Bringing mental health in line with physical health has long been a mission of Geraldine Strathdee. Here, she explains how CCGs have so far made way to do so and what can be done in the future
Awareness of mental health and its importance in terms of improving healthcare is ever-increasing.
Bringing mental health in line with physical health has long been a mission of Geraldine Strathdee. Here, she explains how CCGs have so far made way to do so and what can be done in the future
Awareness of mental health and its importance in terms of improving healthcare is ever-increasing.
Parity of esteem – that is treating mental health on a level with physical health – was very much on the radar of the previous government. And new Labour leader Jeremy Corbyn raised this issue at the request from a member of the public in his first crack at Prime Minister’s Question time in mid September stating that the services was “on its knees”.
It’s up to Dr Geraldine Strathdee as NHS England’s national clinical director for mental health to lead the way in ensuring it doesn’t fall off the agenda and that services are fit for purpose.
Strathdee, who specialised in psychosis for 30 years, is acutely aware of how important it is for mental health to be on commissioners’ radars.
She has been pleased with the response from clinical commissioning groups (CCGs) to a recent scheme called the Mental Health Leaders programme. The aim was for it to give leaders experience of the reality of commissioning and service improvement for mental health.
It has five components commissioners learn from. The first is building personal leadership. “Helping people develop their own personal leadership style and resilience is important because being a leader is a tough gig,” she says.
The second part is on the importance of understanding one’s own population. “Obviously, if you are commissioning services for Lambeth that’s going to be very different to commissioning services for Richmond. It’s about really knowing your local population, its strengths and needs,” says Strathdee.
And thirdly, “absolutely knowing what good looks like elsewhere. So, where are people implementing really good National Institute for Clinical Excellence (NICE) guideline evidence-based care and publishing outcomes”.
The fourth part to the programme is learning to work with the media and realising how it can be used to the benefit of CCGs. “We always advise new leaders to secure comms training. The ability to communicate well and commission public facing campaigns and information material is a really important modern leadership skill,” says Strathdee who has been in her current role for two and half years.
The final part to the programme was that CCGs were asked to identify an area of mental health commissioning they felt needed major improvement. “Every one of the CCG leaders has done such a project and each constitutes really good learning. These case studies have been written up and can be shared if useful,” she says. In Bradford there was a redesign of a whole care pathway, evaluating the use of routine suicide assessment. Bradford CCG, Bradford District Care trust and local partners launched this with excellent outcomes in the first three months.
The first 32 CCG leaders that took part in the Mental Health Leaders programme in 2012/2013 came from London and are “cooking on gas” and working with strategic networks.
“They are really motoring ahead with the implementation plans for our [NHS England’s] access standards [Guidance to support the introduction of access and waiting time standards for mental health services in 2015/2016]. They are integrating diabetic care and acute care, they’re working on children and young people and there is a network of 350 people working on perinatal health: midwifes, nurses, school nurses, health visitors, GPs, obstetricians and mental health professionals – its completely incredible.”
The programme has been rolled out across the country and 150 CCG leaders have taken part. Strathdee spoke highly of the CCGs’ achievements so far.
“Where we are seeing fantastic transformation, much quicker access for people and a better response is where there are partnerships between patients, their families, commissioners, providers and local government.”
As part of CCGs bringing mental health to the forefront of their organisations Strathdee believes it is essential to have mental health within clinical pathways. And she believes that when you register for an appointment whether it’s with your GP for the first time or a secondary care issue you should be asked questions about your mental health, as well as your physical health.
“It’s a strange thing to go and get care for your diabetes without people understanding that you may be depressed, or anxious. [And if you are] will you be able to engage with treatment?
“At registration appointments there should be mental health and psychological questions, as well as the physical ones.”
There are many who would question whether it’s financially beneficial or possible to focus on mental healthcare, given the extra time it would take an already pressured system.
According to Strathdee, “mental health is the cheapest form of healthcare”.
“There is some great analysis about where we are spending money in health. In society we are spending an enormous amount doing non-evidence based things. Recently in the British Medical Journal there was a fantastic paper by the Academy of Royal Colleges looking at the numbers of people who are having investigations, ultrasounds and blood tests when actually what they have is an unidentified mental health condition.
“This country spends £8.8 billion on diabetes care, of which £1.8 billion is the cost related to mental health; people are not being treated for ill mental health.”
Primary care is a key area that needs to be focused on with regards to mental health, according to Strathdee.
“We need to absolutely help primary care. I sometimes compare the attitudes to people with psychosis to the attitudes there were to leprosy 20 years ago, HIV 15 years ago and actually most people with psychosis are just wonderful, wonderful people who just haven’t got the treatment. And then on top of that there is the stigmatising of mental illnesses.”
