.1 Risk factors for mental health problems – Sutton

7.1.1 Community mental health profiles – risk factors

The community mental health profiles produced by the national network of public health

observatories29 give an indication of the risk factors for mental health and how these fit with

Sutton’s demographics. There are many areas in which Sutton fares better than the

national average regarding risk factors for mental health issues, such as:

lower levels of violent crime,

lower levels of deprivation,

lower proportion of the population with a limiting long terms illness (2001 census).

There are a small number of risk factors in which Sutton fares significantly worse than

England:

Working age adults who are unemployed per 1000 population30

2010/11 Sutton 63/1000 England 59.4/1000

% of adults participating in physical activity31

2009/10 to 2011/12 Sutton 9.0 per 1000 England 11.2/1000

Numbers of people aged 18 to 75 in drug treatment 2011/12 significantly lower than England

2011/12 Sutton 4.2/1000 London 5.6 England 5.2

7.1.2 UCL benchmarking and comparison – risk factors

UCL partners have summarised the particular groups with a higher risk of mental illness:

Looked after children (Ford et al 2007: 5 fold increase and 46% have a mental

disorder national estimate)32

People with long term conditions (NICE 2009: 2-3 fold increased risk depression)33

Black and minority ethnic groups and schizophrenia (Kirkbride et al 2012: 5.6x

higher black Caribbean group, 4.7x higher black African group)

28

http://www.apho.org.uk/prevalencemodelling last accessed 4 Nov 2013. 29

www.nepho.org.uk/cmhp Sutton pages 30

Community mental health profiles – health observatories 2013. 31

Community mental health profiles health observatories 2013. 32

UCL partners document 33

UCL partners 2013 powerpoint.

http://www.apho.org.uk/prevalencemodelling

http://www.nepho.org.uk/cmhp


There are particular risk factors that increase the prevalence of mental illness.

These risks are then applied to Sutton and we see from the figure below that the risks are

actually low compared with the rest of London. Low levels of maternal smoking (5.4%), low

birth weight babies (2.7%), 16-18yo not in education employment or training (3.9%) and

under 18s with a history of childhood sexual abuse (almost 3000) are similar to other London

boroughs. More detail is at Annex 3.

7.1.3 Prevention of mental ill-health in Sutton

Considering the evidence base informs priorities for prevention in Sutton. Although child

mental health is outside the scope of this document, the main targets for preventing mental

health problems in adult life would be:

Support for looked after children as they have high levels of mental disorder (46%,

Ford et al 2007)

Support for new mothers (to reduce perinatal depression)

Support for parents and infants

School based mental health interventions/prevention eg targeted mental health in

schools (TAMHS)

Prevention of child abuse, and intervention when detected

Treatment of self harm in children and adolescents34

Support for people with a long term limiting illness to reduce depression

7.2 Best estimates - expected prevalence for mental health problems

7.2.1 Common mental disorders

These are ‘mental conditions that cause marked emotional distress and interfere with daily

function, though they do not usually affect insight or cognition’.

34

Sutton has the third highest levels in London - again this is an adult needs assessment but this is very important and worthy of note. Rate is 88.20 admissions in children and adolescents per 100,000


The National survey of adult psychiatric morbidity35 estimated that for adults (defined as

persons aged 16 years and over) the prevalence is 16.2% of adults meeting the criteria in

the week prior to interview. We can then age and sex stratify this to match the Sutton

population and estimate the expected prevalence of common mental disorders.

Age group Prevalence % on England adult psychiatric morbidity survey 2007

Sutton population in that age group

Numbers in Sutton with common mental disorders

Prevalence % on England adult psychiatric morbidity survey 2007


Numbers in Sutton with common mental disorders

male male male female female female

16-24 years 11.9 6195 737 21.0 6027 1266

25-34 13.3 9844 1309 21.8 10457 2280

35-44 13.3 10462 1391 18.4 11928 2195

45-54 13.8 10353 1429 23.4 11656 2728

55-64 10.2 8409 858 16.1 9550 1538

Total expected numbers CMD 16 to 64 yrs

45263 5724 males with CMD

49618 10007 females with CMD

Using these national estimates and applying them to Sutton, we would expect approximately

16,000 adults aged 16 to 64 years with common mental disorders at any one time.

7.2.2 Psychotic disorder

Prevalence of probable psychosis by age and sex (please note age bands aggregated for

16-34 year olds).

Age group Prevalence % on England adult psychiatric morbidity survey 2007


Numbers in Sutton with psychosis

Prevalence % on England adult psychiatric morbidity survey 2007


Numbers in Sutton with psychosis


16-34 years 0.4 16039 64 0.3 16484 49

35-44 0.7 10462 73 1.0 11928 119

45-54 0.3 10353 31 0.9 11656 105

55-64 0.2 8409 17 0.6 9550 57

Total expected numbers Psychosis in the last year 16 to 64 yrs

45263 185 49618 330

35

England adult psychiatric morbidity survey 2007.


The table above shows that for adults aged 16 to 64 in Sutton we would expect 515 persons

with a diagnosis of psychosis in the last year.

Incidence of new cases of psychotic disorder

If we consider the rates per 100000 population in Sutton (Psympatic 2013) – the rate is 27.9

per 100000 persons in Sutton compared with the rest of London this sits within the lowest 5

boroughs of incidence and the second lowest in South West London. Please note that

incidence refers to new cases and prevalence to existing cases, which may explain the

discrepancy between the expected prevalence and the incidence listed by Psympatic above.


2013.


7.2.3 Depression

There are age stratified data from the adult psychiatric morbidity survey (only in 2000)

however the age bands were difficult to match to existing age bands for Sutton. For that

reason a pragmatic decision was taken to estimate the range possible using the King’s Fund

report on mental heath care36.

Depression – severe and enduring

Age group Prevalence % on England 2000


Numbers in Sutton with depression

Prevalence % on England


Numbers in Sutton with depression


16-34 years 16039 16484

35-44 10462 11928

45-54 10353 11656

55-64 8409 9550

Total expected numbers depression in the last year all ages from 16 to 64

29-42 per 1000 persons (not stratified by sex)

45263 1313 to 1901 29 to 42 per 1000

49618 1439 to 2084

Using estimates from the King’s Fund, we see that there could be 2800 to 4000 adults aged

16 to 65 with severe and enduring depression in Sutton.

Long term conditions and depression

There is a 2-3 fold greater risk of depression in persons with a long term condition compared

with the rest of the population. The percentage of people living with LTC is 22.3% in Sutton

which is the second highest in South West London, but similar to the rest of London. For a

figure showing the London comparison see Annex 4.

