Leeds Mental Health Needs Assessment 2011

Mental Health and Wellbeing in Leeds: An Assessment of Need in the Adult Population
May 2011
Report Authors Victoria Eaton, Consultant in Public Health, NHS Leeds Catherine Ward, Emotional Health & Wellbeing Lead, NHS Leeds James Womack, Senior Public Health Information Analyst, NHS Leeds Adam Taylor, Senior Public Health Information Analyst, NHS Leeds
Acknowledgements and Contributions We are very grateful to numerous colleagues and partners for their contribution to this report, including Jacky Pruckner, Stuart Cameron-Strickland and Irene Dee at Leeds City Council, Pip Goff at Leeds Volition, Jon Beech at Touchstone and Nichola Stephens, Pia Bruhn, Richard Wall, Jane Williams, Jo Alldred, Maroof Shah and Jenny Thornton at NHS Leeds. And finally to Sam Leamy for all her invaluable support. We would also like to acknowledge the contribution of all the members of the previous Mental Health Needs Assessment Steering Group, who influenced the need for the production of this report and shaped its content.
Cover Image (by Dawn Smallwood) - Hyde Park Leeds
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population
Foreward You should pray to have a sound mind in a sound body JUVENAL (c. AD 60-130), Satires In publishing No Health Without Mental Health, the cross-government mental health outcomes strategy for people of all ages, the compelling case is made for the equal importance of mental health in relation to the physical health agenda. This is clearly not only a recent view and the chosen quote illustrates how this perspective is at least two thousand years old. Good mental health is not only fundamental to our physical health and wellbeing, but in the way we live all of our lives through relationships, work and in achieving our potential, as well as bringing wider social and economic benefits. Mental health and wellbeing is shaped and influenced by many underlying factors, including the way in which we organise ourselves as a society, how we distribute our resources and what we value. The purpose of this report is to increase our understanding of local mental health and wellbeing needs in order to shape the decisions we take and the priorities we set. This report should be the start of an active process around decision-making which is informed by need, and focused on outcomes which will influence the future needs of our population. This emphasis on need (rather than on demand or other historical factors) should improve the way we address inequality and population mental health and wellbeing. Our challenge is how we use this knowledge of need to influence the complex breadth of factors involved in making a positive difference to the mental health and wellbeing of the people of Leeds. So what do we understand about the mental health and wellbeing of the people of Leeds? This report aims to contribute to a better understanding of local mental health and wellbeing needs, and also raises some questions about areas we need to further explore and understand better. The report is not comprehensive, has many gaps and there are limitations in each of the data sources which inform our understanding of our citys mental health and wellbeing. It does however, aim to increase our understanding of how mental health and wellbeing is distributed amongst the population of Leeds, and give us a greater insight into some of our key challenges to improve population mental health and wellbeing locally. If you would like to send any comments on this report, these would be welcomed. These should be sent to me at victoria.eaton@nhsleeds.nhs.uk
Victoria Eaton FFPH Consultant in Public Health, NHS Leeds
Contents Summary of key findings Recommendations 1. Background and Context 2. Mental Health Needs Data pack - Section 1: Mental Health Minimum Data Set (MHMDS) 2009-2010 - Section 2: Psychiatric Morbidity - Section 3: Primary Care Mental Health Presentations - Section 4: Suicide & Self Harm - Section 5: Mental Health Audit Data (Severe Mental Illness Register) - Section 6: Quality & Outcomes Framework (QOF) - Section 7: Prescribing - Section 8: Projecting Adult Needs & Service Information (PANSI) & Projecting Older People Population Information (POPPI) 3. Summary of Qualitative Data Glossary pg. 5 pg. 7 pg. 9 pg. 13 pg. 19 pg. 26 pg. 28 pg. 36 pg. 41 pg. 46 pg. 54 pg. 64 pg. 69 pg. 97
Summary of key findings From the key sources of data included within the report, findings are summarised below. Further work will be needed to explore the factors involved for some key findings, which is reflected in the recommendations. Population Mental Health and Wellbeing ! Psychiatric morbidity data for Leeds broadly reflects national modelling on expected prevalence. However, there are higher levels of mental health problems within population groups experiencing multiple risk factors, resulting in inequalities in mental health outcomes within the Leeds population, for example 90% of all prisoners are estimated to have a diagnosable mental health problem. Higher levels of poor mental health and wellbeing and mental illness are inextricably linked with deprivation within Leeds. Local mapping highlights these issues and emphasises the social gradient of mental health and wellbeing. We have some insight into the needs of the groups with the poorest mental health in Leeds, but this is limited and needs to be further developed. Data on mental wellbeing is limited and patchy. There is also still an emerging consensus around agreed measures for mental wellbeing. Available data reflects the pattern of inequalities in mental wellbeing within the city. There is evidence that some mental health problems are becoming more prevalent. This is reflected by Leeds data in an increased prevalence of depression, although gaps in local data suggest much under-reporting, particularly amongst older people. Only a third of older people with depression ever discuss it with their GP, yet depression is the most common mental health problem in older people. The number of older people in our population is growing, with a corresponding increase in those at risk of depression. Local data suggests that Leeds has significantly higher levels of recorded psychotic disorders than predicted from national prevalence data. This is both for males and females, but is particularly high in the number of males diagnosed. According to national prevalence data we would expect to see higher prevalence of psychotic disorders amongst women than men. Data for Leeds shows we have more males than females with diagnosed psychotic disorders. The differences between expected prevalence and recorded diagnosis are also related to age; there are relatively high levels of diagnosis of psychotic disorders in older age groups (45-74) in contrast with lower levels of expected prevalence.
