Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning Tuesday 24 June 2014: 15Hatfields, Chadwick Court, London

1. The importance of integration of
physical and mental health:
The commissioning and finance
rationale
Bob Ricketts, Director of Commissioning Support
Services Strategy & Market Development
NHS England
Better Outcomes, Better
Value: integrating physical
and mental health
24th June 2014
1

2. The importance of integration of physical and mental health:
Why is the integration of physical & mental health in
commissioning important?
• Ethical imperative for commissioners
The commissioning and finance rationale:
• To begin to make parity of esteem a reality
• To deliver better outcomes & experience
• To secure a better return on resources
So what does all this mean for commissioners?

3. The importance of integration of physical and mental health:
Parity of esteem:
• Key strategic objective & commitment:
“making sure we are just as focused on improving mental health as
physical health and that patients with mental health problems don’t
suffer inequalities, either because of the mental health problem or
because they don’t get the best care for their physical health problems”
NHS England: Everyone Counts

4. The importance of integration of physical and mental health:
Parity of esteem:
• People have a right to expect equally high quality services for their
mental and physical health, which are person-centred & ‘joined
up’:
“My family and I have access to services which enable us to maintain both
our mental and physical wellbeing. If I become unwell I use services which
assess and treat mental health disorders or conditions on a par with
physical health illnesses.”
NHS England: Everyone Counts

5. The importance of integration of physical and mental health:
Better outcomes & experience:
Scale:
• Every year 1 in 4 adults experience at least one mental health disorder
• Mental health is the single largest cause of disability in the UK (23%
mental health; 16% CVD; 16% cancer)
• Mental & physical health are indivisible & unitary and should be
considered together by commissioners
Condition: % of people with depression with…
Diabetes 27%
Hypertension 29%
Stroke 31%
Cancer 33%

6. The importance of integration of physical and mental health:
Disparity in Outcomes:
• People with schizophrenia are:
2x more likely to die from CVD
3x more likely to die from respiratory disease
• Life expectancy:
average for men …………………………………… 79 years
average for men with mental health problems… 68 years
• People with diabetes who also have co-morbid mental health
problems are at increased risk of poorer health outcomes &
premature mortality. Co-morbid mental health problems are
associated with poorer glycaemic control, more diabetic
complications & lower medication adherence

7. The importance of integration of physical and mental health:
Return on investment:
Mental health problems = 28% of morbidity, but receive only 13% of
NHS spend
But potentially high return on resources:
ROI for each pound invested in:
• £84 for school-based social & emotional learning programmes to prevent
conduct disorder
• £18 for early interventions in psychosis
• £10 for work-based mental health promotion
• £8 for training interventions with parents with conduct disorder
• £5 for early detection & treatment of depression at work

8. The importance of integration of physical and mental health:
Why commissioning for integration makes financial sense:
• 12-18% of all NHS expenditure on LTCs is linked to poor mental health &
wellbeing = £8bn-£13bn pa (King’s Fund: Long-term conditions and mental
health The cost of co-morbidities, 2012)
• When people with LTCs also have mental health issues the cost of
treatment can rise significantly. 1/3 people with long-term physical conditions
also increase mental health problems, increasing treatment costs
• Co-morbid mental health problems raise total health care costs by at least
45% for each person with a LTC & co-morbid health problem
• At least £1 in £8 spent on LTCs such as CHD or diabetes is linked to poor
health & wellbeing; savings far outweigh the cost of psychological
interventions (NHS Confederation Mental Health Network and King’s Fund)

9. The importance of integration of physical and mental health:
Why commissioning for integration makes financial sense:
“A growing evidence base suggests that more integrated ways of working
… offer the best chance of improving outcomes for both mental health and
physical conditions.”
“There is also evidence that the costs of including psychological or mental
health initiatives within disease management or rehabilitation programmes
can be more than outweighed by the savings form improved physical
health and decreased service use.”
King’s Fund: Long-term conditions and mental health The cost of co-
morbidities, 2012

10. The importance of integration of physical and mental health:
Why commissioning for integration makes financial sense:
• Hillingdon Hospital – incorporating a psychological component into
breathlessness clinics for COPD led to 1.17 fewer A&E attendances &
1.93 fewer hospital bed day admissions per person, saving £837 per
person – saving 4 times the cost
• CBT- based programme for angina led to patients needing 53% fewer
hospital admissions, saving £1,537 per person