36

http://www.kingsfund.org.uk/sites/files/kf/Paying-the-Price-the-cost-of-mental-health-care-England-2026-McCrone-Dhanasiri-Patel-Knapp-Lawton-Smith-Kings-Fund-May-2008_0.pdf: 15, last accessed 310.3.14.

http://www.kingsfund.org.uk/sites/files/kf/Paying-the-Price-the-cost-of-mental-health-care-England-2026-McCrone-Dhanasiri-Patel-Knapp-Lawton-Smith-Kings-Fund-May-2008_0.pdf

http://www.kingsfund.org.uk/sites/files/kf/Paying-the-Price-the-cost-of-mental-health-care-England-2026-McCrone-Dhanasiri-Patel-Knapp-Lawton-Smith-Kings-Fund-May-2008_0.pdf


7.2.4 Bipolar disorder

Age group Prevalence % on England Kings Fund paying the price37


Numbers in Sutton with bipolar disorder

Prevalence % England adult psychiatric morbidity survey 2007


Numbers in Sutton with bipolar


<45 years 1.9% 26501 503 1.9% 28412 540

>45 years 1.4% 18762 263 1.4% 21206 297

Total expected numbers ages 16 to 64

45263 766 49618 837

This King’s Fund report, applied to Sutton gives an expected estimate of approximately 1600

persons aged 16 to 64 living with bipolar disorder.

7.3 Observed prevalence of mental health problems in primary care

The national psychiatric morbidity survey gives national and regional estimates of disease

prevalence for mental health38. The London Health Observatory gives more specific

estimates of prevalence, but unfortunately the last scorecard produced (2011) for the

primary care trust (PCT) included both Sutton and Merton.

7.3.1 Depression in primary care

For 2014/15 there will be one QOF indicator which relate to depression (the bio-psychosocial

review will be retired) and ten which relate to mental health in general.

For depression the indicator is currently: the percentage of patients aged 18 or over with a

new diagnosis of depression in the preceding 1 April to 31 March who have been reviewed

between 2 weeks and 8 weeks after the diagnosis.

For mental health the indicators for 2012/13 (this will reduce in 14/15) include maintaining a

register, care plans, and also the physical checks such as thyroid function related to

particular medications, or cervical screening coverage for women.

Proportion on primary care depression register by Sutton GP practices

The figure below shows the depression prevalence by GP practice (anonymised) and

compared with London and England levels. These QOF data from 2012/13 as of June 2013

are not age adjusted so some practices may have a higher prevalence due to age

demographics. However, we still see that there is variation in the levels of depression

recorded between practices, and six practices with prevalence of depression below that for

London (4.4%).

37

http://www.kingsfund.org.uk/sites/files/kf/Paying-the-Price-the-cost-of-mental-health-care-England-2026-McCrone-Dhanasiri-Patel-Knapp-Lawton-Smith-Kings-Fund-May-2008_0.pdfonth prevalence last accessed 31 Dec 2013. 38

https://catalogue.ic.nhs.uk/publications/mental-health/surveys/adul-psyc-morb-res-hou-sur-eng-2007/adul-psyc-morb-res-hou-sur-eng-2007-rep.pdf last accessed 4 November 2013.

https://catalogue.ic.nhs.uk/publications/mental-health/surveys/adul-psyc-morb-res-hou-sur-eng-2007/adul-psyc-morb-res-hou-sur-eng-2007-rep.pdf

https://catalogue.ic.nhs.uk/publications/mental-health/surveys/adul-psyc-morb-res-hou-sur-eng-2007/adul-psyc-morb-res-hou-sur-eng-2007-rep.pdf


This could be due to differences in practice demographics, variation in help seeking

behaviour, variable recording, or a combination thereof39.

Source: Data source: QMAS database - 2012/13 data as at end of June 2013. Individual practice

data available on request.

Recommendation: ensure increased recording of depression in primary care

7.3.2 Sutton primary care performance indicators

UCL partners has analysed four key primary care mental health indicators from different data

sources so that Sutton primary care performance can be compared with the rest of London.

The figure below shows the comparisons which are then discussed below:

39

With thanks to Dr Vaish Sreeharan SpR Public Health, HNA mental health Hounslow.

1.5 1.7 1.9 2.1

3.7 3.7

4.5 4.5 4.6 4.7 4.8 4.8 5.1 5.4

6.0

6.7 6.7 6.9 6.9 7.0 7.4 7.6 7.6 7.7 7.9

9.1

10.2

11.4

4.4

5.8

0.0

2.0

4.0

6.0

8.0

10.0

12.0

H8

56

62

H8

51

08

H8

51

13

H8

50

19

H8

50

23

H8

50

54

H8

50

30

H8

56

53

H8

56

86

H8

50

53

H8

56

74

H8

56

18

H8

50

63

H8

50

21

H8

50

31

H8

51

05

H8

50

95

H8

50

22

H8

56

65

H8

50

25

H8

51

15

H8

51

03

H8

50

18

H8

51

16

H8

56

93

H8

50

32

H8

56

83

H8

50

86

LON

DO

N

ENG

LAN

D

Depression Prevalence Per Cent % in 18 years and older, by practice



2013.

Proportion on primary care depression register – Sutton compared with London

Sutton’s proportion of adults on primary care depression register is 9.6% which is within

the London range of 4.8% in Barking and Dagenham and 12.6% in Islington. When we

compare Sutton with our statistical London comparator boroughs of Barnet and Harrow40 this

is better than Barnet (8.5%) or Harrow (7.3%). However the more detailed practice level

analysis above shows there is still individual improvement to be made.

40

http://longerlives.phe.org.uk/area-details#are/E09000029/par/IMD10-UTLA-D8 last accessed 31 Dec 2013.

http://longerlives.phe.org.uk/area-details#are/E09000029/par/IMD10-UTLA-D8


Proportion of new cases of depression receiving further assessment between 4-12 weeks –

Sutton/London

The Sutton proportion is 70% which falls between the lowest Bromley at 55% and Kingston

at 83%. Barnet is at 66% and Harrow at 80%. The best performing London borough was

Kingston, so lessons could be learned to see how their re assessment and recording is

flagged within primary care. The timing of review, however, should be caveated in that it is

arbitrary and relates to QOF payments.

Recommendation: ensure improved levels of 4-12 week reassessment for depression to move

towards the levels achieved in Kingston (83%).

Proportion referred for psychological therapies – Sutton/London

This is 4.8%, which is higher than both comparator boroughs of Barnet (2.5%) and Harrow

(2.7%), but broadly similar to Richmond and Kingston (both at 4.8%).

Emergency admissions for neurotic disorder – Sutton/London

In terms of emergency admissions in Sutton adults this is 10.2 per 100,000 population. This

contrasts with Hackney at 28.5/100,000 (highest) and Tower Hamlets at 6.9/100,000

(lowest). A fairer comparison is with Barnet 11.0 and Harrow at 8.2 so Sutton’s figure lies

midway between the two comparator local authorities.

Primary care registration of SMI

Rather than an estimate of prevalence this is a measure of primary care coverage. Sutton is

at 0.8% compared with 0.9% for both Barnet and Harrow41. This may indicate that a high

level of exception reporting is taking place. The boroughs with the highest levels of primary

care coverage are Islington, Kensington and Chelsea and Camden, all inner London

boroughs. Although this may reflect lower prevalence in Sutton, efforts still need to be made

to ensure good recording of SMI on primary care registers, not least to ensure physical

health checks take place.

7.4 Secondary care admissions

7.4.1 Age standardised hospital admissions for schizophrenia

These are variable across London and are often linked to deprivation. However Sutton at

56.2/100000 falls between Barnet (32.5) and Harrow (74.1) which is difficult to explain as we

would expect similar admission rates across similar comparator boroughs. Comparing

Sutton with the other SWL boroughs using the same provider we see that Merton and

Wandsworth admission rates are lower than Sutton, and conversely Kingston and Richmond

admissions are higher. This goes against predictions that admission rates are linked to

deprivation.

