Clinical leadership: a new era

1. Geraldine Strathdee, Consultant Psychiatrist OxleasNHS FT Associate Medical Director, mental health, NHSL Clinical leadership: a new era

2. 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!

3. Clinical leadership going forward What’s the new focus 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 • 70% of healthcare is long term conditions • Home care & Primary care systems • Better clinical & economic outcomes by Integration of • Mind and body • Health and social care • Implementation science • Using science to reduce inequalities • Making evidence based care , routine care • New models of training • Patients leading and self managing care • Applying science to spend more time with our patients and their families

4. A value based, affordable vision of care for people with long term conditions & their families in London “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)

5. Patients keep telling us they want from the NHS, whether we care at home or in a hospital…….. Professor Bruce Keogh, Medical Director of the NHS Plus a London efficiency view

6. What do we need from our scientists?

7. 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!

8. London Scientific problems to take away & solve

9. Interactive science : the causes of psychosis Understanding the health & social determinants of mental health conditions Organic brain & neurodevelopmental Societal Genetic & biochemical • Life cycle times • Unemployment • Redundancy • Long term conditions • Adolescence • Pregnancy • Life trauma: • Bereavement • Losses & isolation • Migration • War. Biochemical ‘causes’ Caffeine, nicotine, alcohol, street drugs Neurotransmitters Endocrine disorders ADHD, ASD, Dyslexia, Dyspraxia ‘What could we do?’ ‘What should we do?’ ‘How should we do it?’

10. 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 meettheir 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.

11. 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 wideningduethe 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, includingdepression, and lower levels of wellbeing — major increase in dementia

12. Parity of care & the economic impact

13. We have very affordable effective treatments

14. Health care needs to be redesigned to meet the challenge of co-morbidity • Health services in many countries fail to provide co-ordinated 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)

15. Co-morbidity is the norm Lancet, Barnett, Mercer et al 2012

16. Mental health, physical health & deprivation Barnett, Mercer et al 2012

17. Mental health raises costs in all sectors • Overall, international research finds that co-morbid MH problems are associated with a 45-75% increase in service costs per patient (after controlling for severity of physical illness) • Between 12% and 18% of all expenditure on long-term conditions is linked to poor mental health and wellbeing – at least £1 in every £8 spent on long-term conditions.

18. Mental health drives LTC costs Annual per patient costs with and without depression (excluding MH treatment costs) Welch et al 2009

19. 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 Isaw 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.

20. Poor outcomes of untreated depression comorbidity in physical LTCs Heart disease Stroke Diabetes

21. 2012 publication Compendium of examples of cost effective programmes for people with Long term physical illnesses in acute trusts & primary care settings

22. Thank you for listeningIf you have ideas on how to improve our implementation of scientifically proven care, please email me on geraldine.strathdee@london.nhs.uk