11. The importance of integration of physical and mental health:
Commissioners & providers should address the factors that enable
good integrated care:
• Information-sharing systems Shared protocols
• Joint funding & commissioning Co-located services
• Multidisciplinary teams Liaison services
• Navigators Research
• Reduction of stigma
Mental Health Foundation: Crossing Boundaries Sept. 2013

12. The importance of integration of physical and mental health:
So what does all this mean for commissioners?
• Make improvements now through incentivising incremental changes
in service specifications (CQUIN)
• Put individuals at the centre of commissioning decisions
• Work effectively with key local partners & communities – influencing
education, work, housing, leisure, lifestyles
• Designing integrated mental health & physical health services
• Develop and incentivise the delivery of integrated mental health &
physical health outcomes
• Use the Better Care Fund creatively
• Where appropriate, exploit the power for transformation of population-
based commissioning for outcomes

13. The importance of integration of physical and mental health:
So what does all this mean for commissioners? Can it be done?
Integrating Physical and Mental Health in Nottingham:
More joined-up & strategic approach across commissioners & providers:
• GP training around mental health
• Mental health staff training around physical health
• Improving access to health improvement
• CQUIN to incentivise physical health checks & smoking support
• Mental health incorporated within long-term conditions pathways
Dr. J. Copping, Dr. M. Bicknell & Dr. Michele Hampson :
Integrated Health Care Summit April 2012

14. Community Health and
Well being
Integrated Practice, Care
For HIV Patients
Veronica Ford

15. COVENTRY’S INTEGRATED
SERVICE
• An integrated Sexual Health and HIV
service, including Family Planning and
GUM
• Trust clinical strategy to develop
Integrated Practice Units

16. Prevalence of HIV in Coventry
• General population in Coventry of
323,132
• Over 600 HIV patients accessing Integrated
Sexual Health Service
• Prevalence of HIV is 3% per 1,000 people
aged 15-59

17. Integrated Practice Unit’s (IPU)
• Organized around the need’s of patient’s
• Provides the full cycle of care for a condition,
including patient education, engagement and
follow-up
• Involves a dedicated team who devote a
significant portion of their time to the medical
condition
• Providers are part of a common organizational
unit
• Co-located in dedicated facilities
Source: Michael Porter 2010

18. Background
• HIV is a complex disease and is considered
to be a treatable Long-Term Condition
• Antiretroviral Therapy has improved
survival dramatically
• Co-morbidities including mental heath
issues have been identified as important co-morbidities
• Management of HIV patients need multidisciplinary team
approach
• Lifestyle advice and Mental Health Support
can improve survival with improved
quality of life (BHIVA Guideline)

19. IPU - Work to Date
• Development of Screening Tool
• Complies with BHIVA Standards of Care for
People Living with HIV
• Leading to Single Assessment
• Integrated working/joint clinics
• Effective use of existing resources
• Increased range of services to clients

20. Previous Pathway
HIV
Consultation
Dietician
THT
iAPT
Psychosexual
Counselling

21. Current progress
HIV
consultation
Lifestyles
service
THT
service
Dietician
iAPT
service
Physiotherapy
Specialist
Psychiatric
and
Psychological
services
Alcohol
support
Smoking
support
Weight
support

22. Lifestyle Health Checks
• Individuals aged 18 and above to identify
risks and make healthy lifestyle changes.
• Initial 45 minute assessment includes:
• BMI measurement
• BP, Glucose & Cholesterol testing
• Smoking status, diet, physical activity,
alcohol consumption
• GAD/PHQ for Mood & Anxiety.

23. Lifestyle Health Checks
• Following initial assessment, the client can
attend a structured six week programme to
improve lifestyle and reduce risk:
Eat & Drink Healthy,
Be active, Reduce Smoking & Alcohol,
Feel good and sleep well
Move onto Case Management or Stop
Smoking Programme

24. •Delivering parallel healthy lifestyle and
IAPT clinics within the service
• Team encouraging HIV patients to
attend Lifestyle check
•Closer liaison and working between
MDT
• Onward support offered with a range of
external agencies
IPU in Practice

25. Results so Far
• IAPT has already identified patients who need
help including Cognitive Behavioural Therapy
– Management plans agreed with consultant
through MDT discussions
– Positive feedback from patients and clinicians
• IPU assists with the early intervention to reduce
the complex co morbidities and also help with
the identification of comorbidities such as
hyperlipidaemia.