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Suicide and Self Harm ! The overall suicide rate in Leeds has risen slightly since 2004. Local data suggests the highest suicide rate is in the 35 64 age range, suicide rates in Leeds are higher in under-65s than regional and national rates, and lower in the over-65 age groups. In Leeds the overall suicide rate is 3 times higher for males than females. There is insufficient quality data collection for completed suicides for the over 75 generic age group. This is not a Leeds specific issue, but should be taken into account when interpreting local data.
Self-harm recorded through admissions to hospital treatment show high rates of first episodes mainly due to self poisoning. Local data shows higher rates of self-harm amongst young women. This data is limited as it only reports incidence of self-harm resulting in hospital admission.
Secondary mental health services ! ! Data suggests the rate of access to NHS secondary mental health services is higher in Leeds in comparison to the national rate for England. Local data on activity within NHS secondary mental health services highlights some key differences for Leeds compared with England and PCT Peers: this includes -a lower rate of social worker contact -a higher rate of Community Psychiatric Nurse contact -a higher percentage of formally detained inpatients
Employment and Financial Inclusion ! ! Unemployment and the economic downturn is having an impact on mental health across the city and not just in deprived Leeds. Leeds has a relatively high level of its working age adult population in receipt of Incapacity Benefit due to mental ill health (50% of IB claimants identify a mental health problem) Employment rates for female users of mental health service users in Leeds are significantly below the national average. Around half of all lifetime mental health problems start in childhood and are associated with multiple risk factors, including inequalities. Leeds data informs us that one fifth of all children in the city live in families where no-one in the household are in work. In deprived Leeds over 40% of children live in workless households.
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Integrated Mental Health and Wellbeing ! Addressing mental health and wellbeing is a key priority within many programmes and services in Leeds, as captured in a review of all health needs assessments across the city. Local data highlights the need for new or extended screening for mental health problems in services in other many other settings, programmes and services, recognising the importance of the voluntary sector outside mental health services. Mental health problems, particularly depression, are more common in people with physical illness including long term conditions. Local data shows over 128,000 people living in Leeds who considered themselves as having a limiting long-term illness (18% of the total resident population), with greater numbers concentrated in deprived Leeds. Local data suggests that the prevalence and complexity of dual diagnosis is increasing locally and collaboration between mental health and substance misuse services increasingly needed to achieve the best outcomes for service users. People with severe mental illness die on average 20 years earlier than the general population, and have higher levels of physical morbidity.