41

HSCIC analysis 2011-12, UCL partners.



2013.

7.4.2 Emergency hospital admissions for schizophrenia

Sutton’s levels are low at 16/100000 compared with Barnet (24) and comparable to Harrow

(15.3). The range across London shows great variation with Hackney at 108.4 and Havering

at 5.3.



2013.

7.4.3 Proportion of admissions under the mental health act (MHA)

This does not typically correlate with deprivation – however Sutton at 35% is at the higher

end in London and is higher that Barnet and Harrow (at 29% and 28% respectively).

7.4.4 Number of bed days used by mental health secondary care is lower than the

England average

Measured per 1000 population data from 2010-11

7.4.4 Inpatient admissions (Ward 3)

Data for 2012/13 were analysed and showed 265 admissions over the course of that year.


Number Per cent %

Not stated 49 19%

Psychoactive substance use 40 15%

Schizophrenia 53 20%

Mood disorders 47 18%

Neurotic disorders 16 6%

Behavioural syndromes * *

Personality disorders 19 7%

Mental retardation * *

Other –non mental health 37 14%

Total 265 100%

Source: Gul Baxter SWL StG Dec 2013.

It is interesting to note that 7% of the admissions were due to personality disorder, and this

will be discussed further in the section below. The King’s Fund note that ‘beds in some

assessment wards are currently being used by people with low-level personality disorders

who may better served in community settings’42.

Alternatives to admission are discussed in the comparative discussion and include ‘”crisis

houses” run by professionals, third sector organisations or service users themselves’. The

King’s Fund notes that ‘they are less expensive than ward accommodation, have higher

‘service user satisfaction’ and ‘service use after one year of discharge dies not differ

between traditional inpatient ward and alternatives, suggesting that the long-term financial

impact of alternative provision might be cost-reducing’ (Lloyd-Evans et al 2009)43.

7.4.5 Out of area placements

The King’s Fund has noted the costs of out of area placements at £34,000 per year

compared with £21,000 ‘for an equivalent local placement’44. Estimates vary in terms of the

savings, but repatriation figures of 50% have been modelled. Crisis resolution home

treatment teams are the way that reductions in out of area placements could be achieved.

Islington has a noted model in which 25/40 out of area non forensic places (63%) were

repatriated. If we extend the more conservative figure of 50% then the following placements

need to be considered.

Further guidance is that commissioning of supported accommodation/ ‘other residential

options’ needs to be prioritised so that people can stay locally instead of requiring an out of

hospital placement45.

A snapshot picture of the Sutton out of area placements was obtained on 1st November

2013 of 46 clients (older age and working age). For just the working age clients there were

38 persons on 1 November 2013. The average placement cost for Sutton is £52K per year.

42

Kings Fund mental health and the productivity challenge: 10. 43

Naylor and Bell Kings Fund mental health and the productivity challenge: 10. 44

Kings Fund mental health and the productivity challenge: 12. 45

Kings Fund mental health and the productivity challenge


Age

The average age for the working aged adults (i.e. 18 to 64 years and 364 days) was 43

years.

Gender

Number Per cent %

Men 24 63%

women 14 37%

38 100% Source: Claire Symonds Sutton CCG

Diagnosis (primary)

number %

Schizophrenia/schizoaffective disorder/psychosis

23 61%

Autistic spectrum disorder *46 *

Personality disorder 6 16%47

Learning disability, other, disability plus psychosis

* *

38 100% Source: Claire Symonds Sutton CCG.

The numbers are small in most diagnosis categories, but the majority of patients (61%,

23/38) had a primary diagnosis of schizophrenia - some were combined with another

diagnosis but that was the primary issue. A small percentage were also placements for

personality disorder – again this will be discussed further in the qualitative section as it

may indicate a gap in provision for such clients in secondary care.

Type of placement

number %

Forensic hostel * *

Locked rehab * *

Locked rehab low level 10 26%

Locked rehab specialist * *

Nursing home * *

Nursing home with mental health

* *

Residential block contracted

7 18%

Residential deaf * *

Residential specialist 10 26%

38 100%

46

A small number of persons had both ASD and schizophrenia. 47

Of which a small number had emotionally unstable PD.


The majority of placements were for low level locked rehabilitation (26%, 10/38) with a

similar proportion for residential specialist placements. The specialist placements were

for a mix of conditions including schizophrenia, autistic spectrum disorders and learning

disability. The locked low level placements were for the largest part, for schizophrenia

and personality disorder and ASD (schizophrenia / schizoaffective disorder or

schizophrenia as part of the diagnosis in 7/10 cases).


Location of placement

Number %

Sussex, Kent, Essex * *

Surrey 6 16%

London 17 45%

Sutton 11 29%

Midlands * *

38 100%

Source: Claire Symons Sutton CCG.

The largest proportion of placements were in London (17/38 placements).

Overview of out of area bed use

It should be explored why the rates of age standardised and emergency admissions for

schizophrenia, and rates of admissions under the MHA are relatively low, when there are

out of area placements for conditions other than schizophrenia. A consideration of what

those specialist placements offer that is not available in secondary care should be

made, to see whether greater efficiencies could be achieved.

Recommendation: Review what those specialist placements offer that is not available in secondary care, to see whether greater efficiencies could be achieved.

7.5 Liaison psychiatry St Helier hospital

An audit of liaison psychiatry was conducted by the service in 2012/13. Of the 736 new

referrals within that year this equates to 61 referrals per month. There were 2707 patient

contacts, which represents an increase of 17% from 2011/12. The main referral sources

were

A&E 26%

Inpatients 64%

outpatients 10%

Over 2/3 patients (64%) were aged 18 to 65 years. It should be noted that only 60% of

clients lived in Sutton but this is a service commissioned across 5 boroughs so there will be

overlap.

7.5.1 Diagnosis liaison psychiatry clients

Commonest primary diagnoses recorded. Diagnostic bands are based on IC10. o Mood disorders 20% o Organic disorders 16% o Neurotic disorders 14% o Psychoactive substance misuse 10% (predominantly alcohol related)

Self harm was recorded as a primary or secondary diagnosis in 150 (20%) referrals.


Learning disability was recorded as a primary or secondary diagnosis in 7 (12%) referrals48.

7.5.2 Frequent flyers

An audit of patients classified as ‘frequent flyers’ was also carried out as a collaboration

between Sutton and Merton PCT, Epsom-St Helier NHS Trust and SWL StG. Frequent

flyers were defined as persons with either 5 or more presentations in the previous 4 weeks

of persons with 12 or more attendance in the last 12 months.

Of 57 patients whose notes were reviewed it is important to note that:

19/57 (33%) had current contact with mental health services

16/57 (28%) no contact

22/57 (39%) had previous contact with mental health services

For the 19 clients in contact with mental health services:

A small number were known to alcohol services, to drug services and 50% to the CMHT.

Some clients were known to more than one service.

This raises queries about the levels of support available from the CMHT and also the ease of

referrals or levels of engagement from substance misuse services.

