Transcript Slide 1

NHS Yorkshire and the Humber
Monthly QIPP resource pack
August 2010
1
Introduction
This is the eighth QIPP monthly resource pack. The pack has three components:
BETTER FOR LESS EXAMPLES: We have worked with you to develop practical examples of schemes
which have been developed locally and have potential to deliver better quality at lower cost. This
month the ‘better for less’ examples focus on mental health.
MENTAL HEALTH ‘HOT TOPIC’: Each month we will produce one ‘hot topic’ briefing which provides
more detailed analysis on a subject relevant to QIPP. This month the hot topic is mental health. The
analyses presented here are designed to offer insight and raise questions about variation in
performance. They need to be interpreted in the local context.
QIPP METRICS: We have developed a set of metrics to help understand system health in the tighter
financial climate. We will publish these metrics monthly although some of the indicators will only be
updated quarterly. The purpose is to offer insight and improve understanding of how the system
delivering with lower growth.
The next resource pack will be published week commencing 6 September. The hot topic will be
cancer. If you have any questions or comments on the pack, please contact Ian Holmes.
([email protected])
2
1) Healthy Ambitions
3
A collaborative approach to commissioning for
out of area placements can significantly reduce
placement costs, improve quality and yield
better outcomes for patients.
Why Out of Area placements?
Around 500 people in Yorkshire & the
Humber are currently supported through a
variety out of area placements. The cost
of these placements to the system is
estimated at £15.6m*.
Out of area placements are necessary in
some circumstances due to the level of
challenge individuals create or the small
number of people nationally needing
specific types of care.
However, for the individual, placements
can make family and community contact
very difficult, lead to a loss of ties and
connections, and make return very
unlikely.
How can we provide better for less?
Working with the Commercial Procurement
Collaborative can help to ensure
consistency of costs, quality and service
for people placed in out of area
placements.
*Data excludes forensics, acute inpatients & PICU
Better for Less – out of area placements
Out of area placements
4
A project led by the regional Specialist
Commissioning Group, is offering a
regional approach to the commissioning
and procurement of high volume high cost
out of area placements.
Patient benefits
Studies have demonstrated that caring for
individuals through local services rather
than out of area placements helps them to
regain independent living skills.
Supporting service users through local
services enables them to maintain family
and community contact, important factors
in mental health wellbeing.
Financial benefits
The Yorkshire & Humber Improvement
Partnership (YHIP) are working to
understand the reliance on out of area
placements in the region. Using early (and
incomplete) data from our region coupled
with national evidence and research a
first estimate of potential savings for the
region has been calculated.
£15.6m was spent in Yorkshire & the
Humber in 2009/10 to deliver out of area
care for around 500 service users, an
average of £31,000 per placement.
Data collected by YHIP found that
commissioners with the lowest cost
placements were paying up to 60% less
than those with the highest cost
contracts.
Better for Less – out of area placements
Out of area placements
5
At an average cost of £31,000, the
potential to save between 30% and 60%
per placement, results in cost savings of
between £9,300 and £18,600 per
placement.
Based on the data collected by YHIP, PCTs
in Yorkshire & the Humber commissioned
between 6 and 111 placements in
2009/10. Using the median value, a PCT
with 23 placements could save an average
of £320,400 through reviewing their use of
placements.
This work to improve procurement has given
increased value for money, supported by
detailed service specifications, quality
measures and stronger market management.
By moving to a new contract and pricing
structure £2.9m was saved initially (4.5% of
the overall total). This will potentially
increase to a saving oh £11 million over the
term of 4 years.
http://www.westmidlands.nhs.uk/LinkClick.
aspx?fileticket=qtm_DHt1SDw%3D&tabid=914
Case Study: West Midlands
For further information:
Y&H Commercial Procurement Collaborative:
[email protected]
West Midlands specialised commissioning
team (WMSCT) has worked across the
West Midlands to commission secure and
other specialists placements.
Y&H Specialist Commissioning Group:
[email protected]
Better for Less – out of area placements
Out of area placements
6
2) Hot topic: Mental Health
7
Contents
Overview
Mental health and employment
Mental health care pathway
Dementia
Annexes
Mental health - Contents
Out of area placements
8
Contents
Overview
Mental health care pathway
Mental health and employment
Dementia
Annexes
Mental health - Contents
Out of area placements
9
Purpose
This information pack is the eighth in a series ‘hot topics’ that will be
produced by the SHA to support organisations in developing their
understanding of some of the challenges and opportunities presented by
the QIPP agenda.
We would be delighted to receive comments on the contents together with
any ideas for further analysis.
Mental health - overview
While recognising that it may raise more questions than answers, we hope
it will stimulate thought and debate within organisations and health
communities. Clearly the data presented need to be interpreted in the
local context.
10
Foreword from the Mental Health Leadership Board
Mental wellbeing is central to the solution in terms of how to achieve QIPP efficiencies
across the whole system. Regardless of the pathway on which a patient is being
treated, there is strong evidence of the QIPP opportunities through maintaining a focus
on mental health and wellbeing within every NHS encounter.
Contemporary mental healthcare is based on the principles of providing quality
evidence-based treatment, predominantly in a community setting. The introduction of
Community Home Treatment teams has led to fewer patients needing hospital
inpatient care. Treatment at home is preferred by service users for its personalised
feel, the evidence suggests comparable clinical and social outcomes to inpatient
settings. In Yorkshire and the Humber there is still wide variation in bed usage.
Commissioners and providers need to consider how to reduce this variation without
compromising safe, effective and personalised care.
Mental health - overview
Particularly for acute care pathways, the use of mental health wellbeing assessments
at the beginning of a spell is shown to improve outcomes for patients: facilitating
speedier recovery and re-enablement. Mental health wellbeing assessments are also a
key component of self-care and directed care models.
11
Overview
Mental illness costs the NHS in our region in excess of £1bn annually. However, it is
estimated that the wider economic burden of mental wellbeing is closer to £10bn.