Recommendations The purpose of carrying out this needs assessment within the broader context of the Joint Strategic Needs Assessment for Leeds is to inform and influence decision-making on the factors affecting mental health and wellbeing of the population of Leeds. Key recommendations are: 1. An overarching recommendation is for available intelligence on need to be actively used to contribute to decisions and priorities on the best use of available resources to improve mental health and wellbeing outcomes across the city. 2. Future needs assessment should be undertaken to capture the needs of those outside the scope of this report, for example dementia, the needs of children, people with long-term conditions, peri-natal mental health and people with learning disabilities. 3. Further focused work should be carried out to gain a greater insight into communities with the greatest need and poorest mental outcomes and levels of wellbeing. This should include population groups and communities of interest as well as geographical areas of need, and build on learning from models of good practice in other areas (e.g. North West Mental Wellbeing Survey). 4. Services and programmes to improve mental health and wellbeing should be designed to meet needs rather than respond to demands. This includes designing mainstream services from this intelligence on need to maximise engagement and access from those with the greatest need. 5. Further work should be carried out to understand local differences in prevalence and service use, including: ! Data relating to higher reported prevalence of psychotic disorders including potential reasons for this difference. ! Data around suggested local differences in social worker and CPN contacts and proportion of inpatients detained in the context of most appropriately meeting local needs and improving outcomes. 6. Responding to the increasing prevalence of depression should be a local priority for integrated service development and partnership working for Leeds, particularly including the needs of older people. This approach should include a broad range of services including primary care and the Voluntary and Community Sector as well as specialist mental health and social care services. 7. A suicide audit for Leeds should be undertaken to provide more up to date intelligence on the factors affecting suicide in Leeds since last carried out in 2006. 8. The suicide prevention action plan should reflect the contribution of all key partners. It should include a focus on depression and financial exclusion as a major risk factor and address issues around the needs of older people.
9. Further work should be carried out on understanding needs around self-harm incidence not resulting in a hospital admission. Preventative work with people who repeatedly selfharm should be included in a local self-harm reduction action plan, in addition to stronger joint work with alcohol and substance use programmes and services. 10. There is a need to build on current programmes and services to address the employment and worklessness agenda in relation to improving population health and wellbeing. This should include ensuring job retention and employment support is included in patient pathways and is integral to care management. We should also maximise the access to appropriate support for those claiming benefit with mental health needs. 11. Further work should be undertaken on strengthening collaboration between physical and mental health programmes and services, recognising the inter-relationship between both. We also need to build on work currently in place to improve the physical health of people with mental health problems. 12. Services and programmes to meet the increasing and complex needs around Dual Diagnosis (including drugs and alcohol) should be further developed. 13. In relation to the needs of older people, we need to ensure real or perceived barriers do not exist in accessing services. We should also ensure that specialist services for older people are properly resourced and prioritise prevention. This should include ensuring good access to primary mental health support for older people. 14. Investment in public mental health, prevention & early intervention should be prioritised. This is most likely to improve outcomes at an individual and population level, as well as reduce costs across the mental health programme budget.
1. Background and Context 1.1 Setting the scene This mental health needs assessment is written within the context of an emergent national policy agenda, both specifically in relation to mental health and wellbeing and more widely in the underlying social policy context of population mental health and wellbeing. It is also set within the rapidly changing social, political and economic climate of the UK today. This report uses definitions of mental health and wellbeing which are consistent with the national mental health strategy No Health Without Mental Health (see Glossary). A definition of good or positive mental health is explained more than in the absence or management of mental health problems; it is the foundation for wellbeing and effective functioning both for individuals and for their communities. Mental capital is the entirety of a persons cognitive and emotional resources. It includes their cognitive ability, how flexible and efficient they are at learning, and their emotional intelligence, such as their social skills and resilience in the face of stress. It therefore conditions how well an individual is able to contribute effectively to society, as well as their ability to enjoy a high quality of life. Mental health problem is an umbrella term to denote the full range of diagnosable mental illnesses and disorders. Mental illness is generally used to refer to more serious mental health problems that often require treatment by specialist services. Such illnesses include depression and anxiety (which may also be referred to as common mental health problems) as well as schizophrenia and bipolar disorder, also referred to as severe mental illness. This report is written amidst major emergent policy and organisational change within public health as well as the commissioning and provision of NHS and Social Care services. This includes Primary Care Trusts (PCTs) transferring many of their commissioning roles to GP Commissioning Consortia and the leadership and accountability for public mental health transferring to local authorities. The key findings and recommendations from this needs assessment will be relevant to the new and emerging organisations and leaders for mental health and wellbeing across the city, as well as for existing stakeholders. This report will contribute to the ongoing development of the Joint Strategic Needs Assessment for Leeds. It should also support future JSNAs and the Health and Wellbeing Strategy for the city through the newly-forming Health and Wellbeing Partnership arrangements 1.2 Scope of Report and Sources of Data The scope of the data used in this report encompasses population mental health and wellbeing for adults. This includes older peoples mental health and wellbeing with the exception of dementia. The scope of the report does not include learning disabilities, dementia, peri-natal mental health and wellbeing and the mental health and wellbeing of children and young people under 18. There are some differences in the age ranges of data sources around young people/adults so this is not entirely consistent, but data generally relating to children and young people is not included in the scope of the report.