If we classify the clients who were frequent flyers known currently to mental health services

on the basis of their primary psychiatric diagnosis the most common diagnosis was

alcohol (either dependence or harmful use) in 13/19 frequent flyers. This may suggest that

there is a cohort of persons with dual diagnosis or co-morbid physical/ alcohol issues

presenting frequently at emergency services49.

This links in strongly with evidence from the Centre for Mental Health that ‘about 20% of

patients admitted to hospital are regularly consuming unsafe levels of alcohol (Royal College

of Physicians 2001.) ‘For patients who are alcohol dependent, a liaison psychiatry service

can support their management while in hospital and arrange their referral on to specialist

community services.50’

48

N.B. these figures give an estimate of the proportional rates of different problems, but will tend to

underestimate overall rates as information on tertiary diagnoses is not available.

49 In terms of the potential for savings, across the 57 persons in one year there were 1107 ED attendances with

16 on average per patient. The savings can be further extrapolated with the information that there were 288

admissions for the 57 clients with each attender having a mean of 5 admissions in a year.

50 Centre for Mental Health Liaison psychiatry in the NHS. Parsonage et al: 20. Last accessed 19 November

2013.


Recommendation: ensure that persons presenting to St Helier hospital already under the care of mental health services or substance misuse services are flagged with their provider and effectively gripped by that service in order to reduce continued A&E use. If we look at the presenting complaints of the patients who are frequent flyers and with a

known mental health issue the most common is self harm. Looking at the last ‘5

attendances for the frequent attendees, self harm accounted for 37% of the attendances.’51

Recommendation: explore potential for evidence based Postcards from the Edge type intervention in persons who self harm, c.f. Australian model52 based on randomised controlled trial using liaison psychiatry to pilot this approach. The levels of physical co-morbidity are high – each client known to mental health services

had an average of 1.75 co-morbid physical conditions with the most common being

asthma/COPD.

Recommendation: ensure that clients with long term conditions are assessed in primary care and offered appropriate psychological support.

7.6 CMHT caseloads

The Recovery and Support service offers treatment and recovery focused support to those

people with ongoing severe and enduring mental health needs following initial assessment

by the assessment team. A snapshot of patients seen by the adult CMHT for all Sutton

clients aged 18 to 64 years shows the following picture for all three CMHTs (Carshalton,

Cheam, Sutton and Wallington) in 2013/14.

51

Dr Bolton Psychiatric characteristics of frequent attenders at St Helier Hospital emergency department. Dec 2012. Paper shared as personal communication. 52

http://bjp.rcpsych.org/content/early/2013/03/12/bjp.bp.112.112664.abstract last accessed 6 Jan 2013.

http://bjp.rcpsych.org/content/early/2013/03/12/bjp.bp.112.112664.abstract


CMHT Sutton borough Number of patients on caseload under 65 years

2013/14 1307

Looking individually at the snapshot of diagnoses for 2013/14 we see the following picture

for clients under 65 years:

Diagnosis for CMHT clients 2013/14 aged <65 years

Number of patients Per cent %

Organic/other 9 0.7%

Mental and behavioural disorders due to alcohol dependent use

20 1.5%

Schizophrenia, psychosis and related disorders53

335 25.6%

Hypomania or bipolar disorder

136 10.4%

Neurotic disorders including anxiety

86 6.6%

Depression / cyclothymia 174 13.3%

Personality disorders 101 7.7%

Disorders of development, Aspergers, autism, attention deficit disorder

11 0.8%

Other incl self harm 28 2.1%

Blank 407 31.1%

Total patients 1307 100%

We see that the majority of clients on the adult CMHT caseload have either schizophrenia

(26%), mood disorders (13%) or bipolar conditions (10%). There was a significant

proportion of clients with no code (blank), which should be noted (31%).

7.7 Specialist team caseloads

A note of caution is sounded by the King’s Fund in terms of the configuration of community

teams – in that, ‘several trusts have been concerned about inefficiencies created by this

multiplicity of community teams’54. The community teams are the borough based

assessment team and three Recovery and Support teams (which encompass assertive

outreach), supplemented by the Early Intervention, Crisis and Home Treatment and

Complex Needs Services. As we could not obtain staffing figures or structures it is unclear

what types of shared management structure exist across the teams.

53

Coded available on request 54

Naylor and Bell Kings Find: 7. Mental health and the productivity challenge.


7.7.1 Early intervention in psychosis (EiP)

These teams typically work with clients aged 14 to 35 who are experiencing a first episode

of psychosis55. There is ‘good evidence that early intervention for psychosis results in a

better course of illness, fewer symptoms at eight years and a halving of the suicide rate, in

addition to reducing relapse rates and decreasing the use of inpatient care when compared

to standard CMHT care’56. There were a small number of Sutton clients (n<5) who were

seen by the Wandsworth early intervention service in the years from 2010/11 to 2013/4. If

we exclude these clients then aggregating the years 2010/11 to 2013/14 we see the

following age breakdown for Sutton patients.

Early intervention teams nationally may also improve employment prospects57, although

this is not borne out by Sutton’s data in the employment section.

Age EIP clients

Age in yrs clients Per cent

16-17yrs * *

18-25 195 49%

26-64 199 50%

396 100%

Half of clients were aged 18-25 years old, although we do not have a breakdown between

25-35 and older up to 64 years, it is not possible to say whether there is appropriate referral

to this service for this target cohort. We can see that a small number58 of clients in 2013/14

under the EIP team were aged 16-17 in Sutton.

Gender of EIP clients

Number of clients 2010/11 to 2013/14

Per cent

Male 235 59%

female 161 41%

Total 396 100%

The majority of EIP clients were male (59%) and this is in line with expectations that there is

a higher level of schizophrenia in men compared with women59.

55

http://www.rethink.org/diagnosis-treatment/treatment-and-support/early-intervention last accessed 3 Jan 2014. 56

Dr Vaishnavee Sreeharan Public Health SpR Mental health needs assessment Hounslow, citing refs from Bird 2011 British Journal of Psychiatry and Craig 2004 BMJ. 57

Naylor and Bell mental health and the productivity challenge: 8. 58

Number under 5 so suppressed. 59

http://bjp.rcpsych.org/content/161/4/556.abstract last accessed 3 Jan 2014.

http://www.rethink.org/diagnosis-treatment/treatment-and-support/early-intervention

http://bjp.rcpsych.org/content/161/4/556.abstract


Ethnicity EIP clients

Ethnicity of clients 2013/14 snapshot

Per cent Sutton general population

Black 15 14% 5%

Mixed/other/any other

9 9% 4%

Asian 12 11% 12%

White 69 66% 79%

Total 105 100%

For the snapshot of 2013/14 clients we see that although the majority of clients were White

there is an overrepresentation in Black ethnic groups (14%) and mixed groups (9%) when

the Sutton population overall has only small proportions of persons from black (5%) and

mixed (4%) ethnic groups. This is in line with expected national findings, with an

increased risk of schizophrenia in Black African and Caribbean groups60.