Strathdee is under no illusions of the difficulties that primary care faces on a day-to-day base and credits general practice as being “one of the most amazingly skilled jobs you can do”.
“My sister is a GP, and you will see 20 to 30 people with completely different healthcare conditions and you have a 10 to 12 minute appointment to take the history, understand the problem, make the diagnosis, communicate it to the patient and get the treatment in place and make the next appointment – it’s a very skilled job.”
Strathdee feels that if there is one way primary care can develop it’s understanding of mental health.
“At the moment only a third of GPs get access to post graduate training in mental health and less than 1% of practice nurses who do the long-term condition checks get access to post graduate training in mental health and less than 2% of midwifes.”
Strathdee believes that moving forward primary care needs to have mental health training.
“We should also look at the current model in primary care, there needs to be more direct access to liaison mental health services in primary care to psychological therapies, we should also be looking at the best models in the Scandinavian countries, Canada, New Zealand and Australia.
“In America there are some services that are of direct access to children and family practitioners. They are doing care early, with assessments of child development, family relationships enabling them to identify conditions developing early and to get in quickly and stop referrals in secondary care.”
The UK has often disregarded America’s attitude to its mainstream approach to mental health. For many years therapy, as its called across the pond, has been championed by people of all walks of life and been integral to many Hollywood storylines. Given that the US often leads the way, does Strathdee think the UK will follow in America’s footstep where therapy may become mainstream?
“I don’t want to get totally sucked into this. We are stepping up in this country. We are now looking at psychological literacy and understanding ourselves more. People are saying I know how to get my cardiac state improved and I know how to keep my diabetes under control but now I want to understand about my mood and mindfulness.”
Strathdee wants psychological health to become integral to the way our society works.
“I don’t know anybody who hasn’t had really bad times,” she says.
“Think about how you respond in these very difficult situations. Who is your support team? How do you get your head in a different place? I think our society is craving to understand their psychological and mental health.”
It’s not surprising that Strathdee thinks this given the way the media has highlighted mental health issues and championed celebrities and public figures for speaking out about their own mental health issues.
It seems to have trickled down into people’s every day lives, according to Strathdee. “Suddenly people with lived experience, people who you know and go to the gym with started talking about their own mental health problems and the terrible impact on their lives of not getting treatment.”
This is demonstrated by the fact that the NHS Choices website has now become one of the most hit upon websites due to its information on mental health.
Not only does Strathdee desire the expansion of literacy and primary care for mental health but she also wants children and young people’s mental health to be on the agenda. As a mother of four herself and former school governor she is more than aware of the challenges faced by young people. She feels that children’s mental health may have been overlooked, due to the focus on dementia.
“To have really good child mental health you need a warm, loving, safe, secure environment with parents, a place to live and a school that nurtures. People look at mental health and children and say that’s education’s problem; it’s a police community safety problem.
“I think I only know of one primary care service where there is a children’s mental health service imbedded in primary care. And yet that is where most parents take their children [to the GP]. It was just wonderful that the last government committed £1.25 billion over five years to start this reorganisation of children’s and young people’s services.”
“From what I can see this government is just carrying on the work of the last government, there is a real continuing commitment to understanding more about mental health, funding our research and helping our science.
“Seventy per cent of mental ill health starts before the age of 24 and therefore if you put in place evidence based interventions you can prevent it.”
While prevention is an avenue Strathdee feels strongly about, she is also mindful of those already in need who do not receive the help required.
The historic shift of mental healthcare from hospitals to communities did leave many with a feeling that patients and careers weren’t supported properly. As the general consensus is that more care should be out of hospital and in the community can lessons be learned from that earlier shift and its consequences?
“I bear personal scars from this. I started my career with an absolute commitment to help people live at home safely and successfully and I think we have a lot to learn from the way we moved out of hospital for mental health.
“One of the problems is we moved out with no bridge funding and thought everybody would be fine. It has to be about partnership,” she says.
She harks back to her view that integration must take shape in communities. She says: “It’s important to work really close with partners. To keep people successfully in their own homes you have to focus on what that person needs.”
The bottom line is always about the money and the decisions around where it must be spent.
“For every one person that you have in a bed you could spend that money looking after between 50 to 100 people in the community. If I had one plea to commissioners it is, please do not disinvest in community teams. If you do disinvest in those teams you will end up using more beds.”
Ill mental health is an issue that one in four people will suffer with at some point in their life. Across the country commissioners and local organisations joining together to help support suffers is important.
As Strathdee says: “Mental health leaders are very clear about what they need –commissioner’s support.”
