Transcript Physical Health and Mental Health

Integrating Physical and Mental
Health in Nottingham
Dr Joanna Copping: Consultant in Public Health Medicine, NHS Nottingham City
Dr Marcus Bicknell: GP and Nottingham City CCG lead for mental health
Dr Michele Hampson: Consultant Psychiatrist & Clinical Director, Notts Healthcare Trust
Integrated Health Care Summit 17th April 2012
Outline of the presentation
(1) People with mental illness have more physical
illness
(2) People with long term health problems are more
likely to suffer from mental health issues
(3) Lifestyle issues (exercise, smoking, obesity & alcohol) and how
they affect health
(4) What we are doing in Nottingham
People with mental illness have
worse physical health
People with severe mental illness:
• 2 x death rate from cardiovascular disease (Brown
2000)
• 4 x death rate from respiratory disease
• 2 x more likely to have diabetes (Robson 2007)
• People with schizophrenia die 10-25 years
earlier than general population (Newman 1991, Parks 2006)
People with mental illness in Nottingham have
more hospital admissions for physical illness
Under 75 hospital admissions for COPD, Cancers, Circulatory Disease and Diabetes (Jan 08-Dec 10)
60.0
Crude Rate per 1000
50.0
40.0
City Residents
30.0
MH Patients
20.0
10.0
0.0
COPD with Bronchitis
All Cancers
Circulatory Disease
Primary Diagnosis
Diabetes
Why do people with mental illness have
more physical illness?
• Lifestyle
• Poor access to healthcare
• Diagnostic overshadowing
• Side effects of treatment
• Suicide contributes to higher mortality rate
People with ‘Long Term Conditions’
have worse mental health
• COPD (lung disease) 2.5 x more likely to have
depression and anxiety (van Manen 2002)
• 20% of people develop depression following a heart
attack (Krishnan 2002)
• Depression is highly associated with a number of
cancers: mouth/throat 22-57%, pancreatic 33-50%,
lung 11-44% ( Massie 2004)
• Diabetes associated with depression and anxiety
and associated with poorer blood sugar control &
complications (Mollema 2001)
Why do people with Long Term
Conditions have co-morbid mental health
conditions?
• Chronic pain causing depression
• Anxiety re symptoms and loss of confidence
• Clinical barriers- short appointment times, lack of knowledge around MH
issues
• Stigma -patients reluctant to seek help
• Mental health symptoms dismissed as being
understandable reactions to physical illness
• Missed diagnoses – over half cases of depression in general hospitals is
unrecognised (ref Cepoiu 2008)
• Vicious circle- chronic illness leading to job loss, poverty, poor housing and
environment
Lifestyle and how it impacts on health
• Physical activity
• Smoking
• Obesity and poor diet
• Alcohol
Physical activity CMOs report 2011
• Reduces risk of:
-cardiovascular disease (35%),
-diabetes (40%)
-cancer (breast 20%, colon 30%)
-obesity
-musculoskeletal conditions (hip fracture 36-68%)
-mental health problems (20-30%)
• Schizophrenia associated with lower levels of
physical activity (Kilbourne 2009)
Smoking
• Greatest cause of preventable illness and
premature death in the UK
• Smoking rates much higher amongst people
with mental illness- Schizophrenia 58-88% (Sacco
2005), bipolar 78-83% (Lasser 2000)
• Nottm Uni study found barriers to reducing
smoking but that people with SMI could be
supported to stop smoking
• Need to supportively challenge culture of
smoking amongst those with mental illness (Reilly
2006)
Obesity and Diet
• Obesity linked to diabetes, cardiovascular
disease and cancers (Kopelman 2007)
• Bidirectional association between depression
and obesity (National Obesity Observatory 2011)
• 3X rate of obesity in schizophrenia, 1.5 x rate
in severe depression and bipolar disease (de Hert
2011)
• Antipsychotic medication causes obesity (Allison
2009).
• Mental illness linked to poor diet (McCreadie 2003)
Alcohol
• Alcohol consumption is linked to :
-High blood pressure
-Heart disease and stroke
-Cancers (e.g.mouth, throat, breast)
-Pancreatitis
-Liver disease
• Rates of alcohol dependence are higher in
people with mental illness (Inst alcohol studies 2007):
Schizophrenia 3x
Depression 1.9 x
How we are addressing physical & mental
illness link in Nottingham?
Nottingham’s Mental Health Strategy -more joined up and
strategic approach across commissioners and providers.