7.7.2 Home treatment

The King’s Fund cites evidence that crisis resolution home treatment teams can reduce

unplanned admissions to hospital61. A snapshot view of the home treatment team for Sutton

in 2013/14 showed a caseload of 338 persons with the following diagnoses:

Diagnosis for home treatment 2013/14 aged <65 years

Number of patients Per cent %

Organic 0 0

Psychoactive substance misuse * *

Schizophrenia 50 17.7%

Mood disorders 76 27.0%

Neurotic disorders 22 7.8%

Behavioural syndromes 0 0

Personality disorders 17 6%

Disorders of psychological development 0 0

Other (non MH) 31 11%

Blank 80 28.3%

Total number of patients 282

The majority of clients seen by the home treatment team had a blank diagnostic code,

followed by mood disorders (27%) and then schizophrenia (18%).

60

Psychiatry at a glance – Katona et al 2005. 61

Naylor and Bell mental health and the productivity challenge: 8.


7.7.3 Assertive outreach team

This aspect of the service supports and treats clients with a history of severe mental health

problems that had previously resulted in multiple admissions, so that they can remain in the

community wherever possible.

Age

Assertive outreach team numbers

2012/13 to 2013/14 Per cent %

18-25 10 6%

26-64 133 85%

65 plus 14 9%

157 100%

From the data above we see that the majority of clients were aged 26 to 64 years, a broad

range. The number of clients seen across 2 years (2012/13 and 2013/14 minus last quarter)

is relatively small i.e. just under 80 clients per year.

Gender

Female 77

Male 80

The distribution is equal across men and women for assertive outreach.

Diagnosis assertive outreach team clients

Looking at just one year of data 2012/13 clients we see the following breakdown of

diagnoses:

Number seen by assertive outreach team

Per cent %

Bipolar 7 9%

self harm * 5%

drug and alcohol * 4%

depression 8 10%

NULL 21 27%

schizophrenia/schizoaffective/psychosis

22 28%

EUPD 7 9%

other 6 8%

78 100%

The majority of clients (28%, 22/78) had schizophrenia/schizoaffective disorder or psychosis

with the second highest category as unclassified (null). A small number of clients were

under care for substance misuse – it is unclear whether they have dual diagnosis.


Birmingham developed a COMPASS service with the principle that all mental health teams

should have the skills to care for clients with dual substance misuse needs – this has been

successful in ‘reducing problematic alcohol use’ and has been also offered in particular to

the assertive outreach team as they may deal with many dual diagnosis clients62.

Recommendation: clarify arrangements for dual diagnosis and ensure that all specialist teams are skilled to care for such clients. Ensure that clients under assertive outreach /all mental health teams have access to all the psychosocial support that clients with substance misuse needs have access to.

7.8 Comparison of numbers in secondary care with expected prevalence

If we take the national prevalence and compare the expected numbers with different mental

health issues with the numbers in secondary care, we see the following:

Mental health problem

Numbers expected for Sutton using national data

Type of secondary mental health team

Numbers in Sutton secondary mental health care (specialist teams, plus CMHT)

Common mental disorders

16000 persons Home treatment team 338

Psychosis in last year

500 persons CMHT 1307

Depression 2800 to 4000 persons

Assertive outreach 80/year

Bipolar disorder 1600 persons EIP 105

Total with severe and enduring mental illness (expected)

6100 (using highest estimate of depression)

1830

The estimates are crude as they are in some cases an average of activity, but we see that

for the 6100 expected persons with severe mental illness (psychosis, depression, bipolar

disorder) there is an observed number in treatment either with the CMHT or specialist

teams of 1830 persons. There are no conclusions that can be reached as patients may in

primary care, or undiagnosed, but the comparison is worth making.

7.9 Probation caseload for Sutton - mental health needs

Probation clients typically have high levels of mental health needs, similar to those in the

prison population. National estimates are that 90% of prisoners have a mental health need

62

Mental health and the productivity challenge: 14.


(includes substance misuse – Singleton & Meltzer 199863). A smaller sample of 173

offenders under probation care in Lincolnshire showed that 39% had a current mental

illness (Brooker et al)64. The King’s Fund report on increasing productivity noted that

commissioners should improve support with employment and services for offenders’ as a

way to prevent mental health issues arising65.

Probation in Sutton used the OaSys national reporting tool (which assesses the needs

and risks posed by offenders on the probation caseload) to extract a snapshot of key mental

health questions on 10 December 201366. The total number of cases extracted was 363

persons for Sutton at the time of the audit. The OaSys questions extracted were as

follows:

Emotional wellbeing is a need

Current psychological problems/depression

Social isolation

Self-harm, attempted suicide, suicidal thoughts or feelings

Current psychiatric problems

Issues of emotional wellbeing linked to risk of serious harm, risks to the individual

and other risks

Issues of emotional wellbeing linked to offending behaviour

7.9.1 Breakdown of current caseload by Emotional Wellbeing

Emotional wellbeing is a need

Count %

Yes 124 34%

No 239 66%

Grand Total 363 100%

The data show that over one third of the 363 clients on the Sutton probation caseload have

an emotional wellbeing need.

63

http://apt.rcpsych.org/content/9/3/200.full.pdf or http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_4007132 last accessed 3 Jan 2014. 64

http://www.cep-probation.org/uploaded_files/Parallel-II-A-Tackling-the-Health-Needs-of-Offenders-in-the-Community-Brooker-Denney.pdf last accessed 3 Jan 2014. 65

Mental health and the productivity challenge. Naylor & Bell, King’s Fund 2010: x. 66 eOASys is a system used to assess the needs and risks of an offender; individual eOASys

assessments are completed by an offender's Probation Officer. Cases have only been included if

they are currently serving a supervised community based sentence, are in custody or are serving a

licence period following release from custody – Olayinka Macauley Analyst Sutton and Merton LDU,

personal communication 16.12.13.

http://apt.rcpsych.org/content/9/3/200.full.pdf

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_4007132

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_4007132

http://www.cep-probation.org/uploaded_files/Parallel-II-A-Tackling-the-Health-Needs-of-Offenders-in-the-Community-Brooker-Denney.pdf

http://www.cep-probation.org/uploaded_files/Parallel-II-A-Tackling-the-Health-Needs-of-Offenders-in-the-Community-Brooker-Denney.pdf


7.9.2 Breakdown of current caseload by Current Psychological Problems / Depression

Current Psychological Problems/ Depression

Count % Per cent

No problems 136 37%

Some problems 74 20%

Significant problems 17 5%

Not Known 136 37%


We see that one quarter of clients (25%, 91/363) had current psychological problems or

depression.

7.9.3 Breakdown of current caseload by social isolation

Social Isolation Count %

No problems 152 42%

Some problems 64 18%


Not Known 136 37%


21% of the probation cohort (75/363) identified that they experience social isolation, which

seems an underestimate and may reflect that over one third had ‘unknown’ status recorded.

7.9.4 Breakdown of current caseload by Self-harm/ Attempted Suicide/ Suicidal

Thoughts

Self Harm/ Attempted Suicide// Suicidal Thoughts

Count %

No problems 160 44%

Some problems 0 0%


Not Known 136 37%


18% of 363 clients noted either self harm/attempted suicide or suicidal thoughts. Over

one third of clients did not have this recorded (not known) so this should be completed as

this is a high risk group.

Recommendation: ensure that all clients under probation care have their suicide and self harm risk documented with onward support available.