Also, within the scope of the report there are gaps around some population groups, needs and/or services due to gaps in availability of data or poor data quality. Some of these gaps are highlighted in the reports recommendations. Future needs assessment should be undertaken to capture the needs of those outside the scope of this report. The report uses data and intelligence already available, in many different forms including local activity data, national prevalence data and qualitative information on the needs of the adult population of Leeds. Where possible this data is combined to inform the content and findings of local need. Due to the complex nature of the mental health and wellbeing agenda, and the inter-relationships with other programmes and services, key links to related programmes and documents are made throughout the report. The report is not comprehensive. It has many gaps and there are limitations in each of the data sources which inform our understanding of the mental health and wellbeing needs for our city. The strengths and limitations of each data source should be taken into account when reading the report, examining the data, and drawing conclusions on local need. Further work is needed on some elements of the report to give us a more accurate and comprehensive picture of need, and to more fully understand the influencing factors behind the data. The approach used within this needs assessment process is for the key findings and recommendations of the report to be shaped by the data and intelligence contained in the report. Where there are gaps in this data, this is reflected in the key findings and recommendations.
1.3 Policy Context for Mental Health and Wellbeing In relation to Mental Health & Wellbeing, this report takes into account the following policy context: The new mental health strategy No Health without Mental Health was published in February 2011. The strategys two aims are to improve the mental health and wellbeing of the population and keep people well; and to improve outcomes for people with mental health problems through high quality services that are equally accessible to all. The strategy calls to action a wide range of partner organisations through six objectives: i) More people will have good mental health ii) More people with mental health problems will recover iii) More people with mental health problems will have good physical health iv) More people will have a positive experience of care and support v) Fewer people will suffer avoidable harm vi) Fewer people will experience stigma and discrimination This strategy sits well with the new approach for the NHS, Public Health and Adult Social Care now set out in the NHS White Paper Equity and Excellence:, Liberating the NHS, the Public Health White Paper Healthy Lives, healthy people and in A Vision for Adult Social Care Capable communities and active citizens
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Key developments include: A focus on outcomes Local leadership via health and wellbeing boards; and the role of local authorities in commissioning for public health, including public mental health A new integrated public health service including Public Health England An independent NHS Commissioning Board GP commissioning consortia Health Watch England an independent consumer champion within the Care Quality Commission (CQC) Local Health Watch to represent the views of patients, carers and the public to commissioners and provide local intelligence for Health Watch England A range of ways of improving quality of services and meeting the aspirations of service users including NICE Quality Standards, the CQC, Payment by results, Quality Accounts and a more competitive market for providers. Three outcomes frameworks have been developed: for the NHS, public health and adult social care. Together they will provide a coherent and comprehensive approach to tracking national progress against an agreed range of critical outcomes. The NHS Outcomes Framework will be refined on an annual basis to make sure that the outcomes that matter to patients are included and that the indicators being used best capture those outcomes. The Public Health and Adult Social Care Outcomes Frameworks are at the time of this writing currently subject to consultation. The local delivery of the mental health and wellbeing agenda will include elements of all of the three outcomes frameworks. A further key driver to the mental health and wellbeing agenda in Leeds is the Marmot review of health inequalities post 2010 Fair Society Healthy Lives. In this report Sir Michael Marmot presents the evidence around key measures to reduce health inequalities and address the social gradient of health. This requires action by central and local government, the NHS, the third and private sectors and community groups. National policies will not work without effective local delivery systems focused on health equity in all policies. Key themes in Fair Society, Healthy Lives that also reflect newer frameworks and the well cited Mental Health, Resilience and Inequalities publication (Friedli WHO 2009) is the fact that mental health and wellbeing is everyones business.
1.4 Key Themes One of the key themes of the policies and publications above is that mental health can only be improved by input from all agencies, sectors and government departments. It isnt just a health issue but a major social issue demanding action across all parts of the government. Mental health and well-being needs to be considered in all national and local policy and programmes. Policy makers across all sectors have to think in terms of mental health impact. Action to tackle health inequalities needs to be across all sectors for examples the impact of housing and access to green space on health in the context of a total place whole area approach to public services.
