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Index Number:No. 10.3Document:Northumberland CCG Mental Health Model of CareDescription:Local strategic needs analysis, including the number of children living in homes where there is a parent/carer known to be receiving treatment for drug or alcohol misuse, known to be suffering from mental ill health and/or experiencing domestic abuse. This should also include details of any commissioned services in support of children and families living in these circumstances. The number and needs of looked after children and care leavers should also be included in respect of the provision of sufficient placements and choices for care leavers. Northumberland CCG Mental Health Model of Care

2Northumberland CCGs Mental Health Model of Care DevelopmentNorthumberland CCG spends almost 50 million per year on Mental Health services for the population of Northumberland

In April 2013, the CCG began a process to develop a model of care for mental health to describe the services and outcomes we want to commission

Aims of the model of care:

Describe the future care pathways that the CCG will be commissioning for mental health and the desired outcomes at each stage in the pathway

Ensure the spend on mental health is on services that have the capacity to deliver high quality services that meet all of the mental health needs of the people of Northumberland

3Current Service ProvisionWe currently commission a broad range of services for people of all ages suffering with mental health difficulties

At present service users do not always systematically access the right service pathways to meet their needs

Pathways are sometimes fragmented and incoherent

The current arrangement of services does not always ensure service users receive evidence based, best practice interventions

Pathways are not always designed around the patient and therefore do not deliver the outcomes needed

We currently commission a broad range of services for people of all ages suffering with mental health difficulties. Our main providers are Northumberland, Tyne and Wear NHS Foundation Trust (NTW), Northumbria Healthcare NHS Foundation Trust (NHFT) and Mental Health Concern and Oakdale (MHCO), however, we also commission a number of services from private and third sector providers.

At present, service users do not always systematically access the right service pathways to meet their needs. Pathways are sometimes fragmented and incoherent. The current arrangement of services does not always ensure service users receive evidence based, best practice interventions. Pathways are not always designed around the patient and therefore do not deliver the outcomes needed.

4Stakeholder FeedbackWe need faster access to servicesServices need to communicate with each other betterServices need to support people to build emotional resilience There needs to be a greater focus on early identification and interventionTransitions between children to adults services need to be smooth and effectiveWe need more services for people with dementiaCommunity mental health teams need to have better links to primary careWe need a directory of services for people with mental health issuesMore training in mental health is needed for practice nursesWe need better continuity of care for young people and their carers transitioning to adult servicesBetter advice & support for family and friends coping with a relative with a mental health problemServices need to work with each other to meet all the needs of a personWe need better integration of services between Physical and Mental HealthWe want faster response times; waiting lists are too longKey Themes:

Faster accessFocus on earlier identification and interventionIntegration of services better communication between services Better transitions between services; particularly children's to adults5Local21.6% of the population of Northumberland is aged 0-19The level of child poverty is better than the England average however, 18.4% of children aged under 16 are living in povertyYoung people aged under 18 admitted to hospital as a result of mental health is lower than the England averageThe hospital admission rate for substance misuse (age 15-24) and young people aged under 18 admitted to hospital as a result of self-harm is higher than the England averageNationalChildren with learning disabilities are six times more likely to have mental health problems than other childrenOne in 100 children has autism, and that more than seven in ten children with autism have a co-morbid mental health problemChildren with a long-lasting physical illness are twice as likely to suffer from emotional problems or disturbed behaviourMany looked after children have complex needs and high levels of mental health problemsChildren and young people in the criminal justice system are far more likely to experience mental health problems than their peersChildren and Young People Current Service Provision & Mental Health ProfileChildren and Young Peoples Services

Northumberland, Tyne and Wear NHS FT (NTW) Children and Young Peoples Service (CYPS) provides a single service to all children and young people aged 0-18 years living in Northumberland who present with mental health difficulties. The service provides assessment, diagnosis and intervention on a range of mental health issues.

NTW also provides intensive response and home-based treatment; an intensive Eating Disorder Service; a comprehensive transition support package to those young people need continuing support as adults and training, consultation, support and advice to front line staff working in targeted services for children.

Northumbria Healthcare NHS FT provides a Primary Mental Health Workers Service which provides support to staff within Tier 1, in relation to early identification and intervention with childrens mental health needs.

