Questions/Answers

The mortality gap for those with severe and enduring mental illness (SMI) in the United Kingdom is a well-documented health crisis. People with SMI typically die 15-20 years earlier than the general population. A number of factors contribute to this: SMI can make self-management harder; people with SMI are more likely to participate in negative health behaviours such as cigarette smoking and substance abuse; mental health medication frequently has physical side effects; and people with SMI have unequal access to physical healthcare. Similarly, 30% of people with long term physical health conditions, such as diabetes or arthritis, also have a mental health condition. These mental health conditions can impact treatment of their physical health conditions: self-management can be more difficult; recovery times are often longer; and the cost and intensity of treatment is greater. £1 in every £8 spent treating long term physical health conditions in the UK is linked to mental health problems, costing the National Health Service (NHS) £8-13 billion a year. King's Health Partners' Mind & Body Programme addresses the separation of mental and physical healthcare in South East London by: · Educating staff to recognise both physical and mental health conditions, through training opportunities to improve their understanding of mind and body issues, as well as the 'Champions Network' for staff. · Developing routine holistic screening, the programme supports the ‘Integrating Mental & Physical healthcare: Research, Training & Services’ (IMPARTS) project, a digital screening service for mental and physical health symptoms in patients and service users. · Supporting service improvement and transformation, for example, Sexual and Reproductive Health Rights, Inclusion and Empowerment (SHRINE), a sexual health service for vulnerable people with intellectual disabilities, SMI or substance abuse issues, and physical health services in serious mental illness.

The overall aims of the initiative are to close the mortality gap for people with SMI in Southeast London, to provide this group with equal access to healthcare and to reduce costs associated with co-morbid mental health conditions in long term physical conditions. Life expectancy for a male mental health service user in Southeast London is 18.1 years lower than the general population; for female patients it is 16.1 years below that of the rest of the population. As life expectancy for the general population increases the mortality gap is widening. The Mind and Body Programme is committed to closing the gap. One contributor to the mortality gap is the disparity in access to physical healthcare for people with SMI. The Mind and Body Programme aims to embed screening and treatment for physical health issues in mental healthcare settings to address this major inequality. Finally, the cost of co-morbid mental health issues represents a public health crisis at a time when health service funding is being reduced. The programme aims to screen for and prevent co-morbid mental health issues before they exacerbate physical health and offer holistic care to patients treating both the mind and body.

The initiative falls into the category of 'reaching the poorest and most vulnerable through inclusive services and partnerships'. As a partnership organisation between both physical and mental health providers and a world-renowned research centre, and partnering with other public and third sector organisations, King's Health Partners is building a model of service delivery that ensures no one is left behind. People with SMI are one of the most vulnerable populations in society: they are overrepresented in the homeless population, are overwhelmingly more likely to live in deprivation, which in turn impacts on mental health, and are more vulnerable to experiencing abuse. By implementing physical health screenings, up-skilling mental healthcare staff to understand physical health needs, and enhancing the quality of care to include biopsychosocial support for those with SMI, the Mind and Body programme is committed to delivering equal access to healthcare that has long been denied to those with SMI, improving the health and wellbeing of this vulnerable and frequently excluded population. For example, the Psychology in Hostels project is an initiative to embed psychologists in hostels serving London’s homeless population, working directly with these individuals to support their health and social needs.

The initiative will improve the delivery of public services by allowing equal access to healthcare for people with SMI through improved screening and treatment, while supporting those with mental illness alongside physical health conditions to better cope with their conditions. Education is key to addressing public health issues; for example, many clinicians believe that smoking cessation disrupts care for people with SMI and that this group has no desire to stop. In reality, most smokers with SMI want to quit but may not support to do so. Stigma and misinformation can promote health inequalities, particularly at the interface of mental and physical health needs. As such the Mind and Body Programme has a significant focus on education and training to address such issues. The Programme has also won funding to expand services developed and offered in the partnership; for example, 3 Dimensions of Care for Diabetes, a programme providing biopsychosocial support for those with Diabetes, was expanded to 3 Dimensions of Care for Long Term Conditions which covers heart failure, hypertension and chronic obstructive pulmonary disorder. These initiatives increase equal access to healthcare and address concurrent issues such as housing and benefits, integrating the delivery of several key public services.