7.9.5 Breakdown of current caseload by Psychiatric Problems

Psychiatric Problems Count %

No problems 183 50%

Some problems 26 7%


Not Known 136 37%


12% had a note of psychiatric problems. This is likely to be an underestimate given that

Brooker et al in Lincolnshire probation estimated the need at 39% of clients.

7.9.6 Issues of emotional wellbeing linked to risk of serious harm, risks to the

individual and other risks

Section 10 Linked to Risk Count %

Yes 63 17%

No 257 71%

Not Known 43 12%

Grand Total 363

The at-risk cohort here for emotional wellbeing issues linked to risk of serious harm is 17%.

This is important as it identifies a group of 63 individuals with high needs.

Recommendation: ensure that the high risk cohort has access to secondary mental health services with clear referral pathways from probation to mental health assessment teams.

7.9.7 Issues of emotional wellbeing linked to offending behaviour

Section 10 Linked to Risk Count %

Yes 124 34%

No 239 66%

Not Known 0 0%

Grand Total 363


The cohort with emotional wellbeing needs linked to offending behaviour is high at 124/363

or one third. This points to an opportunity to reduce offending by addressing the emotional

needs of the individual under the care of probation.

Recommendation: commission a forensic mental health practitioner to both correctly identify and then work with this group in probation clients, including persons with emotional needs and also the higher risk cohort with suicide risk/self harm risk (approx 20%)-now in place as of July 2014.


8 Suicide in adults Suicide rates in Sutton will be covered by the JSNA together with data sheets. Sutton ranks

half way compared to other London authorities with a Directly Standardised Rate of 7.5

suicides per 100,000 population and is similar to the overall London rate, but lower than the

national rate (though this is not statistically significant).

9 Measured performance around mental health

9.1 Primary care

Case finding of mental health problems in people with long term conditions

The Kings Fund (Naylor& Bell) identified this as a key intervention for primary care67 in that

‘providers of physical health care must...deliver more integrated and cost effective care to

people with co-morbid physical and mental health problems, in particular older people and

people with long term conditions.68’ This also ties in with the liaison and diversion work

described above that the St Helier team worked with a cohort of mental health clients who

had on average 1.75 co-morbid physical health conditions.

IAPT

The following table shows the percentage of adults with either anxiety or depression (Sutton

is the second highest in London at 4.8% although caveat that this is low level mental health

issues and may reflect a very health literate and demanding population, however is higher

than Barnet (2.5%) or Harrow (2.7%).

67

Naylor and Bell – mental health and the productivity challenge 2010: ix. 68

Naylor and Bell – mental health and the productivity challenge 2010: ix.


Performance in terms of recovery in Sutton is worse than national average, with Sutton at

37.3% and the England average 43.8%.

Recommendation: address issues with IAPT recovery and pathways.

9.2 Secondary care

9.2.1 Smoking cessation for clients

Smoking cessation is an important area for mental health. McManus et al (2010) highlighted

that 42% of tobacco consumption in England is by people with a mental disorder.

Recommendation: ensure stop smoking and health checks are offered to CMHT clients.

9.2.2 Care programme approach

The Care Programme Approach is a way of co-ordinating community mental health

services for people with severe and enduring mental health problems. It involves carrying

out a comprehensive assessment and producing a care plan for each patient. Numbers on a


care programme approach per 1000 population CPA is lower for Sutton than the England

average for 2010-1169 (NEPHO community health profiles70).

9.2.3 Settled accommodation

Additional outcomes for CPA are noted by UCL partners. In terms of patients on CPA with

settled accommodation Sutton has a performance within the London range at 88.5%,

comparable to Wandsworth at 85.9% and Richmond at 91.2%. See Annex 5.

9.2.4 Employment

In terms of employment this is higher in Sutton (8.4%) than Wandsworth (7.9%) and

Croydon (5.6%) but worse than the rest of South West London. See Annex 6.

Recommendation: improve performance around employment for persons with mental health illness in Sutton.

9.2.5 Contact with community psychiatric nurse

This indicator records the number of contacts that Outpatient and Community Psychiatric

Nurse have with patients each year per 1,000 population. The data is sourced from the

Mental Health Minimum Dataset.

Number of total contacts with mental health services, rate per 1,000 population, 2010/11 –

significantly lower than England average

This indicator measures all contacts with mental health staff, including Consultant

Psychiatrists, Community Psychiatric, Nurses, Clinical Psychologists, Occupational

Therapists, Physiotherapists, Consultant Psychotherapists & Social Workers. Rate per 1000

population - Contact with CPN is lower than the national average 2010/11. For Sutton this

was 82 per 1000 population using 2010-11 data but it should be noted these data are old.

69

NEPHO. NHS community mental health profiles mental health minimum dataset 70

NEPHO community health profiles for mental health 2013.


10 Qualitative views - what do people think about services?

Professionals

Professional Commissioner / clinical project manager

Service Director SWL StG

Consultant psychiatrist for liaison psychiatry

Healthwatch

Strengths

There have been marked improvements in some of the processes of Ward 3 since the Enter and view report of 2012.

Gaps

Lack of support around alcohol. Staff training around alcohol would be helpful.

Gaps in service for clients with PD who are getting unwell in earlier stages, and lack of services as a step down once they have had intensive support as an inpatient

Complex referrals to social care with a lack of integration around social care

Gaps around the frail elderly pathway from St Helier –

Poor discharge processes for clients. For Ward 3 social services referrals sometimes a two week delay before being seen on the ward. This leads to patients being delayed unnecessarily in hospital.

Poor discharge, patients report being sent home to a flat that they last left in disarray

GPs not sufficiently skilled or attentive enough towards mental health clients, and not taking their mental health condition into account during the consultations. Failure to support people adequately in primary care as GPs lack an understanding of mental health

Areas for change or improvement

Pathways between primary care and mental health services with differing levels of knowledge amongst GPs

Increased OT provision with cover for that role when on holiday

could be better risk stratification of primary care lists to identify people with long terms conditions at risk of mental


health issues

Long term condition management – for all, need advice on self care, for moderate need, refer to IAPT and for more complex needs with complex c-morbidity then needs referral to liaison psychiatry

General comments

High numbers of persons with personality disorder who need specialist support e.g. DBT, little Sutton borough provision for then so have to become out of area placement

For the crisis model proposed in light of the consultation, the best model would be to boost the capacity of the home treatment team and also have support from peer supporters

The points raised by professionals span a broad range of topics, and in terms of

recommendations for action, these are summarised to a few main points:

Ensure that the alcohol pathways for identification and onward referral by St Helier are clarifies and made effective.

Review the services for personality disorder in the borough, in particular after residential placements.

Review discharge processes from Ward 3, as well as social care processes in the discharge system.

Look at the work with mental health clients in primary care to ensure that GPs feel confident and skilled to address mental health, and are checking for mental health conditions in patients with LTCs as well as ensuring good physical health checks are made for their clients under secondary mental health services.