This resource pack focuses on 3 areas where evidence suggests significant gains in quality
and productivity can be achieved:
• Dementia care - particularly relating to acute episodes
• Out of area placements
• Mental health care pathway
Mental health - overview
Times of economic slowdown are particularly challenging for mental health services, with
numerous studies linking joblessness and other economic pressures with poorer mental
health. It is against this backdrop of rising demand for mental health services that the
NHS will have to deliver the biggest programme of efficiency savings in its history. The
scale of the challenge is significant, but we know that there are a number of areas where
better care can cost less by:
• Focusing on earlier identification and preventative services
• Redesigning pathways to support care in the most appropriate setting
• Ensuring that when patients with mental health problems require acute care they
receive care that reflects their more complex needs
• Recognising that understanding mental health and wellbeing issues is key to all
care pathways, particularly recovery and rehabilitation
12
Overview - prevalence and future costs
Prevalence of any neurotic disorder (based on 2006 populations)
In England at any one time, 1 in 6 people
will experience a diagnosable mental
health problem. Mental illness covers a
broad spectrum of conditions, and
prevalence varies significantly by PCT.
PCT
197.2
190.1
Bradford & Airedale
187.1
Calderdale
182.7
Kirklees
178.2
Wakefield District
177.8
Sheffield
171.7
Doncaster
162.2
Barnsley
161.9
Rotherham
159.2
NE Lincolnshire
159.1
N Yorkshire & York
135.3
E Riding of Yorkshire
125.6
N Lincolnshire
119.8
0
20
40
60
80
100
120
140
160
180
200
Prevalence of any neurotic disorder, rate per 1000 population
Source: Mental Health Observatory 2008
QOF data reflects the prevalence of more
severe conditions. The proportion of
patients on registers varies across the
region, the average for Yorkshire & Humber
is below England. The ability of QOF to
reflect actual prevalence relies on people
with such problems consulting their GP and
GPs adding their patients to mental health
registers.
Mental health - overview
Psychological therapies are used to treat
milder conditions (neurotic disorders). Data
about these services demonstrates a range
of prevalence from less than 120 per 1,000
population to more than 197.
Hull
Leeds
Mental Health Prevalence - Percentage of patients on G
Mental Health Prevalence - Percentage of patients on GP lists that are on
QOF mental health registers 2008-09
QOF mental health registers 2008-09
PCT
PCT
England
Leeds
0.86
Bradford & Airedale
0.83
0.78
Kirklees
0.78
Calderdale
0.77
Calderdale
0.77
Hull
0.73
Hull
0.73
Yorks & Humber
0.73
Yorks & Humber
0.73
Sheffield
0.72
Sheffield
0.72
NE Lincolnshire
0.71
NE Lincolnshire
0.71
Rotherham
0.71
Rotherham
0.71
N Lincolnshire
0.69
N Lincolnshire
0.69
Wakefield District
0.68
Wakefield District
0.68
N Yorkshire & York
0.66
N Yorkshire & York
0.66
Doncaster
0.65
Doncaster
0.65
Barnsley
0.61
Barnsley
E Riding of Yorkshire
0.53
0.61
E Riding of Yorkshire
0.53
Leeds
0.86
Bradford & Airedale
0.83
Kirklees
0.0
0.2
0.4
0.6
0.0
Mental health prevalence (%)
Source: Health and Social Care Information Centre (IC) 2009
0.8
1.0
0.2
0.4
Mental health p
Source: Health and Social Care Information Centre (IC) 2009
13
Overview - variation in expenditure
East Yorkshire
Bradford
Doncaster
Rotherham
Hull
North Yorkshire
NE Lincolnshire
Calderdale
Leeds
Wakefield
Barnsley
Sheffield
Kirklees
To what extent does this variation
reflect greater service need or
relate to quality of care?
North Lincolnshire
£0
£50
£100
£150
£200
Source: Y&H LIT Results of Financial Mapping Report’s 2009/10 ,
DH/Mental Health Strategies
The 2009/10 data was collected based on LITs, this
organisational structure ceased to be in existence
earlier this year. Local Implementation Teams (LITs)
were coterminous with PCTs, responsible for
progressing mental health work streams with
responsibility for both NHS and non-NHS spend.
£250
Mental health - overview
(For more information on the source
of this finance data see Annex B).
Y&H Average
England Average
Local Implementation Team
Average spend on mental health per
weighted population in Yorkshire &
the Humber is less than the national
average. The regional average
however masks large variation
across Local Implementation Teams.
Total Cost of Adult Mental Health per Weighted Population Aged 18 to 64 - 09/10
14
Contents
Overview
Mental health care pathway
Mental health and employment
Dementia
Annexes
Mental health - Contents
Out of area placements
15
National and regional policy
direction over a number of
years has been to increase
emphasis on prevention and
provision of care in community
settings over acute and other
secondary care settings.
The table opposite from the
National Mental Health
Development Unit sets out an
illustrative example of how the
pattern of care may shift over
the next 5 years.
Changing mental health investment profiles - £s...
Investment
Levels
Prevention,
public mental
health
Primary/
social care,
housing, day
resources
Community
teams liaison
services
Other
secondary continuing
care
Acute inPatient
Specialised
and Secure
Services
2010/11
£0.5m
£11m
£10m
£11m
£20m
£8.5m
2015/16
£4.5m
£14m
£11m
£6m
£14m
£5.5m
[NB: Values illustrative only]
NMHDU (National Mental Health Development Unit)
The profile of mental health services has already been to reflect these patterns of
provision – for example, nationally, there are one third less mental health beds now
compared with 15 years ago. But the rate of change has varied considerably across our
region, and there is large variation in the way services are currently delivered.
Mental health – mental health care pathway
Care pathway – Overview
16
The national Improving Access to Psychological Therapies (IAPT) programme is aimed at improving access
for everybody with common mental health problems of depression and anxiety in primary & other
community settings. The National Institute of Health and Clinical Excellence (NICE) has recognised the
contribution that psychotherapeutic treatments (see annex C for examples) can make to the care of
people with a wide range of debilitating mental and physical illnesses (CSIP, 2007).
IAPT has been rolled out in 3 waves. The
variation illustrated in the chart reflects the
wave at which IAPT has been implemented. The
higher values for sites with developed IAPT
services demonstrates the effectiveness of the
programme in implementing mental health
services in the primary & community settings.
Once IAPT is fully implemented and matured it is
expected that 50% of people completing
treatment would move to recovery. 4 LITs in our
area already have services exceeding this target.