One objective of strategy is to improve physical health
-GP training around mental health, plus monitoring of new QOF
-Mental health staff training around physical health
-Raising awareness of need for physical healthcare amongst service
users
-Improving access to health improvement (e.g Healthy Change)
- CQUIN to incentivise physical health checks and smoking support
-‘Physform’
-long term conditions pathways ensuring mental health incorporated
-IAPT (talking therapies) to include long term conditions
-Health facilitators?
PART ONE- Annual Physical Health Summary and Action Plan
Physform
Name
Care Coordinator
Consultant
Long Term
Diabetes
Conditions
Date of Birth:
Date reviewed
Y/N
COPD
Date reviewed
Y/N
CVD
Date reviewed
Y/N
GP
NHS No:
Ethnicity
Asthma
Date reviewed
Y/N
Result
Action Needed
(Date if not
date of form)
(e.g. Care Plan, written information, encourage
use primary care, name of person responsible )
Epilepsy
Date reviewed
Y/N
Action
Complete
Regular contact with primary care
Would attend primary care with support
Thyroid
Date reviewed
Other
Date reviewed
Yes/No
Yes/No
Allergies
Date reviewed
Y/N
Information/Guidance
See associated leaflet for contact details of health improvement services
(Cigarettes per day)
Ask and record smoking status, Advise of health benefits of quitting, Act on response eg referral
to smoking cessation service
Blood Pressure
If ≥ 140/90 or above refer to primary care for assessment ( NICE CG 127
Urinalysis(Blood/Glucose/Protein)
If positive for blood, glucose or protein refers to primary care for assessment.
BMI
Underweight <18.5: Healthy 18.5<25: Overweight 25<30: Obese 30+ (27.5+ethnicity Asian). If
25+ lifestyle advice, consider refer to weight management
Cholesterol
Total chol.≤ 5mmol, LDL≤3 mmol recommended for healthy adults. Total chol.≤ 4mmol, LDL≤2
mmol recommended for adults at high risk.
Smoking
(Total or Ratio total/hdl)
Blood Glucose
(random or fasting or HBA1c)
If blood glucose (pref fasting) is ≥5.5 mmol/l, or HBA1c is ≥ 6% or 42 mmol/mol refer to primary
care.
(Units per Week/ AUDIT C )
AUDIT C Score ≥ 5 do full AUDIT. AUDIT ≥ 8 brief advice & Last Orders leaflet. ≥16 refer to
Last Orders
Illicit Drugs (type, frequency, method,
Offer brief intervention and information on support and treatment services (NICE CG 51)
Alcohol
quantity)
Cervical Smear
Women 25-49 every 3 years & 50-64 every 5 years
Mammogram
Women 50-70 every 3 years.
Over 70 can self refer. Encourage breast awareness.
Men and women 60-69 every 2 years
Over 70 on request. Awareness to report bowel symptoms
Bowel Screening
Sexual Health
(STI’s, safe sex, access to condoms)
Contraception
(Type used/ date last review)
Under 25 promote Chlamydia screening.
Inform of local services-CASH and GUM and how to access condoms.
Caution: harmful effects of medication on pregnancy. Check aware of emergency contraception
and LARC options.
status/risk factors
Risk factors for Hep B, Hep C or HIV include –injecting drug use, unsafe sex, ethnic origin.
Refer for testing
Optical Health (Last appt)
Check up every 2 years, Annual retinopathy screen if diabetic. (all ages)
Dental Health (Last appt)
Annual check up. Promote oral health
Blood Borne Viruses
Date form completedCompleted by-
Copy given to patient: yes/no
Copy given to care co-ordinator: yes/no
Copy given to GP: yes/no
Physical health for those with severe
mental illness: more than a form!
•
•
•
•
•
•
•
Know issues at population level √
Know issues at individual level Physform
To share the key concerns with the individual
To offer range of effective interventions
To treat illnesses effectively
Review & encourage individual with care plan
Review outcomes at individual and local level.
Whose job is it?
Everyone’s!
Patient/service user
Primary care
Secondary care
MH and acute care
Relative importance determined at level of individual.
Implementing the Physform
• Staff training
-why it is so important?
-how to do it
-interventions available
• User & carer information
-written
-courses
• Guidance on how to
determine the balance of
responsibility for completion of data collection.
• Use incentives
-QOF and CQUIN
Develop interventions to promote health
A = Activity
B = Blood Tests
C =Cigarettes
D = Diet
E =Excess alcohol
Focus on outcomes
Transparency in Outcomes: Framework for the NHS
1.Preventing early death
2.Enhancing quality of life for those with lifelong
conditions.
We should be judged by our ability to
demonstrate improvements in these areas…
But give us a bit of time to get there!