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Mental health is linked with inequality. Addressing wider determinants of health will impact on both mental health and inequalities. Reducing inequalities will result in improved wellbeing, better mental health and less disability; children flourish and live in sustainable cohesive communities (Marmot, 2010). Levels of mental distress among communities need to be understood less in terms of individual pathology and more as a response to relative deprivation and social injustice (Friedli, 2009). We also know inequalities in mental health and wellbeing are influenced by broader social and economic inequalities as more people tend to have mental health problems in more unequal places. (Wilkinson & Pickett, 2009) There is overwhelming evidence to support relationship between good mental health and better physical health outcomes. Interventions to improve mental health also tackle health inequalities and vice versa. Cognitive Behavioural Therapy (CBT) is highly recommended for people who have long term health conditions. The physical health care of people who have mental health problems needs to improve markedly and effective health care should address both. A recovery approach will facilitate this improvement for individuals but also improvements for the whole of society as this approach promotes social inclusion including support for people to work. A policy objective in Marmot (2010) is to create fair employment and good work for all (including people who are disadvantaged) Being in good employment is protective of health, whereas people with mental health problems are often trapped in a cycle of low-paid, poor quality work and unemployment. Housing, employment, education and participation in mainstream community and leisure activities are central objectives for mental health services, not just things that professionals hope will happen if the person is cured (Centre for Mental Health). A life course approach is a key framework within current policy. For too many, lifetime mental health problems start in childhood. There is overwhelming evidence that to start initiatives early and work with families is crucial to reducing this trend. Giving every child the best start in life is the highest priority in addressing inequalities in health along the social gradient (Marmot 2010). A life course approach examines the individual within their environments across time and this approach views an individual's life as a journey with many different phases and transitions. Although the scope of this report does not include children, a life course approach is central to understanding the factors affecting mental health and wellbeing amongst adults. We need to be mindful of the limitations of separating an analysis of the needs of adults from those of children and ensure that the inter-relationships are wellmanaged and the strengths of the life course approach are maximised.
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Mental Health Needs Data Pack
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Definitions
The following terms are used throughout this data pack in terms of deprivation and geographical areas.
What is deprived Leeds? This report sometimes focuses on deprived Leeds; this is the area of Leeds within the 10% most deprived in England, according to the Index of Multiple Deprivation 2004. It is shown on Map 1 as the dark grey area and contains approximately 20% of the total Leeds population.
Map 1
What is the Index of Multiple Deprivation (IMD)? The Index of Multiple Deprivation is a measure of multiple deprivation at the small area level (LSOAs and MSOAs are used in this report), based on the idea of distinct dimensions of deprivation which can be recognised and measured separately. These are experienced by individuals living in an area. People may be counted as deprived in one or more of the domains, depending on the number of types of deprivation that they experience. The overall IMD is conceptualised as a weighted area level aggregation of these specific dimensions of deprivation (i.e. the individual indices of deprivation are combined to produce one overall percentage of deprivation in an area which allows comparison with other areas in terms of deprivation). Communities and Local Government: http://www.communities.gov.uk/publications/communities/indiciesdeprivation07
What are Super Output Areas (SOAs)? Super Output Areas are a geography for the collection and publication of small area statistics. The SOA layers form a hierarchy based on aggregations of Output Areas (OAs). SOAs avoid the problems caused by the inconsistent and unstable electoral ward geography. They are better for statistical comparison as they are of much more consistent size and each layer has a specified minimum population to avoid the risk of data disclosure (releasing data that could be traced to individuals). SOAs will not be subject to frequent boundary change, so are more suitable for comparison over time. In addition they will build on the existing availability of data for OAs. Office for National Statistics: http://www.neighbourhood.statistics.gov.uk/ 14
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population There are currently two levels of SOA in use in England and therefore in Leeds. These are Lower Layer Super Output Areas (LSOA) and Medium Layer Super Output areas (MSOA). There are 476 LSOAs within Leeds which are grouped together to form 108 MSOAs. When formed in 2004, LSOAs had a minimum size of 1,000 residents and 400 households, and an average population size of 1,500. MSOAs had a minimum size of 5,000 residents and 2,000 households, and an average population size of 7,200. A common misconception in Leeds seems to be that SOAs only cover deprived Leeds with deprived Leeds been described as the SOAs or the Super Output Areas. The SOAs in fact cover the whole of Leeds and only the 20% most deprived of these SOAs fall within deprived Leeds.