Percentage of people who have completed IAPT treatment and achieved "caseness"
at initial assessment who are "moving to recovery", Q4 2009/10
East Riding of Yorkshire
85.5%
Kirklees
65.4%
North Lincolnshire
60.0%
Calderdale
55.9%
Rotherham
45.6%
Doncaster
44.5%
Leeds
39.5%
Yorkshire & the Humber
39.0%
Sheffield
38.7%
Barnsley
38.5%
North East Lincolnshire
32.4%
Wakefield District
9.3%
Hull
3.2%
North Yorkshire & York
-
Bradford & Airedale
-
0%
20%
40%
60%
80%
100%
% of people completing treatment and achieved "caseness" at initial assessment "moving to recovery"
“Caseness” defines the level of mental illness
at which an individual will benefit from
treatment. It is a threshold for a standardised
measure of symptoms defined using: the
General Anxiety Disorder Assessment (GAD7)
and the Patient Health Questionnaire (PHQ9).
Source: Omnibus Survey Q4 2009/10 (Health and Social Care Information Centre (IC))
Completing treatment includes those that dropped out or were sign posted on
Note: Low numbers are likely to reflect later wave
adopters of IAPT.
Mental health – Mental health care pathway
Care pathway – psychological therapies
17
In North Lincolnshire, the IAPT programme has been used to further enhance services
offered. Using IAPT standard data for a sample of 38 patients, a comprehensive “clinical
medication review” was undertaken by an IAPT nurse.
Of the patients included, only one had clinical need for extended use of antidepressant
medication as defined by NICE Guidance. In light of the findings, the others were either
helped to stop, referred on or treatment changed with positive outcomes.
Savings from the project were defined as the reduction in costs (based on current
treatment pricing) as a result of no longer prescribing inappropriate treatments. Through
prescribing in accordance with NICE guidance, this small project produced a cost saving
of £17,500. 6 patients successfully stopped using anti-depressants, and 7 successfully
reduced use.
As a result of the pilot RDASH has seconded a full-time nurse prescriber to continue the
work across the organisation and GP practices to release more cost savings.
Mental health – Mental health care pathway
Care pathway - psychological therapies: example
18
Average Direct Cost per Weighted Adult on the Top 5 Highest spend Adult
Mental Health Serivces in Y&H, plus IAPT
The pie chart shows the major sections of
direct cost for all types of adult mental
health services across Yorkshire & the
Humber.
£32.2
Secure and High Dependency
Provision
Clinical Services
Continuing Care
The chart below shows the ratio of spend
on services accessed by people with
general mental health needs:
- clinical (secondary care) services,
- community mental health teams and,
- access and crisis services.
To what extent are PCTs with relatively
high secondary (clinical) care spend
assessing the options for shifting care into
community settings?
£3.2
Community Mental Health Teams
Access & Crisis Services
£22.9
£17.6
Psychological Therapy Services (IAPT)
Other
£18.6
£20.2
Direct cost per weighted population (18-64) on: clinical services,
access & crisis services and community mental health teams (2009/10)
Local Implementation Team
Whilst the ideal pattern of care will differ
across different localities, reflecting
patient needs and geography, over time we
would anticipate the proportion of care
delivered in secondary care to decline and
be replaced by primary and community
services.
£32.6
England Average
Y & H SHA Average
Leeds
North Yorkshire
North Lincolnshire
NE Lincolnshire
Barnsley
Sheffield
Hull
Wakefield
Rotherham
Doncaster
Bradford
Kirklees
Calderdale
East Yorkshire
0%
Clinical Services
20%
40%
Access & Crisis Services
60%
80%
100%
Community Mental Health Teams
Mental health – Mental health care pathway
Care pathway– community vs secondary care
19
Rates of community mental health
services are calculated to take account
of different needs of the local
populations.
Early intervention services are for
younger adults aged 15-34 who have
had their first psychotic episode.
Home treatments provided by crisis
resolution teams are for adults with
more longstanding mental health
problems.
There is no apparent correlation
between PCTs providing comparable
levels of both types of service. East
Riding for example has one of the
lowest rates of early intervention but
above average home treatment
episodes.
People receiving early intervention services by commissioner, rates per 100,000
weighted adult population, Q4 2009-10
PCT
North Lincs
79
Sheffield
78
Wakefield
78
Calderdale
76
Rotherham
75
Barnsley
75
Brad&Aire
74
Doncaster
73
Hull
72
Kirklees
72
Yorks & Humber
64
N East Lincs
59
North Yorks
45
East Riding
42
Leeds
41
0
20
40
60
80
100
People receiving early intervention services, rates per 100,000 weighted adult population
Source: VSMR data (SHA) 2010
Home treatment episodes by commissioner, rates per 100,000 weighted adult
population, Q4 2009-10
PCT
Calderdale
454
Wakefield District
437
Kirklees
419
N Yorkshire & York
411
E Riding of Yorkshire
385
NE Lincolnshire
382
Yorks & Humber
365
Doncaster
358
Leeds
351
Sheffield
344
N Lincolnshire
338
Barnsley
335
Bradford & Airedale
333
Hull
328
Rotherham
311
0
100
200
300
400
Home treatment episodes, rates per 100,000 weighted adult population
Source: VSMR data (SHA) 2010
500
Mental health – Mental health care pathway
Care pathway - Community mental health services
Considerable variation exists across
the region in the number of
admissions to mental health inpatient
services.
A reduction in admissions and LOS
could free up substantial resources for
some PCTs
Admissions to mental health inpatient services by commissioner, rates
per 100,000 weighted population 2008-09
England
PCT
Wakefield District
460
Brad fo rd & Aired ale
448
N Yorkshire & York
400
N Lincolnshire
386
Ro th erham
352
NE Lincolnshire
346
Yo rks & Humber
298
Barnsley
277
Kirklees
255
Doncaster
246
Calderdale
236
Leed s
224
Hull
223
Sh effield
174
E Riding of Yorkshire
165
0
Early calculations by YHIP indicate
that reducing admissions rates in line
with the best performing trusts could
free up £25 million across the region.
100
200
300
500
Source: Health and Social Care Information Centre (IC) 2009
Distribution of average length of stay in a psychiatric hospital, by
provider, 2008/09
Distribution of average length of stay in a psychiatric h
under 1 month
1-2 months
2-3
months 2008/09
3months - 1 year
Over 1 year
provider,
Provider
NE Lincolnshire Care Trust Plus
Provider
under 1 month
1-2 months
NE Lincolnshire Care Trust Plus
Barnsley PCT
Barnsley PCT
Sheffield Care Trust
There is wide variation in the length
of stay profile of providers in the
region however, average performance
is in line with England.