Service users

Service user focus group 13.11.13, n=8

STRENGTHS

physical health checks physical health check on arrival to the inpatient ward only became 'mandatory' in 2013 - but this is an improvement

St Helier stop smoking (now stopped)

St Helier hospital used to have a good stop smoking service in the community

SMHF stop smoking advisor there is some support for stop smoking from the SMHF advisor in Belmont

complementary therapies referrals to complementary therapy can be very helpful e.g. Homeopathy, T'ai chi. There is a perception that 'carers seem to get more', but that these services would be beneficial

Sutton Reach Sutton Reach based at Cafe Nero - some positives there but the venue is not ideal.

housing support good support for people in social housing but not in private sector (or owner occupied)

WEAKNESSES

primary care awareness primary care (GPs) are not aware of mental health issues

poor communication between professionals, dignity

clients have to 're-tell' their story many times to different doctors and nurses because the turnover in the system is so high - 'they don't read the notes'

continuity of meds there is perception of no communication between the psychiatric team and patients' GPs, so that there is no taking into account medication for chronic long term physical conditions - 'they throw away your medication when you go into hospital'

recovery college access to get into the recovery college you have to have been so unwell to be under the care of SWL StG, you can't access it just if you are in the community, you need to be under the care of the CMHT

stop smoking the CMHT stop smoking advisors 'don't understand how hard it is to quit because they don't smoke themselves'

for smoking, the trust used to just ask you to set the quit date, and then do nothing afterwards [because that was the target]

appointments for stop smoking advisors weren't well kept by the stop smoking service

medication side effects no information on medication side effects e.g. Effects on psychosexual health due to medication - 'we need more counselling about medication side effects', 'we are not made aware of side effects', e.g. Around birth defects also, this information would be helpful to inform choice of medication. 'we just take the tablets with no information', they say the side effects are not due to the medication', example given of being told not to breastfeed, but no reason given

respect and dignity we are afraid to disagree with people [professionals] - they are in control - it is about control' - feeling this was a current issue still in services

oral health and dentistry some discussion of how dental care affects self image and confidence and that access to a sympathetic dentistry service with consideration for anxiety issues would be very helpful. Oral health promotion (once clients are feeling better) would also be welcomed.


site location at Jubilee East in depth discussion that the proposed model was that the Jubilee health center would be open to all patients (primary care and mental health services) to avoid any potential stigma of a separate location. This had been agreed by the CAG, and the group felt disappointed that the offices were now separate, 'people are pointing at you' and they felt this was a stigmatising experience. the small reception area, previously locked toilets and unwelcoming atmosphere were not helpful. Clients felt that reception staff were constantly phoning to locate their case worker due to the hot desk policy, and an experience was given of a client being 15 mins late and then being told they could not find their professional to see them. 'when you have been in hospital you are scared of being locked in again'. The high floor location adds to this mood.

HONOS classification changes the changes have led to great disruption - your care coordinator and diagnosis changed constantly

housing support good support for people in social housing but not in private sector (or owner occupied)

SUGGESTED CHANGES

primary care a primary care model of mental health would really help

can CPNs work with the GPs?'

we used to have GPs on the wards!' [in the inpatient mental health wards] - in discussion with Chris Keers earlier - outside of the focus group

a physical health 'MOT'

patient education and empowerment/choice

some dedicated time with a Pharmacist for in depth counselling around medication side effects

more patient education c.f. Enzyme sensitivities (trial phase) and drug effectiveness

complementary therapies access to complementary therapies

Ecolocal opportunities for community initiatives e.g. horticulture (Ecolocal)

Additional comments submitted after the focus group are at Annex 7.

The main points arising from the clients views are as follows:

Ensure good physical health checks for inpatients and clients under primary health care, including easy access to stop smoking services in the community

Ensure better up-skilling of GPs to recognise and work with mental health clients

Ensuring secondary care services check with clients’ GPs what medications they are on in the community, and communicate with one another in secondary care to reduce clients’ perception of telling their story again and again, with better continuity of case managers.

Ensure that explanation of psychiatric medications is done sensitively by the doctor and ideally a pharmacist also, with clear guidance on what side effects may occur, and advice so that clients can make decisions about their lives.

Look at clear referrals to NHS dentists who understand mental health clients’ needs.

Look at support in the community and the availability of complementary therapies.


11 Comparisons with other areas: innovations This section summarises key developments and potential changes in particular for

community treatment of mental health issues. The key developments are primarily peer /

community support. Day hospitals include both day treatment programmes and transitional

day hospitals. The psychiatric day hospital is ‘a unit that provides “diagnostic and treatment

services for acutely ill patients who would otherwise be treated on traditional psychiatric

inpatient units” Rosie 1987.71’ the types of support on offer in day hospitals are essentially –

an intensive alternative to outpatient/day treatment/or inpatient treatment- ‘diagnostic

and treatment services for acutely ill patients who would otherwise be treated on traditional

psychiatric inpatient units’ (Rosie 1987)72. Other new ways of thinking are a strong primary

care element to address the physical health needs of such clients (c.f. St Charles health

and wellbeing centre73 model).

Type of service

Evidence base Description Views on the service Indicative costs of service

Acute day hospital or day centres

Cochrane review: day centres for severe mental illness. Catty et al 2008 Bandolier LEVEL 1

The authors examined the ‘the effects of non-medical day centre care for people with severe mental illness’, and concluded that ‘the inclusion of any studies less rigorous than randomised trials would result in misleading findings’

Quality of papers means that rigorous evaluation is not possible

N/a

Cochrane review: day hospital versus outpatient care for people with schizophrenia (review). Shek et al 2010. Bandolier Level 1

The review looked for RCTs which compared day hospital care with outpatient care for those with schizophrenia and other similar severe mental illness. 4 trials identified.

Key findings are: ‘less people admitted to day hospital care tend to be admitted to hospital’ (beyond one year n=242, 2 RCTs, RR 0.71 CI 0.56 to 0.89) Day hospital may decrease the risk of unemployment (RR 0.86 CI 0.69 to 1.06)

Not included

Cochrane review: day hospital versus admission for acute psychiatric disorders (review). Marshall et al 2011. Bandolier Level 1

10 trials were identified. For duration of admission (inpatient versus day hospital) there was a longer duration of admission to day hospital care.

This should be supplemented with cost information - as a longer duration, cheaper intervention (day hospital) may be more cost effective than a high intensity expensive but shorter admission to an inpatient unit.

Not included

Daleham Gardens Camden and Islington service in Swiss Cottage

71 Cochrane review: Day hospital versus admission for acute psychiatric disorders (review). Marshall et al 2011: 7.

72 Cochrane review: Day hospital versus admission for acute psychiatric disorders (review). Marshall et al 2011: 7.

73 http://www.westlondonccg.nhs.uk/news/st-charles-health-and-wellbeing-centre-goes-green.aspx Last accessed 8 October 2013.


Crisis support – peer led models

Leeds survivor led crisis service. Set up in 1999 by service users and initially run with social services74

“The service was set up to be a place of sanctuary, which was an alternative to hospital admission and statutory services for people in acute mental health crisis. The service was established, and continues to be governed and managed, by people with direct experience of mental health problem”

Works with people in crisis/suicidal. Work is client led.