The separations between physical and mental healthcare, between primary and secondary healthcare and between health and social care, represent significant obstacles in the delivery of integrated person-centred health services. Despite overwhelming evidence that physical and mental health conditions impact upon one another and should be treated in an integrated way, this is often not how healthcare is delivered. Patients can be lost between different stages of the healthcare system, often receiving no recognition of their social needs and how those needs might impact upon their health and wellbeing. The issue has been highlighted by numerous research and policy papers, all concluding that more should be done to address the problem. The Mind and Body Programme, dedicated to bridging these divides, facilitates projects that allow for the integration of healthcare, through holistic screening of both mind and body, development of staff who are able to recognise and treat physical and mental health needs, and enhancing models of service provision to respond to all the needs of an individual, rather than being restricted by profession or specialism.

People with long-term physical health conditions (LTCs) and people with SMI have been targeted by the Programme. A large number of outpatient clinics now use the IMPARTS screening programme, thereby routinely detecting mental health conditions (needs which otherwise would be unidentified and unmet) and referring patients with LTCs to appropriate support. The 3 Dimensions of Care for Diabetes and 3 Dimensions of Care for Long Term Conditions projects support the psychosocial needs those with LTCs, improving clinical outcomes – psychological, physiological and in terms of quality of life. The Programme supports people with SMI to improve their access to healthcare and experience of health services, particularly for their physical health. Services supported by the Programme have had excellent results; the Psychology in Hostels project has improved rates of staying in housing, employment, and reduced re-offending. Ongoing work includes an ECG linkage project for clinical interpretation of ECGs in psychiatric settings, diabetes outreach into community mental health teams, and the development of exercise and physical activity guidelines for those with psychosis. The Mind and Body learning and development offer has up-skilled 1000s staff in key service delivery roles, ensuring those with LTCs and SMI have their needs addressed.

Healthcare in the UK has long separated physical and mental healthcare despite the clear links between the two. The historic structure of the National Health Service, with separate physical and mental health trusts and separate training paths for nurses and clinicians, has not been one of integrated care. A report in 2011 suggested that integrated care initiatives, in England and elsewhere, to date have paid insufficient attention to the relationship between physical and mental health. The divides continue, with separation between primary and secondary care, and health and social care, despite these services frequently facing similar challenges. The Programme addresses these three great divides in one co-ordinated programme of work which is accountable for health integration in the area. The Mind and Body Programme supports innovation in bridging organisational boundaries, working in a partnership between physical health, mental health and research bodies; bridges cultural boundaries, encouraging joined up working in fields that have been historically separated, and supporting an overhaul in the approach used to commission services. The programme is also working with digital partners, for example, through a screening project to explore how digital solutions might address gaps in healthcare provision or join up services.

The innovation is an original programme of work borne from the creation of King’s Health Partners and other Academic Health Science Centres (AHSCs) in England and responding to a need identified through experience and research. AHSCs were launched in England to ensure that patients see the clinical benefits of medical research by partnering universities and hospital trusts. This allows us a unique position within healthcare; drawing on research and innovations by partners to shape the programme and effect change in the local healthcare system. The Mind and Body Programme aims to capitalise on this unique partnership between the UK’s largest mental health provider, two prestigious hospital trusts, and a world-leading research University to support integrated care. The issue of the separation of services in healthcare had been highlighted in multiple reports and research, and it has also been commented that too little work is currently being undertaken to address it. The Mind and Body Programme is a priority of King’s Health Partners who aim to respond to the need for action on this issue.

The initiative began with limited resources, with just one full time member of staff and oversight from a clinical director. In the last year the Mind & Body Programme team has expanded to include two full time members of staff, one 0.5 full time equivalent staff member, and oversight from Clinical and Academic Directors two days per week. The programme also partners with the Civil Service Fast Stream, the accelerated talent programme in central government, to offer secondment opportunities for participants on the scheme, rotating every 6 months. Previously financial resource for the initiative has been drawn from the central King's Health Partner's budget. For the financial year 2017/18 the partner trusts (Guy's and St Thomas’, King's College Hospital, and South London and Maudsley NHS Foundation Trusts) and King's Health Partner's central team each pledged £100,000. The initiative requires very few material resources, though funding from the Mind & Body Programme purchases material resources (mainly IT supplies) for a number of the programme’s partner projects. There were also existing resources the initiative was fortunate to be able to draw on: the material resources of the partners, an existing human resources structure, and existing infrastructure and digital services.