400
Admission rates per 100,000 weighted population
Mental health – Mental health care pathway
Care pathway – acute care services
Sheffield Care Trust
Bradford District Care Trust
Rotherham, Doncaster & S
Humber MH NHS FT
Bradford District Care Trust
N Yorkshire & York PCT
Rotherham, Doncaster & S
Humber MH NHS FT
Humber MH Teaching NHS Trust
N Yorkshire & York PCT
Yorks & Humber
Humber MH Teaching NHS Trust
SW Yorkshire Partnership NHS FT
Yorks & Humber
ENGLAND
SW Yorkshire Partnership NHS FT
ENGLAND
Leeds Partnerships NHS FT
Leeds Partnerships NHS FT
0%
20%
40%
60%
80%
100%
Percentage of records in Mental Health Minimum
Data Set 20%
0%
Source: Health and Social Care Information Centre (IC) 2009
2-3 m
40%
Percentage of record
Source: Health and Social Care Information Centre (IC) 2009
21
Personality disorders are common conditions, between 5% and 13% of people living in
the community suffer with such problems and between 50% and 70% of the prison
population are affected.
The psychological, social and economic consequences of personality disorder affect not
only the individual but families, friends, communities and society in general. Some
people survive asking little of public or voluntary services; others use a range of
services of varying benefit. Although sufferers may access A&E departments and
primary care services, these contacts are not able to respond to the real needs of such
patients.
The Personality Disorder Development Programme was established in 2003 and is based
in the Department of Health and Ministry of Justice. This programme has overseen
investment in national pilot services to test ways of developing new local responses.
The outcomes of the pilot based in Leeds suggest:
-investment in dedicated multi agency personality disorder services substantially
improve outcomes for the population
- investment significantly reduces the impact on wider mental health services and the
wider health care, social care and criminal justice systems
Mental health – Mental health care pathway
Care pathway – personality disorders
22
Following the pilot scheme in Leeds, an audit project has been undertaken to
determine the effectiveness of a dedicated personality disorder resource.
Data for a cohort of individuals that access the Leeds Managed Clinical
Network for personality disorder has been compared with a relative cohort
from Sheffield.
In a sample of 22 patients (typically 75 cases will access services at any given
time) the following outcomes were observed:
- 60% reduction in acute mental health service admissions
- 100% reduction in PICU admission
- 20% reduction in A&E attendances
The reduction in health care service usage resulted in net savings of £104k,
service users reported improved satisfaction and clinical outcomes.
Mental health – Mental health care pathway
Care pathway – personality disorders (2)
23
Contents
Overview
Mental health care pathway
Mental health and employment
Dementia
Annexes
Mental health - Contents
Out of area placements
24
Out of area placements include long term placements in hospital or residential & nursing
homes.
The challenge of placements results from the need for PCTs to commission from multiple,
often independent sector providers creating variation in costs and quality to meet
additional demand. These arrangements lack consistent service specifications and
performance monitoring arrangements and usually are much more expensive than services
that are provided through normal contracting routes.
Out of area placements are necessary in some circumstances due to the level of challenge
individuals create or the small number of people nationally needing specific types of
care. However, for the individual, placements can make family and community contact
very difficult, lead to a loss of ties and connections, and make return very unlikely.
The Royal College of psychiatrists estimates that 22% of all people in placements are in out
of area treatments. A recent survey by the Royal College showed that out of area
treatments are 65% more expensive than in-borough placements (£34,000 vs £21,000).
In 2009/10 Yorkshire & the Humber had approximately 500 episodes of out of area
placements. PCTs in Yorkshire & the Humber commission services from 11 NHS providers
across the country and 17 private provider organisations.
Mental health - Out of area placements
Out of area placements - overview
25
Out of area placements – expenditure
Scaling up the data submitted to account for missing
data points, commissioners in Yorkshire & the Humber
spend approximately £15.6m on out of area specialist
mental health placements.
The available data indicates wide variation in the
types of OAP being utilised by each commissioner
group. Whilst the data is not sensitive to the
complexities of individual cases, high level
comparisons suggest more than 2 fold variation in the
costs of placements.
Eating disorders and locked rehabilitation account for
the highest volume and highest cost out of area
placements* – over £10m in regional spend. There is
also wide variation in the associated costs across the
region, commissioners should consider both as areas
for high potential savings.
While eating disorders are the highest area of spend,
the mental health board believe that locked rehab
offers the greatest potential for savings - A high
volume of spot contracts are used for these
placements in area which are not reflected in the
data.
Estimated total cost of placements by type 2009/10
£7,000,000
£6,000,000
£5,000,000
£4,000,000
£3,000,000
£2,000,000
£1,000,000
£0
Placement type
Bed day cost Min
(£)
Max
Eating disorder Rehabilitation
332
410
850
920
* The survey excluded accurate data collections
relating to acute and PICU placements, these
are the highest cost & volume placements in
the region.
Mental health - Out of area placements
The following information for Yorkshire & the Humber
is based on initial and incomplete data returns from
commissioners in the region.
26
Out of area placements - opportunity
In the shorter term, the high cost of oats can be reduced through improved commissioning. The
potential for localities in the Yorkshire and Humber region to realise cost efficiencies and improved
quality outcomes as a result of reviewing their utilisation of out of area placements is variable and is
dependent upon their:
- unique circumstances,
- resource provision and,
- service configuration.
(http://www.rcpsych.ac.uk/press/pressreleases2010/oats.aspx)
Working with the Commercial & procurement Collaborative can help to ensure consistency of costs,
quality and service for people placed in out of area placements. A project, led by the regional
Specialist Commissioning Group, is offering a regional approach to the commissioning and procurement
of high volume high cost out of area placements.
The model seeks to generate competitive markets where appropriate to incentivise competition
amongst providers to improve patient outcomes and deliver improved value for money. Experiences in
East & West Midlands have successfully reduced costs and generated savings for the commissioners
involved.
Mental health - Out of area placements
Nationally, around £330m is spent annually on out of area treatments at a net additional cost of £134m
relative to local services. The majority of oats are thought to be replaceable, reducing the net cost by
half would generate savings in the region of £6.7m per SHA. The lack of local services is a significant
obstacle to realising savings.
27
Contents
Overview
Mental health care pathway
Mental health &
employment
and
employment
Dementia
Annexes
Mental health - Contents
Out of area placements
28
The Yorkshire and Humber Improvement
Partnership (YHIP) have estimated the cost of
mental illness across our region to be £9.3bn;
this estimate is based on total system costs for
services and employers spend.
Projections by the Kings Fund suggest an
increased pull on the mental health system as a
consequence of rising unemployment occurring
in times of fiscal prudence. Access to
employment and meaningful activity is as such,
highly relevant in this respect.
