Mental Health and how it impacts on your Business The role of the GP

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Mental Health and how it impacts on your Business
The role of the GP

• Dr John Hague
• Governing Body GP
• Ipswich and East Suffolk CCG

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What am I going to discuss?

• How big the problem is
• What my problems are
• What your problems are
• Some solutions from a commissioners viewpoint

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How it all fits together
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The Area

• Around 72,000 people aged 16-74 with anxiety,
  depression or both. (Higher than expected)
• Around 9,500 children in Suffolk have a mental
  health disorder, of which some 5,800 have a
  conduct disorder
• Self harm prevalence for 15-16 year olds is 10
  of girls and 3 of boys.
• Up to 1500 women in Suffolk per year experience
  depression and anxiety during and after
  pregnancy.
• Prevalence of personality disorder is around
  24,000 people aged 16 to 74

• 66 GP practices
• 450 GPs
• 2 acute hospitals
• 4 community hospitals
• A recently retendered community health provider
• A single mental health trust
• Childrens universal health services delivered by
  the local authority

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The Burden

• Only around a quarter of those with mental health
  conditions are in treatment
• Only 13 per cent of the NHS budget goes on such
  treatments yet mental illness ..
• Accounts for almost a quarter of the total burden
  of disease.
• Suicide in teenagers has risen by 12 since the
  start of the 2007 recession
•  Anti-depressant prescriptions have almost
  doubled since 2002 and is now over 40 million
  items per year in England alone

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The causes? (in no order)

• Economic downturn
• Bullying (at work)
• Poor HR practice
• Debt Poverty
• Perceptions of Job Centre / DWP
• Bereavement / relationship issues / physical
  health
• Family History

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The impact, for you

• Poor performance
• Reduced profit
• Disciplinary issues
• Presenteeism
• Bullying
• Unemployment
• Bankruptcy

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The reality, for me

• There is no more money
• There are no more clinicians (today, or tomorrow
  recruitment is very, very hard)
• There are always more patients
• There is always more illness
• Acute hospitals always take the money from the
  system
• Around 14 unfilled GP vacancies in East Suffolk
  today
• ½ of GP training places locally unfilled
• Hard to recruit practice nurses

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The reality, for me

• A GP will have up to 110 patient contacts a day
• 40-60 is absolutely normal
• After that there is 20-40 letters, 20-40 repeat
  prescriptions, and 20-40 laboratory results (each
  consisting of up to 40 individual results)
• Do the maths!

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The reality, for me

• That is our environment
• We are where we are
• We would like to be more efficient, offer more,
  offer more time etc but this depends on
  national solutions, that will take years to
  implement
• Of course we can do better ourselves
• Constant improvement is a given
• As is workforce innovation

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The reality

• GPs do not provide an occupational health
  service, as the taxpayer does not pay for it
• Employers need to do this themselves
• You could start at NHS Health at work
• (Other providers are available)

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The reality

• Mental illness represents 1/3 of an average GPs
  workload
• In my case its more like 60
• I am very keen to explore system wide solutions

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What People Tell Us
It is helpful to talk to people with similar
experiences
There are gaps between existing services
Services should not keep discharging me and
making it hard to re-refer
Services need to be more personalised
More support earlier in schools
Services should listen and not label
The 1st person you speak to should be skilled
enough to get you to the right service at the
right time
I dont want secondary care services if I dont
need them
Should be easy to go back to services and ask for
help
People should not need to navigate pathways.
Services should be accessible
The wider workforce needs better understanding of
mental health
More join up with physical health services
Debt, housing and other social issues effect
mental health
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The reality

• Most medication comes from a GP prescription
• Most fit notes are signed by GPs
• Talking treatment via Suffolk Wellbeing service
  (and its partners)

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• The wellbeing service sees over 15 of those with
  anxiety and depression in Suffolk every year
• Around ½ of patients will recover (about as good
  as medication)
• This is performance as expected
• People can self refer by phone or web
• No need to take medication as well
• Over 80 languages available on website
• Free workplace workshops
• (Other providers are available)

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Primary care the CCG

• The CCG now co-commissions primary care
• Patch wide investors in people
• Work on recruitment and retention with HEE, NHSE,
  SCC
• Monthly education sessions
• Regular feedback example below
• Contract query line
• Support of CCG for system wide reform
• Genuine involvement of 14 GPs in commissioining,
  with good relationship with officers and NHS
  England

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Primary Care Mental Health Our Commissioning
Approach

• Joined up commissioning
• Co-production
• Innovation
• Developmental
• Evolutionary
• Outcomes focus
• GPs will continue to do what they do

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What We Want to Achieve
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Vision for Common Mental Health Problems
Signs Symptoms and Risks
Flourishing
Moderate mental health
Languishing
Mental disorder

• Huppert Ch.12 in Huppert et al. The Science of
  Well-being

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Who is it for
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Outcomes
Service Level Outcome
Exceeding all national IAPT targets Timely access to all services An increased proportion of people in PBR cluster four managed in primary care
Patient Level Outcomes
Sustained recovery and improve functioning A meaningful role (including employment and learning) Satisfaction with the service Carers feel supported in their caring role Improved physical health e.g. healthy weight, stop smoking, achieve responsible drinking levels Family mental health and wellbeing is improved Right step, first time
System Impact
A more empowered, knowledgeable and confident system-wide workforce Joined up pathways with other health, care and support services Integrated pathways for people with long term conditions Integrated care pathways for common mental health disorders
Impact on Secondary Mental Health Care
Reducing length of stay in secondary care for people with complex needs Reducing referrals to secondary care No-one falls in a gap between primary and secondary care
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Why is this different?

• A strong family focus
• A complete pathway for all common mental health
  problems, no gaps
• Integrated working between all providers
• A strong focus on outcomes and recovery
• Good relationships with primary care and services
  for children and young people

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Early Intervention But Not Prevention

• Relationship with 5 steps to mental wellbeing,
  Action for Happiness, Happy City
• This is all a Public Health responsibility

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Workplace well-being programmes
Target Working-age adult population accessed through their place of employment
Inter-vention Multi-component health promoting programme, including a health risk appraisal and information and advice tailored to the employees readiness to change health-related behaviours. Cost 80 per year employee per year
Outcome evidence Quasi-experimental evaluation in UK company reported significantly reduced stress levels, reduced absenteeism and improved productivity (Mills et al 2007).
Economic pay-offs Reductions in sickness absence and presenteeism reduced costs of avoidable mental health problems to NHS
Findings Total savings 9.69 for every 1 invested (Slide from Paul McKrone, LSE)
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You could Read
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You could

• Pay well
• Be an Investor in People
• Tackle bullying at work
• Practice superb HR practice
• Offer debt poverty advice
• Offer help with bereavement / relationship
  issues / physical health / stress
• Take a long view

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Thank you

• Any Questions?
• johnhague_at_nhs.net