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The learning from the initiative is adaptable to other contexts and several of the insights and specific projects of the initiative have been transferred to other contexts. Certain projects within the initiative have been transferred to other contexts with great success. For example, Maudsley Simulation, an innovative simulation learning experience, delivers a number of courses on mind and body. The training has been delivered to thousands of people, mostly within healthcare but also emergency services, private companies, and other public services. The Maudsley Simulation team have delivered training throughout Europe to train other providers in their model and the initiative has been successfully transferred internationally. In this way, certain aspects of the Programme can be transferred to other contexts. At programme level, the entire initiative has not been replicated. However, the project team and close collaborators have many on-going conversations with similar institutions internationally to advise how they might develop their own Mind and Body Programmes and how the Programme can learn from them. Principles of the Programme, for example providing time, resource, and financial support to dynamic clinicians and academic to develop their services, and designating a responsible, accountable team to support integrated care, can certainly be transferred elsewhere.

The initiative is socially, economically, and environmentally sustainable and these features have been planned and built into the initiative from its inception. The initiative works to advance equity in healthcare, to guarantee the human rights of marginalised populations and build community cohesion. The initiative aims to develop healthcare systems that support future generations to build a community with equal access to healthcare and equal regard for those currently marginalised through illness and stigma. The psycho-social work of the initiative, with support for housing and economic assistance, has a focus not just on health but wellbeing and quality of life. There has been evidence the financial impact of projects, where integrated models of service delivery have shown a reduction in ongoing care costs related to healthcare utilisation and management of LTCs and SMI. Where these models can be scaled up, the potential for cost avoidance and increased efficiency of care delivery is significant. The initiative is also environmentally sustainable, again due to the few physical resources needed to achieve its aims. All of the learning and development materials and project resources are designed to be viewed electronically, avoiding potential printing and waste. The focus on e-learning provided by the initiative is a further commitment to environmental and economic sustainability with no costs or emissions incurred by participant travel through London, a city that struggles with air pollution.

The programme has a clear long-term aim - to help close the mortality gap and reduce the morbidity burden from physical and mental health co-morbidities. Generating sustainable change can take years; in this first stage of the initiative it focusses on improving partners' understanding of the population of mind and body needs, up-skilling existing staff and evaluating initiatives and best practice pulled from elsewhere. The aim in this phase is to enhance existing service infrastructure to build mind and body care into a variety of care pathways. In the medium term (within 5 years) we expect to achieve a series of outputs which will mark progress in delivering system change: routine use of integrated assessments of health and wellbeing; a new focus on integrated physical and mental healthcare embedded within undergraduate and postgraduate curricula to ensure future generations of clinicians will require no up-skilling in this area; demonstration of clear patient benefits (clinical outcomes, experience and quality of life) as well as economic impacts to the economy as a whole. The learning and evidence from the Programme will be shared and transferred nationally and possibly internationally. The value this represents to the UK health economy could be immense, as illustrated in a previous answer, and the health benefits to the population can be huge. In 20 years’ time the ambition is to have contributed to a decrease in the mortality gap in the service area for those with SMI and a reduction of the morbidity burden, as equitable healthcare becomes a reality.

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Through the Mind and Body Programme, the ability to better identify depression and anxiety, respond to that need in an appropriate way, and educate and train staff presents a fundamental value proposition to care as currently configured. Mind and Body projects have been subject to various evaluation approaches: · IMPARTS: qualitative evaluation based on patient and clinician interviews and feedback. Data produced has also been used in epidemiological research and service evaluations. · 3 Dimensions of Care for Diabetes: formal mixed methods evaluation with University of York, including physical health markers, psychological well-being, and healthcare utilisation. · Learning and Development: mixed methods evaluations included pre, post-training, and 2-3 month follow-up using validated survey measures, as well as incident reporting quality and rates, and qualitative interviews and focus groups using thematic analysis. · Psychology in Hostels: formal mixed methods evaluation with Southampton University, Resolving Chaos CIC, and London School of Economics to determine the impact on quality of life and well-being, as well as healthcare utilisations and social factors such as re-offending rates, employment, and time in permanent accommodation.