Evans, Francis 2009
Where people recover from mental illness and return to work, evidence shows that there are
savings not only in lower welfare spending, but also that individuals make less use of public
services, including mental health services (Sainsbury Centre for Mental Health, 2009b).
As a result of work commissioned by YHIP, a tool to support the evaluation and costing of
potential savings through employment strategies that will encourage better decision making
will be available next year. The work will also determine the most effective employment
based on cost benefit analysis.
Mental health – Mental health & employment
Mental health and employment - Overview
29
There is strong evidence on the
therapeutic benefits of paid
employment and the likely long
term savings to the health
system (Drake 2009). Work
provides protection against
mental illness( Foresight) and
has a strong therapeutic value,
especially for people with
severe and enduring mental
health conditions (NICE,
McLean & Carmona 2005).
Percentage of adults receiving secondary mental health services
known to be in paid employment at time of most recent assessment,
formal review or multi-disciplinary care planning meeting 2008-09
England
North East…
8.7
Calderdale
8.0
Sheffield
7.5
Leeds
5.2
Wakerfield District
3.4
Yorkshire & the… 3.2
Doncaster
2.4
North Yorkshire &… 2.0
Kirklees
1.9
East Riding of… 1.8
Rotherham
1.4
Bradford & Airedale
0.8
Barnsley
0.8
North Lincolnshire
0.0
Hull
0
2
4
6
8
10
% of adults receiving secondary MHS in paid employment
Source: Health and Social Care Information Centre (IC) 2010
There is wide variation in the proportion of adults using secondary mental
health services known to be in paid employment. The local economy and labour
market conditions will have a significant role in determining employment levels
in conjunction with services offered to individuals. The average for the region is
below the national average.
Mental health – Mental health & employment
Mental health & employment - settled employment
30
The Individual Placement Support (IPS) model helps people with mental health
problems into paid competitive work.
A multi-site European trial found that individual placement support clients had fewer and
shorter hospital stays than clients in traditional services (Burns et al, 2007), which contributed
to significant savings in in-patient costs over an 18-month period. A US study recently
corroborated these findings: mental health service costs over a 10-year period were 50% lower
for people supported into regular employment than among other groups (Bush et al, 2009).
The annual cost of implementing IPS in line with government commissioning guidance on
vocational services is estimated at around £6.7 million per SHA, £440,000 per average PCT. In
comparison, current spending on day and employment services is around £18.4 million a year.
There are a range of tools to help with this including:
- Vocational Guidance for Commissioners (DH/DWP) and;
- Implementing Recovery, a Model for Organisational Change (Sainsbury Centre for Mental Health
2010).
There is a strong argument for recovery focussed delivery within mental health, with investment
in effective vocational rehabilitation at it’s core.
Mental health – Mental health & employment
Mental health & employment - example
31
Contents
Overview
Mental health care pathway
Mental health and employment
Dementia
Annexes
Mental health - Contents
Out of area placements
32
Dementia - overview
The National Dementia Strategy (NDS) published by The Department of Health in 2009 has brought a
long overdue focus to the types of services and supports offered to the estimated 820,000 people
directly affected in the UK.
“Dementia describes a group of symptoms associated with a progressive decline of brain functions, such
as memory, understanding, judgement, language and thinking. The most common form of dementia is
Alzheimer’s disease.”
The scale of resources required to support dementia sufferers each year is almost 5 times more than
other cancer:
Dementia
£27,647
Cancer
£5,999
Stroke
£4,770
Heart Disease
£3,445
Dementia diagnoses are often made at the time of crises that could have potentially been avoided.
Dementia patients often also have a much poorer experience and worse outcomes associated with
other pathways, especially urgent care.
Mental health - Dementia
“People with dementia become increasingly dependent on health and social care services and on other
people. Dementia has a significant economic impact: the total cost of dementia in terms of care and
lost productivity is estimated at £23 billion across the UK. (The Alzheimer’s Research Trust)
33
Dementia - Overview
Around 60,000 people in Yorkshire and the
Humber suffer from dementia.
Across the UK, healthcare costs for dementia
are £1.3bn (where dementia is the primary
diagnosis), of which 44% is spent on hospital
inpatient stays.
63% of all spend on dementia is on care home
costs. This includes both self funders and
social services monies.
Source: Adapted from Knapp et al (2007) Dementia UK and the King's Fund (2008) Paying the Price
NOTE Direct costs of dementia exclude informal care costs of £5.8 billion borne by families. Two-thirds of
the direct costs, £6.42 billion, relate to the provision of care home places for people with dementia and are
split
Mental health - Dementia
At present there is significant underdiagnosis of dementia across our region and
it is estimated that approximately 60% of
cases in our region are undiagnosed. East
Riding of Yorkshire having the highest
estimated level of under-reporting (27% of
cases identified) and Bradford and Airedale
having the lowest levels of under-reporting
(51% of cases identified).
34
Dementia – future trends
Dementia incidence and prevalence increases as the population ages. Between 2008 and
2025, prevalence is forecast to rise by 51% across Yorkshire and the Humber. The LA
area expected to experience the highest growth is East Riding (78%) and the lowest
growth is expected in Sheffield (33%).
Chart 5: Number Predicted to have Late On-set Dementia
Yorkshire & Humber 2008 & 2025 by Local Authority District
20,000
68%
13,876
33%
47%
70%
52%
31%
2,928
1,932
3,308
1,947
3,274
2,222
2,360
3,461
% Change
3,850
2,523
3,304
2025
4,397
5,059
2,795
4,000
3,347
3,587
4,170
5,641
6,245
2008
2,493
8,130
4,563
4,873
6,084
6,861
8,047
Le
ed
s
8,000
8,108
10,872
8,264
sh
ire
12,000
C
al
de
rd
N
al
or
e
th
Li
nc
ol
ns
hi
N
re
E
Li
nc
ol
ns
hi
re
or
k
Y
sl
ey
B
ar
n
H
ul
l
te
r
he
rh
am
R
ot
D
on
ca
s
ld
ak
ef
ie
W
irk
le
es
K
R
id
in
g
d
ra
df
or
B
fie
ld
he
f
S
as
t
E
th
Y
or
k
0
N
or
Number Aged 65 Years & Over
47%
41%
35%
16,000
54%
51%
50%
Source: Using Projecting Older People Population Information System - Crown Copyright 2007
Mental health - Dementia
57%
57%
78%
35
Dementia – medication and prescribing
Figure 1: Yorkshire & The Humber PCTs: Weighted Prescribing of Low doses of Olanza
5mg), Risperidone (500 micrograms & 1mg), Haloperidol (500 micrograms & 1mg & 1.5m
(5mg
&10mg)
Weighted prescribing costs(25mg)
(per and
100Aripiprazole
dementia
patients)
of
April 2007 - March 2010
all relevant low dose anti-psychotics (2009/10)
4500
A Department of Health commissioned review of
anti-psychotic drugs prescribing for dementia
found an unacceptable level of elderly people
dying with dementia as a result of their prescribed
4000
medication.