Flexible community resource: peer support, drop in, and one-one support

Personal communication with Together partnership

Together Your Way – Wandsworth, Southwark and Lambeth The original Your Way project started in Wandsworth (in place for 2 years), commissioned by the PCT – but now it is subcontracted by SWL StG as the lead. The idea emerged because service users and commissioners were not content with the day service and wanted to try a model that reflected personalisation and personal budgets. Wandsworth now want to target it at a tighter patient group but Together prefer to keep it wide. It is very much service user led, there is a tiny base office but all the work is carried out with clients in their homes, meeting in other community settings, cafes, anywhere the service user wants to meet. The model has become part of the community and with the use of peer support, extends social capital, and is seen as a community resource.

The day centre model in Southwark75 was changed to this service after March 2012, and comprises 2 support workers who work with 60 clients at a time (90 per year). Referrals from CMHT, in patients, GP and self referrals. 4 groups run by people with a lived experience. There is an office base co-located with Southwark disablement which enables good referrals. Majority of client meetings are held in community settings such as cafes. Excellent opportunity for 1-1 working with bespoke goals set with the client, and good outcomes with employment. In terms of the type of client – it can be walk in, referrals from GPs or people in recovery76.

£100-200K per year77 would fund 4 FTE key workers

Shared lives schemes

Investing in shared lives. RSA 2020. July 2013

Summary paper notes that ‘an NHS trust has commissioned a successful Shared Lives scheme for people in the acute phase of mental illness

Net cost for local authorities for people with mental health needs is £28K per year, with shared lives this is £20K per year.

74

http://www.lslcs.org.uk/what-do-we-do/history last accessed 30 Sept 2013. 75

Personal communication – Southwark Your Way support worker Sept 30, 2013. 76

Personal communication Rowena Naylor Morrell Regional Manager Together 26.9.13 77

Personal communication Together Sept 2013.

http://www.lslcs.org.uk/what-do-we-do/history


Nidotherapy ‘the collaborative systematic assessment and modification of the environment to minimise the impact of any form of mental disorder on the individual or on society’ (Tyrer et al 2003)

‘concentrating only on the environment and its interaction with the patient’78

A focus on the environment ‘when ‘when a problem has become chronic and intractable’. Looking at the patient in his /her own environment, going in to the home, helping with improvements to the home.

Skilled keyworking under the supervision of a nidotherapist – need to explore

Recommendation: support a wider consideration of new innovations - led by primary care and the CCG

78

The place for nidotherapy in psychiatric practice. Tyrer et al 2007. The Psychiatrist, 31: 1-3.


Annex 1 –Sutton and Merton mental health strategy 6.3 Primary Care 6.3.1 We will promote education in mental health matters at all ages for the public and professionals to improve the understanding of and reduce the stigma of mental illness. Maintaining and restoring sound mental health not only for those who have suffered problems, but for the population as a whole, is a major objective of this strategy. 6.3.2 We will encourage the development of primary care services provided in familiar surroundings, for example in GP surgeries, local libraries and religious centres. 6.4 Community Care 6.4.1 We will develop care pathways which will include prevention, early intervention and good quality diagnosis. This will be supported by simple referral processes and assessments which cover all the needs of the individual in treatment and recovery. 6.4.2 We will be ensure that personalised care is based on the individual’s needs and wishes and directed at recovery where possible, managed through personal care budgets. 6.4.3 We will track the changes being brought about by such policy as Transforming Social Care and work closely together as joint commissioners to ensure that implementation is supported and the effects monitored from the perspective of both mental health and social services. 6.5 Community Care and Inpatient Services 6.5.1 We will re-balance community and inpatient services so that the use of inpatient services is reduced as far as possible, complemented by growth in effective community care, support, rehabilitation and day services. 6.5.2 We will in the first year of the strategy review current commissioning of day services to evaluate effectiveness and appropriateness of the care model and its fit within future models of care. 6.6 Inpatient and Acute Services 6.6.1 Working at a regional (south-west London) level we will provide modern and therapeutic inpatient services backed by rehabilitation and supported accommodation facilities. 6.6.2 We will address the lack of dignity and privacy, and the fear and lack of security, reported in surveys and engagement groups especially by women while on inpatient wards. 6.6.3 We will in the first year of this strategy reduce the number of commissioned working age adult acute beds across Sutton and Merton (Sutton from 30 to 22 and Merton from 34 to 28). We will look to develop a revised model of care for older people, seeing inpatient admission as an infrequent treatment option, supported by an enhanced community model. 6.6.4 We will look in the first year of the strategy to revise the model of care for rehabilitation, moving more towards an individual needs/placement model seeing a significant reduction in current “inpatient” rehabilitation beds. 6.6.5 Inpatient facilities based at Sutton Hospital were temporally transferred to Springfield Hospital, Wandsworth in September 2009. 6.6.6 The configuration and location of NHS inpatient beds is subject to the South West London Acute Services Review, which is informed by the 5 borough-based mental health strategies. The service review will consider quality indicators and the patient and carer experience. 6.6.7 Healthcare for South West London is now reviewing the configuration of mental health inpatient beds across the sector, and a decision regarding the future of inpatient services at Sutton Hospital will be made and as necessary consulted on towards the end of 2010. 6.6.8 NHS Sutton and Merton will maintain the temporary arrangement until the outcome of the


South West London Acute Services Review is concluded. In the interim the PCT is independently seeking a quality review of the current arrangements (as at 31 January 2010). 6.7 In All Areas 6.7.1 We will work for the reduction or removal of inequalities, including inequalities in the awareness of, access to and outcomes from the use of mental health services, across different cultural, ethnic, gender, religious, age and socio-economic groups. This will involve engagement and research work to improve the understanding of local cultures and ethnic groups, especially of the differing effects of stigma and discrimination in different groups and of the best ways to address the particular needs of different groups. Research will also address known inequalities, for instance the disproportionately high number of black people whose first contact with services is at the acute stage. We will research the effects of discrimination or stigma on minorities whose position has not been studied in depth recently. 6.7.2 We will promote service user and carer involvement in all areas of service provision and in the development of mental health services in future. 6.7.3 We will look to providers of services to ensure that when services are age specific that transition between these services are seamless and that they continue to meet the needs of the individual. 6.7.4 We will, through the implementation of local Older People Mental Health Strategies, promote a measurable improvement in services for older people, especially as they relate to dementia and hospitalisation, to address inequalities of access and to deliver services on the basis of need rather than age. 6.7.5 We will encourage strong multi-agency collaboration and commissioning, co-ordinating the work of mental health and social services with agencies dealing with housing, transport, welfare, benefits, employment, education and other services. This will lead to a ‘whole-system’ or ‘holistic’ approach to support and treatment and to an ability to use the entire market when commissioning mental health services.

Annex 2 - Social work structure for mental health LBS


Annex 3 – risk factors for mental health Sutton compared with

London


Annex 4 – long term conditions Sutton

Annex 5 – settled accommodation


Annex 6 – CPA employment

Annex 7 – additional comments Sutton Reach - prefer if this was renamed as floating support services and an extension of this

service which would be limited to short time interventions and reflects and meets the needs of

individuals

Recovery College Access this would be preferable if it was accessible to people with mental health

needs in a primary care settings There should be more liaison and joint working around health

promotion and self management. A unified programme from the recovery college, IAPT, Expert

Patient Programme should be developed

Suggested Changes The group felt that a dynamic wellbeing focused primary mental health

service model should be developed - more than just IAPT - and a partnership between a range of

providers to promote peer support and community resilience