What are deprivation quintiles? Deprivation quintiles are based on the IMD scores of the LSOAs/MSOAs. They are calculated by listing all of the SOAs in order of their IMD score and dividing the list into 5 equally sized groups (in terms of the number of SOAs each group contains). As there are five groups these are the quintiles.
Map 2 shows the MSOAs and the MSOA deprivation quintiles. The overall map of Leeds is broken down into smaller sections these are the MSOAs within Leeds. Each of these MSOAs is assigned one of five colours (the darker the colour the more deprived the quintile) based on the IMD score of that MSOA. The five colours show the five deprivation quintiles (each MSOA of the same colour is in the same deprivation quintile). The thick orange lines show the boundaries of deprived Leeds.
Map 2
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Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population What are the NHS Leeds target practices? The target practices are the 42 practices within Leeds which have at least 20% of their registered population living within the Leeds LSOAs which fall into the top 10% most deprived LSOAs nationally. This equates to practices having at least 20% of their registered population living within Deprived Leeds. The target practices are shown on Map 3 as the blue diamonds. Their combined contracted practice boundaries are shown as the blue area, and the boundaries of deprived Leeds are shown as the thick orange lines.
Map 3
What are directly standardised rates? Directly standardised rates show the expected number of events/cases that would occur in a standard population, if the population had the same age-specific rates as the local area. The standard population that is most commonly used is the European Standard population which is a hypothetical population of 2 million people, split by 5 year age bands. The rates are usually calculated per 100,000 and, because rates are applied to the same population, rates across areas can be compared.
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Leeds Population Data

Registered Population April 2010 People registered with an NHS Leeds GP may not live within the Leeds boundaries. Likewise there are people who live within the Leeds boundaries but are not registered with an NHS Leeds GP (they may be registered outside Leeds or not registered with a GP at all). These people will not be included in these figures.
Area Deprived Leeds Non-Deprived Leeds All Leeds Living Outside Leeds Registered with a target practice Registered with a non-target practice Registered Population Total
Population 171,922 621,803 793,725 18,028 252,836 558,917 811,753
% of Reg. Pop 21.18% 76.60% 97.78% 2.22% 31.15% 68.85%
% of Leeds Pop 21.66% 78.34%
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Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Resident Population April 2010 Registered with a Leeds GP Includes only people who are registered with a Leeds GP and live within the Leeds boundaries. Anyone living inside the Leeds boundaries but registered with a non-Leeds GP, or registered with a Leeds GP and living outside the Leeds boundaries are excluded.
Deprived Leeds Population Pyramid
Non-Deprived Leeds Population Pyramid
The two population pyramids show that a higher percentage of the population of deprived Leeds are under the age of 20 compared with Non-Deprived Leeds and with Leeds as a whole. Similarly it can be seen that a higher percentage of people living in Non-Deprived Leeds are over the age of 45 compared to Non-Deprived Leeds. It can be seen that the population profile of the whole of Leeds fits more closely with the profile of Non-Deprived Leeds than that of Deprived Leeds, however this is due to the fact that 78% of the total Leeds population live in NonDeprived Leeds and hence only 22% live in Deprived Leeds. Hence Non-Deprived Leeds would be expected to be more reflective of the whole.
