Title slide
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