Figure 1: Yorkshire & The Humber PCTs:
Bar
Weighted Prescribing of Low doses of Olanzapine (2.5mg &
5mg), Risperidone (500 micrograms & 1mg), Haloperidol (500 micrograms & 1mg & 1.5mg), Quetiapine
(25mg)
3500 and Aripiprazole (5mg &10mg)
from the use of
April 2007 - March 2010
DDD/100 dementia patients
Cal
DDD/100 dementia patients
4500
DDD/100 dementia patients
The government’s response to the report stated
that “people with dementia should only be
offered
anti-psychotics if they are severely
4000
3000
distressed or there is an immediate risk of harm to
the person or others. The NHS locally should be
following
NICE guidance and PCTs have a
3500
responsibility to ensure that this2500
happens.”
3000
Eas
Hul
Kirk
Lee
Nor
Nor
Nor
Barnsley
Rot
Bradford & Airedale
Wa
Calderdale
2000
3500
Don
She
Doncaster
East Riding of Yorkshire
Hull Teaching
1500
0809Q1
2000
0809Q2
0809Q3
0809Q4
0910Q1
Kirklees
0910Q2
0910Q3
Barnsley
Leeds
Bradford & Airedale
North East Lincolnshire Care Trust Plus
Calderdale
North Lincolnshire
Doncaster
North Yorkshire & York
East Riding of Yorkshire
Rotherham
Hull Teaching
Wakefield District
Kirklees
Sheffield
0910Q4
Leeds
DDD (Defined Daily
Dose system): Value assigned to
North Lincolnshire
North Yorkshire & York
each 0910Q1
drug 0910Q2
representing
assumed average
0809Q4
0910Q3
0910Q4
Rotherham
maintenance dose/day
when used for its main
Wakefield District
Sheffield
indication in adults.
North East Lincolnshire Care Trust Plus
2500
1500
0809Q1
0809Q2
0809Q3
2000
1500
0809Q1
0809Q2
0809Q3
0809Q4
0910Q1
0910Q2
0910Q3
Mental health - Dementia
There is little evidence of benefit
antipsychotics in elderly patients4500
with dementia,
yet there is evidence of an increased incidence of
3000
stroke in the short term, and increased mortality
in the short Figure
and longer
term.
The
levelPCTs:
of Weighted Prescribing of Low doses of Olanzapine (2.5mg &
1: Yorkshire
& The
Humber
4000
2500
5mg), Risperidone
(500 micrograms
1mg),
Haloperidol (500 micrograms
& 1mg & 1.5mg), Quetiapine
increased mortality
was found
to be 10 &for
every
(25mg) and Aripiprazole (5mg &10mg)
1000 patients over 12 weeks.
April 2007 - March 2010
Bra
0910Q4
36
Figure 2:45
Yorkshire & The Humber PCTs: Low Dose Risperidone (500 micrograms and 1mg)
as a Percentage of All Risperidone Prescribing
Dementia – medication and prescribing
ADQ percentage
50
45
30
35
ADQ percentage
ADQ percentage
50
40
Prescribers should continue to follow NICESCIE guidelines on dementia which advises
avoiding the use of any antipsychotics for
non-cognitive symptoms or challenging
behaviour of dementia unless the patient is
severely distressed or where there is a risk
of immediate harm to them or others.
Calderdale
Doncaster
Figure
& The Humber PCTs: Low Dose Risperidone (500 micrograms
Barnsley 2: Yorkshire Leeds
as a Percentage of All Risperidone Prescribing
35
25
Bradford & Airedale
Quarterly low-dose risperidone
as a percentage of all
East Ridingprescribing
of Yorkshire
Hull Teaching
risperidone
prescribing 2009/10
Kirklees
40
The harms and limited benefits of using
antipsychotic drugs both first generation
typical and second generation (atypical)
for the treatment of people with
dementia, who exhibit challenging
behaviours is well recognised.
45
Barnsley
40
Bradford & Airedale
North East Lincolnshire Care Trust Plus
Calderdale
North Lincolnshire
Doncaster
North Yorkshire & York
East Riding of Yorkshire
Rotherham
Hull Teaching
Wakefield District
Kirklees
Sheffield
B
Leeds
B
North East Lincolnshire Care Trust Plus
C
North Lincolnshire
D
North Yorkshire & York
E
Rotherham
H
0708Q1 0708Q2 0708Q3 0708Q4 0809Q1 0809Q2 0809Q3 0809Q4 0910Q1 0910Q2 0910Q3 0910Q4
30
L
Sheffield
35
30
0708Q1 0708Q2 0708Q3 0708Q4 0809Q1 0809Q2 0809Q3 0809Q4 0910Q1 0910Q2 0910Q3 0910Q4
Figure 3: Yorkshire & The Humber PCTs: Weighted Prescribing of Risperidone
January - March 2010
25
Hull Teaching
0708Q1 0708Q2 0708Q3 0708Q4 0809Q1 0809Q2 0809Q3 0809Q4 0910Q1 0910Q2 0910Q3 0910Q4
North East Lincolnshire Care Trust Plus
Figure 3: Yorkshire
The Humber
PCTs: Weighted
Weighted Prescribing
of Risperidone
Figure 3: Yorkshire
& The&Humber
PCTs:
Prescribing
of Risperidone
Kirklees
January - March 2010
January - March 2010
PCTs should review their prescribing of low
dose antipsychotics using practice registers
Hull Teaching
and where appropriate work with clinical
North East Lincolnshire Care Trust Plus
colleagues to revise prescribing at local
Kirklees
level.