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Section 1: Mental Health Minimum Data Set (MHMDS) 2009-2010

The MHMDS only reports on activity within NHS Secondary Mental Health Services. The data is collated from all providers and for Leeds includes data from out of area providers such as North Yorkshire & York PCT, South West Yorkshire Partnership Foundation Trust and Bradford District Care Trust, among others, as well as the data from Leeds Partnership Foundation Trust (LPFT). Service Number Rates of access (per 100,000) to NHS secondary mental health services; 2009-2010 Age & Gender standardised rate of access Number 1,607 18,335 596 20,538 789 818 1,607 3,431 17,094 20,525 1,869 1,862 25,992 112,135 14,775 16,994 1,712 4,961 6,532 183,101 14.2% 61.2% 8.1% 9.3% 0.9% 2.7% 3.6% 100.0% 12.7% 53.6% 6.4% 14.1% 1.5% 1.6% 10.1% 100.0% 12.9% 53.7% 7.4% 11.1% 1.4% 2.1% 11.4% 100.0% Leeds Rate per 100,000 3,000 PCT Peers * Rate per 100,000 England Rate per 100,000 2,713
Number of people using (in contact with) NHS mental health services
Admitted Only non-admitted No care Total Formally Detained Informal Total CPA No CPA Total Admissions Discharges Psychiatrist contacts CPN contacts Psychologist contacts OT contacts Physio contacts Psychotherapist contacts Social worker contacts Total
% 7.8% 89.3% 2.9% 100.0% 49.1% 50.9% 100.0% 16.7% 83.3% 100.0%
% 8.3% 86.2% 5.5% 100.0% 42.6% 57.4% 100.0% 0.0% 100.0% 100.0%
% 8.5% 84.8% 6.7% 100.0% 39.4% 60.6% 100.0% 18.1% 81.9% 100.0%
Number of inpatients detained in hospital (under the Mental Health act 1983) Number of people on Care Programme Approach (CPA) Inpatient activity LPFT Outpatient and community activity
* PCT Peers Other PCTs with similar population structures and demographics to NHS Leeds. The PCTs which make up the PCT peers for NHS Leeds are: Brighton and Hove City PCT Bristol PCT Liverpool PCT Newcastle PCT Plymouth Teaching PCT Portsmouth City Teaching PCT Salford PCT Sheffield PCT Southampton City PCT
~A data quality report for all providers can be found through the following link: http://www.ic.nhs.uk/services/mhmds/dq. Based on this, further investigation may be required for some areas of the above table before using this to influence future decision making~ Source: The Information Centre for health and social care
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Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Rates of access (per 100,000) to NHS secondary mental health services; 2009-2010
The report shows the rate of access to NHS mental health services. Feedback from users on the 2008-09 release suggested that a single age and gender standardised rate for each commissioner would be more useful than the separate crude rates shown for 2008-09. Hence the change in the presentation of the figures between the two years. Definitions: Rate of access Number of people per 100,000 population accessing adult and elderly secondary mental health services.
The rate of access to NHS Mental Health Services for people registered with an NHS Leeds GP was 3,000 per 100,000 population in 2009-2010. This was approximately 300 people higher, per 100,000, than the rate for England as a whole. There is no data currently provided for the PCT peers for this year so no comparison can be made. The way the data was reported has changed between the 2008-2009 report and 2009-2010 so a direct comparison cannot be made between the two without further data and calculations based on this.
Figure 1
Leeds
England
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StandardisedrateofaccesstoNHSsecondarymentalhealthservices
Number of people using (in contact with) NHS secondary mental health services; 2009-2010
The report shows the number of people who used NHS adult and elderly secondary mental health services during the year. Many of these people will have had more than one episode of care during the year or received care from more than one provider, but each person is only counted once. The numbers are divided into those whose care during the year included at least one day as an inpatient (admitted), those for whom there are records of contact with outpatient or community services or a CPA review, but who did not spend any time as an inpatient (only non admitted) and those for whom no kind of contact, attendance or time in hospital was recorded during the year (no care). Each person is counted in one category only, with admitted ranked first and no care last. Definitions: Admitted People who spent at least one day as an inpatient during the year. This category is ranked over the other two so if a patient is in the admitted category they will not be counted in either of the other categories. Only non-admitted care People who had contact with outpatient or community services or attended a day hospital, but who did not spend any time in hospital as an inpatient. No care People who had a record with the provider during the year but for whom there is no record of any care being delivered.
The percentage of people admitted as inpatients from Leeds was slightly below the percentage for the PCT peers and for England as a whole. The percentage receiving no care is approximately 2-4% lower for Leeds than for the PCT Peers and England, with the proportional difference made up of those who received non-admitted care. The actual total number of people in contact with NHS secondary mental health services, registered with Leeds, has increased between 2008-2009 and 2009-2010 with increases in all areas of contact (admitted, non-admitted and no care). Proportionally there have been increases in the percentages receiving non-admitted care and non care and a reduction in those receiving admitted care however the differences are all under 1%. The PCT peers have moved in a similar direction to Leeds, in terms of proportions of each type of contact, while there has been little change proportionally across England as a whole. 20
Figure 2
Leeds
PCTPeers*
England
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10%
20%
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Admitted
40%
50%
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Nocare
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Onlynonadmitted
Number of inpatients detained in hospital (under the Mental Health act 1983); 2009-2010
This report shows the number of people who spent time formally detained in an NHS hospital under the Mental Health Act 1983 during the year. This number is shown as a proportion of all people who spent time as inpatients in mental health services. Each person is counted only once and in one category with formal ranked before informal, so if a person spent time as a formally detained patient and time as an informal patient, they are counted once only in the formal category. Legal status was not recorded for some inpatients and it is assumed that this is because they were never formally detained during the year. Although they are assumed to be in the informal category these people are grouped separately. Definitions: Formally detained People who spent at least one day formally retained in hospital under the Mental Health Act 1983 (or previous related legislation). Informal patients People who spent at least one day in hospital but were not formally detained under the Mental Health Act during the year (although they may have been in the previous year).
