C&I Integrated Practice Unit for Psychosis & long term conditions – North London

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5 year population based programme to integrate the care for psychosis with that for long term conditions such as diabetes and COPD, including preventing secondary conditions by addressing smoking, diet, exercise , substance misuse. Covers everyone currently under trust treatment PLUS everyone on GP SMI registers not currently known.

Co-Production

  • From start: No
  • During process: Yes
  • In evaluation: No

Evaluation

  • Peer: No
  • Academic: No
  • PP Collaborative: Yes

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What We Did

5 year population based programme to integrate the care for psychosis with that for long term conditions such as diabetes and COPD, including preventing secondary conditions by addressing smoking, diet, exercise , substance misuse. Covers everyone currently under trust treatment PLUS everyone on GP SMI registers not currently known.
Approx 7000 people over C&I.
C&I trust are the lead partner in developing care pathways built around individual need and including all local care partners – Whittington Health, UCLH, Royal Free, Camden provider services, CCGs and primary care.

 

Wider Active Support

Building shared community clinics with CH services
Have joint clinics in with Whittington acute at Highgate Mental Health Centre
Sector wide Psychosis clinical group brings clinicians from all organisations together to agree improved care pathways

Everyone working to same 18 outcomes – half of which are CROMS (mortality, suicide, prevalence of LTCs, screening for LTCs) Half are PROMs ( quality of life measures)

 

Co-Production

All staff who work with psychosis trained in smoking cessation
Nurses and OTs have bespoke diabetes care and COPD care training and run C&I clinics
Community matrons and nurse managers are developing clinics with community health services.
All trust service users asked to complete PROM ( 500 in 2016 completed)
Psychosis Expert Group of SUs sits in governance structure.

 

Looking Back/Challenges Faced

Would have engaged mainstream GPs more widely than just GP commissioners, and sorted out the information governance issues with sharing GP data

 

Challenges Faced   –

  1. Workforce – IPU training programme underway.
  2. Primary care involvement – used our commissioning colleagues to support engagement and set up pathways through primary care mental health services where they exist.3. VBC contract not signed in 2016 because of other STP priorities – put outcomes as quality indicators and going for MOU for 2017/19.

 

Sustainability

Communications plan that emphasizes the benefits to service users.

Our clinical strategy which builds from primary care MH and is the basic block for the IPU to work

All sector has same outcomes in mind.

Still aiming for VBC contract at some point in future.

Evaluation 

We are still awaiting first outcomes reports from CCGs

Internal reporting shows it is taking off.

 

Sharing

Yes through conferences

Health London partnership

Speaking to MPs

Is there any other information you would like to add?

We would really benefit from joining up with other organisations doing similar stuff

 

 

 

 

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