Leeds
Hull Teaching
North East Lincolnshire Care Trust
Plus
Bradford
Kirklees
Leeds
Bradf ord & Airedale
Leeds
& Airedale
Calderdale
Calderdale
Rotherham
Barnsley
Rotherham
East
Riding of Yorkshire
Bradf ord & Airedale
Barnsley
Doncaster
East Riding of Yorkshire
Calderdale
Wakefield District
Doncaster
Rotherham
North Lincolnshire
ADQ: Average Daily Quantity. This represents the assumed
Wakef ield District
North Lincolnshire Sheffield
Barnsley
average maintenance dose per day for a drug used for its
Shef f ield
North Yorkshire & York
main indication in adults. It is based upon prescribing East Riding of Yorkshire
North Yorkshire & York
behaviour within England, and is an analytical unit used to
0
Doncaster
0
compare treatment activity, not a recommended dose.
500
500
Risperidone_Tab
1mg
Risperidone_Tab
1mg
North Yorkshire & York
1500
Risperidone_Tab
500 micrograms
Others
Risperidone_Tab
500 micrograms
Risperidone_Orodisper Tab 4mg S/F
1500
2000
2000
2500
2500
Others
3000
Risperidone_Orodisper Tab 500mcg S/F
Risperidone_Orodisper Tab 3mg S/F
Risperidone_Orodisper Tab 4mg S/F
Risperidone_Orodisper Tab 2mg S/F
Risperidone_Orodisper Tab 1mg S/F
Risperidone_Orodisper Tab 2mg S/F
Shef f ield
1000
ADQ/100
dementia patients
ADQ/100 dementia
patients
Wakef ield District
North Lincolnshire Risperidone_Orodisper Tab 3mg S/F
1000
Mental health - Dementia
25
K
Wakefield District
Risperidone_Orodisper Tab 1mg S/F
Risperidone_Orodisper Tab 500mcg S/F
37
N
N
N
R
W
S
3
Dementia - acute health care needs
Across the 3 groupings an average of 95%
of admissions of people with dementia
were emergencies. This can reflect the
relatively chaotic way patients receive
care and the poor management of their
condition.
Given the low rate of diagnosis on page 1
it is likely that many of these do not have
effective community case management
arrangements in place which result in
admission to hospital beds in crisis
situations.
Admission Method of Patients in Yorkshire & Humber Acute
Trusts with a Secondary Diagnosis of Dementia 2008/09
Emergency - via A & E
69.1%
Emergency - via GP
16.4%
Emergency - via Bed Bureau
5.5%
Elective
4.3%
Emergency - via other means
2.8%
Transfer from other hospital
provider
1.2%
Emergency - via consultant
outpatient clinic
0.7%
0%
10%
20%
30%
40%
50%
60%
Percentage of total episodes in 2008/09
70%
80%
Mental health - dementia
An analysis of recent admissions of people
with dementia to an acute hospital bed over
a 12 month period 08/09 identified 3 key
groups:
-Those with a primary diagnosis of dementia
-Those with a secondary diagnosis of
dementia
-Those with a diagnosis of senility of which
95% also have dementia
38
Dementia - acute health care needs
Treatment Specialty in Yorkshire & Humber Acute Trusts for
Episodes with a Secondary Diagnosis of Dementia 2008/09
Geriatric Medicine
42.7%
General Medicine
26.9%
Trauma & Orthopaedics
5.8%
Other specialties
5.8%
Respiratory Medicine
4.2%
General Surgery
3.8%
Gastroenterology
3.1%
Accident & Emergency
2.6%
Diabetic Medicine
1.9%
Urology
1.8%
Cardiology
5%
10%
15%
20%
25%
30%
35%
40%
Percentage of total episodes in 2008/09
Median Length of Stay, with interquartile range, of Patients in Yorkshire &
Humber Acute Trusts with a Diagnosis of Dementia 2008/09
35
30
Length of stay (days)
Although there is variation in length
of stay across the 3 groups, overall it
was lower than what was expected.
The findings were consistent with the
recent Nuffield Trust report 2010
which identified an 11.8% rise in
emergency admissions over the last 5
years and a noticeable increase in
short stay admissions.
1.3%
0%
25
20
15
10
5
0
Primary diagnosis of dementia
Secondary diagnosis of dementia
Primary diagnosis of senility
45%
Mental health - Dementia
A high percentage of admissions are to
medical wards with chest infections
and urinary tract infections as primary
reasons for admission. The latter
diagnosis is consistent with a
breakdown in carer support as a
critical trigger to admission to
hospital beds.
39
Dementia - acute health care needs
The chart opposite confirms the national evidence
that an admission to an acute hospital bed for a
patient with dementia is associated with an
increased risk of admission to a care home and
increase risk of mortality. Overall, the physical
health and psychological outcomes for people with
dementia in acute hospitals are poor.
A recent NHS Confederation Report “Acute
Awareness” (2010) suggested that up to 50% of all
dementia on acute and general hospital wards was
undiagnosed.
A local clinical audit and national prevalence rates
would suggest that it is likely that the true
incidence in acute hospitals is in excess of 900,000
OBDs at a cost of up to £196m in Yorkshire &
Humber.
Usual place of residence
70.3%
Death
14.9%
Non-NHS run care home
6.1%
NHS other hospital provider
2.9%
NHS run care home
2.8%
Other
1.8%
Temporary place of residence
1.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Percentage of total episodes in 2008/09
Acute Trusts
Total
Beddays
OBDs
Dementia
%
Dementia
-v- Total
AIREDALE NHS TRUST
104,622
10,169
10
BARNSLEY HOSPITAL NHS FOUNDATION TRUST
143,097
11,838
8
BRADFORD TEACHING HOSPITALS NHS FOUNDATION TRUST
230,093
17,024
7
CALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST
288,504
28,562
10
DONCASTER & BASSET LAW HOSPITALS
217,280
34,073
16
HARROGATE & DISTRICT NHS FOUNDATION TRUST
103,629
10,362
10
HULL & EAST YORKSHIRE HOSPITALS NHS TRUST
415,438
22,977
6
LEEDS TEACHING HOSPITALS NHS TRUST
627,056
47,736
8
MID YORKSHIRE HOSPITALS NHS TRUST
378,272
33,641
9
SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST
555,358
66,533
12
NORTHERN LINCOLNSHIRE AND GOOLE HOSPITALS NHS FOUNDATION
TRUST
222,159
10,200
5
SCARBOROUGH AND NORTH EAST YORKSHIRE HEALTH CARE NHS TRUST
112,842
6,162
5
THE ROTHERHAM NHS FOUNDATION TRUST
170,785
18,423
11
YORK HOSPITALS NHS TRUST HQ
215,127
20,883
10
3,784,262
338,583
9
Grand Total
Mental health - Dementia
The report looked at over 24,000 admissions across
the 3 groups which accounted for over 338,000
Occupied Bed Days (OBDs) at a cost of £70m. This
represented an average of 9% of all acute hospital
beds.