Headlines from key projects: · IMPARTS: 82.5% of clinicians felt that IMPARTS helps them meet patient needs well or very well. Overwhelmingly, clinicians reported that the introduction of IMPARTS has had a positive impact on the daily practice: 95.3% were either extremely or quite satisfied with IMPARTS. · 3 Dimensions of Care for Diabetes: physiological measures (hba1c levels), psychological measures and cost reductions (45% drop in A&E visits; 43% fewer hospital admissions, shorter length of hospital stay) improved significantly. If this model were implemented across all LTCs in local boroughs Lambeth and Southwark, assuming comparable cost improvements, potential savings of c.£40m can be modelled, as well as improved population health. · Learning and Development: Educational interventions have significantly improved confidence, knowledge, and attitudes towards mind and body care. Clinical care has been improved, evidenced through incident reporting quality and rates, and quality improvement initiatives such as ward induction processes, collaborative care conversations, among others. Thematic analyses identified improved empathy and compassion, communication skills, interprofessional and multi-disciplinary working. · Psychology in Hostels: Successful in reaching excluded populations (97% engagement, 1650 therapy sessions offered, 78% attendance), significant psychological improvements, increased engagement with substance misuse services, and reductions in criminal justice system use and repeat homelessness rates.

The indicators used varied depending on the project and nature of the analysis, as described above. In addition, all programme activity is monitored on an ongoing basis through a data dashboard, which presents latest activity/outcome measures across three core workstreams. These indicators include numbers of screenings and clinics where screening is live, project specific metrics (common to many projects is use of the general anxiety disorder 7, and personal health questionnaire 9 measures which look at anxiety and depression levels respectively), numbers of people training, and qualitative feedback from patients, service users and staff.

As a partnership between three health trusts and a world-renowned education and research centre. King’s Health Partners has allowed collaborative working in the Mind & Body Programme from the beginning. Key stakeholders in designing the initiative therefore were the partner trusts. The different specialities complemented one another enabling us to build a programme that addressed the most pressing demands in Southeast London's healthcare system. The research expertise provided by King's College London allowed us to be radically forward thinking in the design of the programme, with academic input meaning new information and knowledge is available quickly and often. Staff from the partner trusts have been the main recipients of education and training initiatives, and make up the membership of the Champions Network, and have been active in providing qualitative evaluation of these offerings. Other stakeholders have been active in the design and implementation of the programme. Local primary care providers (e.g. Clinical Commissioning Groups, local General Practitioners' Federation) have been instrumental in the creation of complete care pathways and 'bridging the gap' between secondary and primary care. The programme has worked closely with Improving Access to Psychological Therapies (IAPT) services to offer psychological help to those with long term conditions who test for anxiety and depression in screenings. A number of the partner projects are also delivered with the help of third sector organizations: the psychosocial model of 3 Dimensions for Long Term Conditions relies on third sector social care provider Thamesreach, whilst the Psychology in Hostels project works with homelessness charities in Southeast London, and Mind and Body support for new models of care such as Local Care Networks include third sector involvement. Finally, the wider health context is important; with national organizations and those from other parts of London offering guidance and assistance.

The Programme highlights the importance of proper resourcing and accountability to drive forward initiatives. A task as considerable as trying to break down decades of institutional barriers requires time and resource to support and implement change, as well as support busy clinicians and academics to engage in this task. Implementation of a dedicated team, with financial backing of committed partners, and clear reporting structure and accountability has facilitated the activity and success of the Programme. The importance of communications and branding when trying to communicate an objective to a large and diverse workforce is crucial. The Programme has benefitted from access the King's Health Partners' communications team for advice and guidance, as well as communications team in partner organisations. Further internally developed projects such as a monthly newsletter, mailing lists, digital communications strategy, and Champions Network have supported staff engagement across all levels of organisations involved. Finally, digital technology will be a critical enabler in helping to build integrated models of care delivery, which are streamlined and responsive to patients’ needs. The programme works with digital innovations and solutions, as well as collaborating with the NHS Accelerator to investigate future healthtech ventures to support integration of mental and physical health.