The service promotes the emotional health of children and young people in the community and provides support, advice and assessment to children, young people and their families. 6Children and Young People Priorities for ChangeWe need to work with existing providers to ensure the successful delivery of service development plans to improve access, develop service user outcome measures and reallocate resource to increase capacity in Tier 1 and 2

We need to develop a new service model which incorporates the Northumberland Children and Young Peoples Emotional Health and Wellbeing Strategy and the principles of the model of care1 work with existing service providers to drive up service quality - Improving access; Early identification and intervention; Developing service user outcome measures; Reallocating resources from Tier 3 to increase capacity in Tier 1 and 2

2 Develop a new service model/specification; go out to tender April 2014; service live April 2015

7Adult Current Service Provision and Mental Health ProfileAdult Services

Northumberland, Tyne and Wear NHS FT (NTW) and Mental Health Concern and Oakdale provide the IAPT Talking Therapies service across Northumberland.

NTW also provides a range of inpatient and community services for adults including:

Adult Assessment and TreatmentPsychiatric Intensive Care Units Crisis Resolution and Home Treatment Community Mental Health Teams Early Intervention in Psychosis Assertive Outreach LocalIn Northumberland, demand on services is expected to increase with the growth of the 25-35 and 55-64 age groups up to 2020, both of whom are associated with higher age related mental health service use Northumberland has a higher than England prevalence rate for depression, but lower for other mental health conditionsNorthumberland has low rates of admissions for schizophrenia and significantly lower rates of admission for depressionNationalMental illness is the single largest cause of disability in the UK, contributing up to 22.8% of the total burden, compared to 15.9% for cancer and 16.2% for cardiovascular diseaseAt least one in four people will experience a mental health problem at some point in their life and one in six adults has a mental health problem at any one timeAlmost half of all adults will experience at least one episode of depression during their lifetimeAbout 1 in 100 people has a severe mental health problem8Adult Priorities for ChangeWe need to ensure that across all age groups there is equity of access to IAPT and other counselling services and that they have adequate capacity to meet the increasing rates of depression and other common mental health problems

We need to transform existing services to ensure they are delivered using an integrated approach with embedded partnership working to meet all of the needs of an individual

We need to implement care pathways and packages to ensure that services deliver best practice interventions

1 Equity of access to IAPT; Primary care MH services; counselling

2 Transformation of existing services to deliver whole system integration

3 Care pathways and packages9Older Adult Current Service Provision and Mental Health ProfileLocalNorthumberland has an increasing over 65 population when compared to all ages. The over 65 age group is set to increase by 14,000 (17.8%) by 2020 compared to a decline of 6800 in under 65The increasing percentage of the over 65 population is likely to increase the demand on social care, older peoples mental health and memory servicesFor 65+ age bands there is a significant increase in the prevalence rates for all mental health issues covering both functional and organic currently one third of national mental health service use is from the over 65 age groupIn 2012, was estimated that there was 5,748 people in Northumberland over 65 with depression, 1,821 with severe depression and 4,465 with DementiaBy 2020 it is estimated there will be 6,955 people in Northumberland over 65 with depression, 2,208 with severe depression and 5,782 with DementiaNorthumberlands current prevalence rate for dementia is in the top 25% in England and the ratio of diagnosis and prevalence is 42%NationalThe morbidity in older people is not just due to dementia, it also includes other functional illnesses such as depression and psychosis though these can, and frequently do, co-exist with dementia Depression affects: 50% of people with Parkinsons disease; 25% following stroke; 20% with coronary heart disease; 4% with neurological disease; and 42% with chronic lung diseaseOlder Adults Services

Northumberland, Tyne and Wear NHS FT (NTW) provide a range of community and inpatient services for older people.

This includes Community Mental Health Teams which provides specialist assessment, treatment and care for older people with mental health problems arising from functional or organic disorders.

NTW also provides inpatient facilities delivering assessment and treatment by multi-disciplinary health and social care teams for older people with mental health problems arising from functional disorders such as depression.10Older Adults Priorities for ChangeWe need to ensure we have appropriate service provision for older adults with dementia and/or functional illnesses, to account for the expected increase in demand on these services

We need to transform existing services to ensure they are delivered with an integrated approach that meets all of the needs of an individual We need to implement care pathways and packages to ensure that services deliver best practice interventions

1 Dementia and functional illnesses for older adults

2 Transformation of existing services to deliver whole system integration

3 Care pathways and packages

11Assessment and FormulationTreatmentDischarge and TransitionServices can be accessed quickly and easilyServices work as part of a whole system delivering integrated care pathwaysServices are focused on early identification and interventionServices are high quality, safe, effective and use evidence based best practice interventions delivered by highly skilled staffServices provide personalised care packages that meet an individuals needsService quality and effectiveness are measured by service user outcomes Services promote positive mental health and the prevention of mental ill healthCommunication between services is seamless Services demonstrate that they provide value for money

Key Principles of Service DeliveryNorthumberland Mental Health Model of CareKey Principles