Destination of Patients Discharged frrom Yorkshire & Humber
Acute Trusts with a Secondary Diagnosis of Dementia 2008/09
40
Dementia – health & social care costs
The National Audit Office suggests that £284m
nationally could be saved immediately through
the adoption of best practice (or £6m per
average general hospital).
‘Improving Services to People with Dementia’:
http://www.yhip.org.uk/silo/files/improvingserv
ices-to-people-with-dementia-and-acute-healthcare-needs.pdf.
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
W
ak
ef
ie
ld
le
es
Ca
ld
er
da
le
Ki
rk
Sh
ef
fie
ld
En
gl
an
d
Br
ad
fo
rd
Yo
rk
Le
ed
s
Ba
rn
s le
y
Hu
m
be
r
ha
m
sa
nd
Ro
th
er
Yo
rk
No
rth
Ea
st
Li
nc
ol
ns
hi
re
sh
i re
Do
nc
as
te
r
Yo
rk
No
rth
Li
nc
ol
ns
hi
re
No
rth
Ri
di
ng
Ki
ng
st
on
up
on
Hu
ll
of
Yo
rk
sh
ire
0.0%
Total Costs in Yorkshire & Humber Acute Trusts for
Patients with Dementia 2008/09
York
SNEY
Sheffield
Rotherham
NLAG
Mid Yorks
Leeds
Hull & EY
Harrogate
Donc & Bass
Cald & Hudd
Bradford
Barnsley
Airedale
0
Senility
Sec Diag Dementia
Prim Diag Dementia
10
20
30
40
50
60
70
80
90
Total costs in 2008/09 (£100,000s)
100
Mental health - Dementia
It is estimated that at least two thirds of all
residential care placements have dementia.
There is local evidence to suggest that a
significant number of admissions to acute beds
and residential care are avoidable with the
development of crisis services, intermediate care
and liaison services. In Bradford it has been
estimated that £13,000 per person, per year can
be saved for a person with dementia. The
current national average spend on a person with
dementia is £27,000 per person per year.
Percentage of total spend on older people in residential homes
2008/09
Ea
st
It is estimated that £567m per annum is spent in
the region on residential care accounting for 57%
of the total budget for social care for older
people compared to 52% nationally.
41
Contents
Overview
Mental health care pathway
Mental health and employment
Dementia
Annexes
Mental health - Contents
Out of area placements
42
Annex A – key contacts
Heather Raistrick – Adult Services Care Manager, NHS Y&H
([email protected])
Sue Baughan – Assistant Director (Knowledge Transfer), YHPHO
([email protected])
Michele Cossey – Pharmacy & prescribing lead, NHS Y&H
([email protected])
Ian Holmes – Associate Director, Economics and System Management, NHS Y&H
([email protected])
Helen Mercer – Economist, Strategy and System Reform Directorate, NHS Y&H
([email protected])
Mental Health - Annexes
Dr Stephen Stericker – Service Improvement Lead, YHIP
([email protected])
43
Annex B - Finance Mapping Data
Data Issues
The data is based on an overall picture of reported investment in adult and older people’s mental health
services, including delivery of services from all providers to, and all commissioners for the LIT, not just NHS
organisations.
The overall quality of the data nationally supplied from organisations inevitably varies but has been validated
by the supplying organisations, LITs and Mental Health Strategies. However, 2009/10 is only the fourth year that
local authorities have collected Old Persons Mental Health (OPMH) finance mapping figures and thus overall,
their figures are unlikely yet, to equal the quality or coverage, of the now well established adult finance
mapping data.
The OPMH analyses should therefore be considered, to a degree, to be provisional, and can be expected to
improve in future
Source: Y&H LIT Results of Financial Mapping Report’s 2009/10 ,
DH/Mental Health Strategies
Mental Health - Annexes
Each year Mental Health Strategies compile a summary for each Local Implementation Team (LIT) of the mental
health financial mapping data. Each LIT corresponds roughly to a PCT region but includes services
commissioned by the non NHS bodies for that region as well.
It is essential that this financial information is not considered alone, but is interpreted along side outcome and
performance measures for each LIT to decide if value for money is being achieved. We have compared data for
the following:
- Total Adult Mental Health Spend per weighted Adult Population 09/10 (plus the percentage
increase/decrease in spend from previous period 08/09)
- Total Indirect costs per weighted Adult & weighted Old Person for 09/10 (plus a graph showing what
percentage of a LITs total adult and old person costs are spent on non direct costs).
- A comparison of how much each LIT in Yorkshire and Humber spent in 09/10 on the top five highest
spending services in England in 09/10
- A comparison of how much each LIT spent on IAPT services in 09/10
Annex C - Psychological therapies
Examples of psychological therapies:
•
•
•
•
Mental Health - Annexes
•
Cognitive–behavioural therapy – a structured problem-focused, goal-orientated
approach aimed at modifying thoughts, assumptions, beliefs and behaviours in order to
influence disturbing emotions and habits.
Psychodynamic therapy – a relatively intensive therapeutic approach aimed at reducing
inner tensions and relational conflicts through the exploration of unconscious meanings
and motivations, often with reference to past formative experiences and current care
relationships.
Systemic therapy – a distinctive approach that aims to study, understand and treat
disorders of the interactional whole (rather than an individual person), for example the
family or a group of individuals.
Integrative therapies – recently developed treatments created from a combination of
elements from one or more other treatments.
Counselling – typically brief interventions that help people cope with challenging
circumstances by providing space for reflection and by restoring their capacity to resolve
problems.
45
Annex D - Useful resources
The YHIP Mental Health programme provides development support to mental
health and social care providers and commissioners in relation to key
government priorities, sharing best practice and development of services in
relation to policy requirements.
http://www.yhip.org.uk/mental-health/
Mental Health - Annexes
The HUB is structured to provide information and dedicated links to
resources, and also a communication tool for people to discuss mental health
in the workplace.
http://www.workplacementalhealth.co.uk/
46
3) QIPP metrics
47
QIPP metrics (1)
48
QIPP metrics (2)
49
QIPP metrics (3)
50
QIPP metrics (4)
51
QIPP metrics (5)
52
QIPP metrics (6)
53
QIPP metrics – definitions and sources
54