Download Clinical leadership: a new era

Clinical leadership: a new era
Geraldine Strathdee, Consultant Psychiatrist Oxleas NHS FT
Associate Medical Director, mental health, NHSL
This talk and some scientific London
takeaway facts for you to solve!
• What do we need from clinical leaders
• What do we need from scientists as leaders
• London Scientific problems to take away & solve!
Clinical leadership going forward
What’s the same
•
Focus on values
•
Vision of care
•
Scientific literate
•
Informatics literate
•
Economics literate
•
Communications literate
•
Emotional intelligence
•
People who nurture leaders
•
Courageous
What’s the new focus
A value based, affordable vision of care for people
with long term conditions & their families in London
I was diagnosed early
I understand what
decisions I can make for
now and for my future
I got the best treatment
I need for my condition
& my life
My family are well
supported in caring for
me
I am treated with
dignity and respect as a
person and a sufferer
of my condition
I know what I can do to
help myself and my life
I continue to be part of
my community and
contribute to it
I am confident that my
end of life wishes will be
respected and my death
will be a good one for
me and my family
I enjoy life among my
family
“Because we were able to have home carers… my husband was able to spend the last
six years of his life in our own home, where he was very happy, instead of going into
residential care, which would have made us all very sad”
(Carer, National Dementia Strategy, 2009)
Patients keep telling us they want from the NHS,
whether we care at home or in a hospital……..
Safety
“Will I be ok?”
From the
patient’s
perspective
Effectiveness
“Will the treatment do
me any good?”
Experience
Efficiency
Will it be a kind, enabling,
experience & will I learn more
about taking care of my health
Will it be fast, safe , near home ,
Helped me get back to work asap
Professor Bruce Keogh, Medical Director of the NHS Plus a London efficiency view
What do we need from our scientists?
We need you to continue to lead discovery of new assessments,
new medications, new treatments, new service models
We need your scientific brains to analyze & innovate where:
Science is being ignored
The patient pathway is tortuous and inefficient
We absolutely need you to help us implement evidence based
care
Where science is needed ..
Care Pathway
• Prevention
• Identification
• Assessment
• Evidence based NICE
pathways
• Recovery & social
inclusion
•
•
Behaviour change & lifestyles
Self screening, self assessment
•
Clinician assessment tools
•
•
Clinician decision support tools
Evidence based service design & delivery
•
•
•
Risk alert awareness technology
Outreach for the most unwell
eRecords, eCare, ePrescribing,
eInvestigation results, efMRI
•
Assistive technology for :
–
•
home based care for LTCs, dementia, LD
Technology to reduce bureaucracy &
duplication &meetings!
London Scientific problems to take
away & solve
Interactive science : the causes of psychosis
Understanding the health & social determinants of mental health conditions
Genetic & biochemical
Organic brain &
neurodevelopmental
Societal
•
Biochemical ‘causes’
Caffeine, nicotine, alcohol, street drugs
Neurotransmitters
Endocrine disorders
Family history
Substance misuse
/mental ill health/
chaotic deprivation /
abuse: physical, sexual,
emotional
Life cycle times
•Unemployment
•Redundancy
•Long term conditions
•Adolescence
•Pregnancy
Life trauma:
•Bereavement
•Losses & isolation
•Migration
•War.
Institutions career
School difficult
Truanting
Dyslexia, Dyspraxia,
ADHD, Autistic
spectrum,
Mental illness starts
Expensive placements
Drug use & dealing
Regarded as ‘bad’ or
‘strange’
Youth offenders
‘What could we do?’
Bullied
Petty crime
In Care
‘What should we do?’
Acute psychiatric wards
Forensic units
‘How should we do it?’
The Schizophrenia Commission 2012
Schizophrenia and psychosis costs society
–
£11.8 billion a year but this could be less if we invested in prevention and effective care.
Increasing numbers of people are having compulsory treatment, acute care needs review
Levels of coercion have increased year on year and are up by 5% in the last year.
Too much is spent on secure care - £1.2 billion or 19% of the mental health budget
Only 1 in 10 of those who could benefit get access to true CBT (Cognitive Behavioural Therapy)
despite it being recommended by NICE (National Institute of Health and Clinical Excellence).
Only 8% of people with schizophrenia are in employment, yet many more could and would like
to work.
Only 14% of people receiving social care services for a primary mental health need are
receiving self-directed support (money to commission their own support to meet identified
needs) compared with 43% for all people receiving social care services.
Families who are carers save the public purse £1.24 billion per year but are not receiving
support, and are not treated as partners.
87% of service users report experiences of stigma and discrimination.
Services for people from African-Caribbean and African backgrounds do not meet
their needs well. In 2010 men from these communities spent twice as long in hospital
People with severe mental illness such as schizophrenia still die 15-20 years earlier than other citizens.
What are the emerging scientific facts in London
•
•
Health inequalities in London are stark.