26. iAPT
15%
42%
43%
% patients offered IAPT
Service
% patients signposted to
another service
% patients who either did not
need or want futher support

27. Life Style Support
15%
17%
17%
25%
2%
24%
patients to stop smoking
support
patients on counterweight
patients on to IAPT
patients referred to
Physiotherapy
patients on to Alcohol
Support Services
patients on to additional
case management support

28. Case study 1
• Male, aged 56 years diagnosed positive for 5
years on ART for 4years
• Completed lifestyle health check and was
motivated to make lifestyle behaviour changes.
• Completed support with ‘Eat Well’ sessions with
Lifestyle advisor.
• He achieved his goals relating to the frequency of eating, portion
size and types of food groups eaten. His starting weight was 103kg
and is now 99kg.
• Quote – ‘Quite surprising the things you take for
granted that are wrong in your life, you think
you are doing good but you can do better, fine
tuning needs to be done.’

29. Case Study 2
• Female, aged 53 years diagnosed 6 years ago
• Supported with behaviour change to ‘sleep well’.
• Her sleep improved and she is also now accessing physiotherapy
after being referred following check for her leg problem.
• Following the sleep improvement she is now accessing
• Counterweight, a weight management programme, with our lifestyle
advisor and is following a personal health plan.
• She has lost 4.6 kg already and is still on the programme. (Starting
weight 75.6kg, now 71kg)
• Quote ‘Feel more self-aware and in control of my eating and
sleeping; realising that you have habits and somebody is helping
you to stop and think. ‘No thank you’ is now my mantra for the
week.’

30. Healthy Lifestyles Sexual Health Feedback Data Analysis
Q6 Do you feel the staff listened to you?
Q7 Is the place where you go for your appointment convenient for you to get to?
Q8 Do you think the support offered by the Health professional has helped you adopt a healthier lifestyle?
Q10 What is your overall view of the service?
Q11 Focus group
NB N/A = Not answered

31. Healthy Lifestyles Sexual Health Data Analysis
Q2 Q3 Q4 Q5
How would you rate the
appointment times offered to
you?
How would you rate the
greeting you received
from reception
staff/Health professional
on arrival?
How would you rate the
approach ability and
professionalism of the
health professional?
How would you rate the
explanation of the
programme and the
information given to you?
Q9
What is your overall
view of the service?
Excellent, 4
Excellent, 7
Excellent, 6 Excellent, 6
Excellent, 5
Good , 7
Good , 4
Good , 5 Good , 5 Good , 5
N/A, 2
0
1
2
3
4
5
6
7
8
Q2 Q3 Q4 Q5 Q9
Excellent
Good
N/A
NB N/A = Not answered

32. BHIVA STANDARDS
Standard 3
• Provision of outpatients treatment and
care for complex co-morbidity- the IPU
may assist with the early intervention to
reduce the complex co morbidities and
also help with the identification of
comorbidities such as hyperlipidaemia.
• Access to emotional support and smoking
services
•

33. Standard 6
• Psychological care – promotes emotional and
cognitive wellbeing that will impact on the quality
of care and wellbeing for people attending the
service
Standard 9
• Promote self-management – smoking cessation
to support wellbeing- encouraging a self-
management weight plan

34. Standard 10
• Participation of people with HIV in their
care – empowering patients to be involved
in the their care pathways .
• The IPU helps patients to participate in
identifying need and identify and
select other areas of care that may help
them to live well.

35. • By implementing an IPU we are working to
ensure HIV patients have the best
programme of health care
• Supporting/encouraging self management to
• Wrapping services around the patients, and
ensuring the clients do not need to be
referred onto other services
• Reduction in client waiting time to access
other health services
Benefits of IPU

36. • Reducing admin time to book new appointments
• Reduces DNA rates
• Reducing time and money spend by healthy
lifestyle services promoting services e.g.
promotional material
• Shared equipment and administration support
Benefits of IPU

37. Future Plans
• Single set of medical records
• Expanding screening tool
• Inclusion of additional services
• Formalising outcome framework
• Training for Sexual Health Staff to
undertake the screening

38. QUESTIONS