Services can be accessed quickly and easilyServices work as part of a whole system delivering integrated care pathwaysServices are focused on early identification and interventionServices are high quality, safe, effective and use evidence based best practice interventions delivered by highly skilled staffServices provide personalised care packages that meet an individuals needsService quality and effectiveness are measured by service user outcomes Services promote positive mental health and the prevention of mental ill healthCommunication between services is seamless Services demonstrate that they provide value for money

12AccessServices have a simple referral process to follow and are accessible to the whole communityReferrals are clinically triaged; referrers and service users are actively engaged and receive clear communication, within agreed timescalesProviders give service users choice and make reasonable adjustments to ease accessRelapse management known service users receive rapid, easy re-entry to servicesReferrers receive signposting and advice when referrals are deemed inappropriateOutcomesService users enter the right pathway, easily and quickly (short waiting times referral to assessment)Service users are engaged and attend appointments (reduced DNA rates)When a service user relapses, they receive rapid access back to services (waiting times)Referrers are supported to make appropriate referrals (referrer feedback)

Assessment and FormulationTreatmentDischarge and TransitionACCESSAccess Phase of the PathwayChildren & Young PeopleNonPsychosisPsychosisCognitive ImpairmentAccess What will happen

Services have a simple referral process to follow and are accessible to the whole communityReferrals are clinically triaged; referrers and service users are actively engaged and receive clear communication, within agreed timescalesProviders give service users choice and make reasonable adjustments to ease accessRelapse management known service users receive rapid, easy re-entry to servicesReferrers receive signposting and advice when referrals are deemed inappropriate

Access The desired outcomes

Service users enter the right pathway, easily and quickly (short waiting times referral to assessment)Service users are engaged and attend appointments (reduced DNA rates)When a service user relapses, they receive rapid access back to services (waiting times)Referrers are supported to make appropriate referrals (referrer feedback)

13Assessment & FormulationService users are put at the centre of a holistic assessment appropriate to their needsWhere appropriate, service users are clustered and kept well informed throughout the processPersonalised service user outcome focused care packages are formulated, in collaboration with service users and their carers and all service providers involvedCarers are also offered a needs assessmentService users rapidly enter the treatment phaseOutcomesService users are effectively involved and engaged with the care planning process and their views are central to it (PREMS)Short waiting times (assessment to treatment)Service users receive a care plan which addresses all identified goals and needs (PROMS, PREMS, CROMS)Service users understand the assessment process, their diagnosis and treatment options (service user feedback)Carers needs are identified and they are supported to meet their needs (carer feedback)Assessment and FormulationTreatmentDischarge and TransitionACCESSAssessment & Formulation Phase of the PathwayChildren & Young PeopleNonPsychosisPsychosisCognitive ImpairmentAssessment and Formulation What will happen

Service users are put at the centre of a holistic assessment appropriate to their needsWhere appropriate, service users are clustered and kept well informed throughout the processPersonalised service user outcome focused care packages are formulated, in collaboration with service users and their carers and all service providers involvedCarers are also offered a needs assessmentService users rapidly enter the treatment phase

Assessment and Formulation The desired outcomes

Service users are effectively involved and engaged with the care planning process and their views are central to it (PREMS)Short waiting times (assessment to treatment)Service users receive a care plan which addresses all identified goals and needs (PROMS, PREMS, CROMS)Service users understand the assessment process, their diagnosis and treatment options (service user feedback)Carers needs are identified and they are supported to meet their needs (carer feedback)14Treatment

OutcomesAssessment and FormulationTreatmentDischarge and TransitionACCESSTreatment Phase of the PathwayChildren & Young PeopleNonPsychosisPsychosisCognitive ImpairmentService users receive a care package of outcome focused, safe, evidence-based interventions from highly skilled staffService users are supported to self-manage their condition, where possibleWhere appropriate, involvement of families and carers is encouraged and supported through active engagement and information sharing Service users recover (PROMS, CROMS, recovery rates)Service users are actively involved in shared decision making and supported in self-management (PREMS)Lower relapse ratesCROMSPatient safety (Incidents)Treatment What will happen

Service users receive a care package of outcome focused, safe, evidence-based interventions from highly skilled staffService users are supported to self-manage their condition, where possibleWhere appropriate, involvement of families and carers is encouraged and supported through active engagement and information sharing

Treatment The desired outcomes

Service users recover (PROMS, CROMS, recovery rates)Service users are actively involved in shared decision making and supported in self-management (PREMS)Lower relapse ratesCROMSPatient safety (Incidents)15Discharge and Transition