Between boroughs life expectancy gaps of 9 years
Within borough differences of 17 years
•
Across England health inequalities are widening due
the social and economic determinants of health,
which shape peoples’ lives and their health
London has more:
• Deprivation:
•
Transport hubs that bring people to London
•
•
•
Mobile populations
Asylum seekers , & no recourse to public funds
More crime
The impact of the economic downturn on health & health inequalities that may occur in London:
— More suicides and attempted suicides; possibly more homicides and domestic violence
— An increase in mental health problems, including depression, and lower levels of wellbeing
— major increase in dementia
Parity of care & the economic impact
Figure 1: Morbidity among people under age 65
Physical illness (e.g.
heart, lung, musculoskeletal, diabetes)
Mental illness
(mainly depression,
anxiety disorders,
and child disorders)
successful outcome. The second point is the level of cost-effectiveness as measured by cost
per QALY. This involves two further factors. First there is the severity of the condition which
is averted, and second the cost per case treated. The concept of severity used by NICE is that
each medical condition involves a reduction in the quality of life, and a successful treatment
thus increases the number of Quality Adjusted Life Years (QALYs). The cost per QALY is
then the (inverse) measure of the cost-effectiveness of the treatment. The informal cut-off
We have very affordable effective treatments
22
Annex B: Prevalence of adult mental health conditions and % in treatment,
England 2007
% of adults
diagnosable
(1)
% of (1) in
treatment
(2)
% of (1) receiving
counselling or
therapy
15.0
24
10
PTSD
3.0
28
10
Psychosis
0.4
80
43
Personality Disorder*
0.7
34
ADHD
0.6
25
4
Eating disorders
1.6
23
15
Alcohol dependence
5.9
14
6
Drug dependence
3.4
Anxiety and/or depression
Cannabis only
2.5
14
7
Other
0.9
36
22
Any condition
23.0
* Includes Anti-social P.D. and Borderline P.D.
Note: The conditions are not mutually exclusive.
18
Table 5: Cost-effectiveness of some treatments for mental and physical illnesses
Mental illness
Depression
Social anxiety disorder
Post-natal depression
Obsessive-Compulsive
Disorder
Physical illness
Diabetes
Asthma
COPD
Cardio-vascular
Epilepsy
Arthritis
Treatment
Numbers
Needed to
Treat
Cost per
additional
QALY
CBT v Placebo
CBT v Treatment As Usual (TAU)
Interpersonal therapy v TAU
CBT v TAU
2
2
5
3
£6,700
£9,600
£4,500
£21,000
Metformin v Insulin
Beta-agonists + Steroids v Steroids
Ditto
Statins v Placebo
Topirimate v Placebo
Cox-2 inhibitors v Placebo
14
73
17
95
3
5
£6,000
£11,600
£41,700
£14,000
£900
£30,000
Health care needs to be redesigned to
meet the challenge of co-morbidity
• Health services in many countries fail to provide coordinated support for patients’ multiple needs.
• Patients frequently experience fragmented care and
opportunities to improve quality & efficiency are missed.
• There is a professional, institutional and cultural
separation between mental and physical health that
must be overcome.
“The greatest mistake in the treatment of diseases is that there are physicians
for the body and physicians for the soul, although the two cannot be
separated”. Plato (427–347 BC)
Co-morbidity is the norm
Lancet, Barnett, Mercer et al 2012
Mental health, physical health & deprivation
Barnett, Mercer et al 2012
Mental health raises costs in all sectors
• Between 12% and 18% of
all expenditure on longterm conditions is linked
to poor mental health and
wellbeing – at least £1 in
every £8 spent on longterm conditions.
180%
160%
% increase in annual per patient costs
(excluding costs of MH care)
• Overall, international
research finds that comorbid MH problems are
associated with a 45-75%
increase in service costs
per patient
(after controlling for
severity of physical illness)
140%
120%
100%
80%
Depression
Anxiety
60%
40%
20%
0%
Mental health drives LTC costs
Annual per patient costs with and without depression
(excluding MH treatment costs)
Welch et al 2009
From a GP …………Clare Gerrada
• I was struck the other day when I saw a patient - who has been off
work for 3 months waiting for CBT. He is depressed and was just
told to go on sick leave- no medication, just a referral for CBT in the
distance future.
• When I saw him , what upset me most was that if he had broken
his leg, he would have been treated asap, given rehab, told to go to
work on crutches and would not have just been abandoned.
• I want to make it impossible for mental health problems to be
treated as second class illnesses - with patients with treatable
conditions languishing on waiting lists or worst still with no
treatment at all
Professor Michael Porter
GPs are trying to do everything for everyone, too much of 21st Century care was being
provided through 19th century organisational models.
Porter is a world authority on strategy in business, & has spent the past decade working in healthcare systems in
dozens of countries.
Poor outcomes of untreated depression
comorbidity in physical LTCs
Stroke
Heart disease
Diabetes
2012 publication Compendium of examples of cost effective programmes for
people with Long term physical illnesses in acute trusts & primary care
settings
Thank you for listening
If you have ideas on how to improve our
implementation of scientifically proven care,
please email me on
[email protected]