Discharge and transition planning is an explicit element of the care planning process with plans formulated collaboratively between service users, carers and providersService users are supported to develop personalised relapse prevention plans, including urgent access to specialist careCommunication about discharge and transition is clear and timely and all involved understand roles and responsibilitiesTransition of service users across pathways is safe and effectiveOutcomesService users and carers are fully informed and involved throughout discharge planning (service user and carer feedback)Lower relapse ratesReduced delayed dischargesReduced average lengths of stayYoung people are supported to transition to adult care pathways safely and effectivelyPROMS, CROMS, PREMSAssessment and FormulationTreatmentDischarge and TransitionACCESSDischarge and Transition Phase of the PathwayChildren & Young PeopleNonPsychosisPsychosisCognitive ImpairmentDischarge and Transition What will happen

Discharge and transition planning is an explicit element of the care planning process with plans formulated collaboratively between service users, carers and providersService users are supported to develop personalised relapse prevention plans, including urgent access to specialist careCommunication about discharge and transition is clear and timely and all involved understand roles and responsibilitiesTransition of service users across pathways is safe and effective

Discharge and Transition the desired outcomes

Service users and carers are fully informed and involved throughout discharge planning (service user and carer feedback)Lower relapse ratesReduced delayed dischargesReduced average lengths of stayYoung people are supported to transition to adult care pathways safely and effectivelyPROMS, CROMS, PREMS16Implementation and What needs to ChangeWe have a good foundation to implement the model of care based on the range of current service provision we have

Successful delivery of the model will require significant cross organisational cultural change and the implementation of new ways of working

The whole system approach to the delivery of mental health care services will require commitment to whole system working by all stakeholders involved

Transformation of existing services to ensure they have the capacity and capability to deliver the desired care pathways

Changes to how and where we allocate resources, taking account of the changing demographics and needs of the people of Northumberland Moving forward, using commissioning and contracting as a lever for driving up service quality, all service specifications with existing providers will be modernised to reflect the key service principles of the model of care. All providers, existing and new, will be required to demonstrate how their services will contribute to the delivery of the model of care and provide agreed performance and safety information including service user outcomes.

The Integration Board will be used to ensure the model of care is strategically aligned, monitor the implementation and delivery of the model and will help to remove any barriers to success

A phase of engagement with key stakeholders, including service users and carers, about the model will now begin

A detailed work plan will be developed and governance arrangements put in place to ensure the successful implementation of the model across Northumberland

17Implementation Work StreamsChildren and Young Peoples Services (CYPS) Tender Children and Young Peoples Service Improvement Transformation of Adult Community Mental Health Services Implementation of Care Pathways and Packages (CPP) Review Primary Mental Health and Psychological Services Transformation of Older Adult Community Mental Health Services Implementation of Care Pathways and Packages (CPP) Dementia Pathway Development Children and Young Peoples Services (CYPS) Tender (September 2013 March 2015) What this will involve: A new service specification that incorporates the Northumberland CYP Emotional Health and Wellbeing strategy and the model of care will be developedThe new service will go out to tender The new service will be live from April 2015Children and Young Peoples Service Improvement (September 2013 March 2015) What this will involve:In parallel with the model development and service tender; we will continue to drive up the standards and quality of existing CYPS with a focus on: Improving access Early identification and intervention Developing service user outcome measuresReallocating resources from Tier 3 to increase capacity in Tier 1 and 2

Transformation of Adult and Older Adult Community Mental Health Services (September 2013 March 2015) What this will involve: Work with existing providers to implement the whole system integration approach to care pathwaysTransformation of existing community services to deliver best practice interventions in line with the model of careImplementation of Care Pathways and Packages (CPP) (September 2013 March 2015) What this will involve:Development of agreed care packages for each clusterAgreement of service user outcome and quality measuresDementia Pathway Development (September 2013 March 2014) What this will involve:Review of existing memory and older adults mental health services Potential service redesign with a focus on:

DiagnosisEarly Identification and InterventionOn-going treatment and supportEnd of life careReview Primary Mental Health and Psychological Services (September 2013 March 2014) What this will involve:Review quality and performance of all current counselling and IAPT services Potential service redesign or service tender

18Implementation Timeline Oct 13 March 14April 14 Sept 14Oct 14 March 15April 15 OnwardsChildren and Young PeopleAdultsOlder AdultsNew Service SpecificationNew Model liveNew Model liveExisting Service ImprovementTender New ServiceTransformation of Community ServicesTransformation of Community ServicesReview Primary MH and Psychological Services Dementia Pathway DevelopmentNew Model livePotentially Tender New ServiceNew Service liveImplementation of Care Pathways and PackagesNew Service live19Questions?20