The percentage of admissions which were recorded as being formally detained from Leeds was just below 50%. This was higher than the percentages for the PCT peers and for England as a whole which were just above and just below 40% respectively. The Leeds figure of formal admissions for 2008-2009 was 8.7% which is much lower than the figure for 2009-2010. The 2007-2008 figure was just under 55% which would suggest there is something unusual about the 2008-2009 figure, however, further investigation would be required to ascertain the cause of this figure. It may be that this could partially be due to a reduced bed base and/or the introduction of the Mental Capacity Act. The percentages of formal admissions for the PCT peers and England are approximately 15% and 10% higher respectively in 2009-2010 than in 2008-2009.
Figure 3
Leeds
PCTPeers*
England
0%
10%
20%
30%
40%
FormallyDetained
50%
Informal
60%
70%
80%
90%
100%
21
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Number of people on Care Programme Approach (CPA); 2009-2010
This report shows the number of people who spent days on the Care Programme Approach during the year. CPA supports people with long term mental health needs and so the statistics show the proportion of patients that had more complex mental health care needs. Each person is counted once only.
The data reporting has changed between 2008-2009 and 2009-2010 with the latter only providing a combined figure for people on CPA while this was previously split between Standard and Enhanced CPA. The percentage of people on CPA during 2009-2010 was just under 17% for Leeds while for England as a whole this was slightly higher. The figure provided for the PCT peers gives 0% of people on a CPA and 100%. These figures would appear to be incorrect however, without further data it is not possible to confirm this or to calculate any other figures for this. It is possible to do some comparison between the two years data as the overall number on CPA can be calculated for the 2008-2009 data. This shows that the overall percentage of people on CPA, for Leeds, has dropped from just under 33% down to just under 17%. The percentage drop for England has been even slightly greater from around 35% down to around 18%. This decrease, at least for Leeds, has been caused by a combination of a decrease in the number of people on CPA, an increase in the number of people with no CPA and also an increase in the number of people accessing services overall.
Figure 4
Leeds
PCTPeers*
England
0%
10%
20%
30%
40%
CPA
50%
NoCPA
60%
70%
80%
90%
100%
Outpatient and community activity; 2009-2010

This report counts contacts with members of the community mental health team and attendances at outpatient clinics (shown at contacts with a consultant psychiatrist).
Leeds patients had a higher percentage of Psychiatrist, CPN, Psychologist and Psychotherapist contacts than the PCT peers and England. The percentage of physio contacts is very similar across Leeds, the PCT peers and England. Leeds patients had a lower percentage of contacts with OTs, Physios and Social Workers than in the PCT peers and England as a whole. The overall number of outpatient and community contacts was lower by approximately 11,500 in 2009-2010 than in 2008-2009. The main decrease was in OT contacts with a 53.5% reduction which accounted for nearly 20,000 contacts. There were also reductions of over 7,000 contacts in Psychiatrist and Social Workers which accounted for 22.9% and 52.4% of the contacts from 2008-2009 respectively. There was also a 30% reduction in physio contacts but due to the lower number of contacts this was only a reduction of around 750. There were increase in CPN, Psychologist, and Psychotherapist contacts of approximately 8,600 (8.4%), 10,300 (232.0%) and 4,800 (2,625.8%) respectively. The high percentage increases were due to relatively low numbers in 2008-2009 with only 182 Psychotherapist contacts during that year.
22
Figure 5
Leeds
PCTPeers*
England
0%
Psychiatristcontacts
10%
CPNcontacts
20%
30%
40%
OTcontacts
50%
60%
70%
80%
90%
100%
Psychologistcontacts
Physiocontacts
Psychotherapistcontacts
Socialworkercontacts
One possible explanation of the differences between the 2008-2009 and the 2009-2010 data could be due to the improvement in data quality of recording at Leeds Partnership Foundation Trust over the period.
LPFT Contracting Data; 2007/08 2009/10

This data is not from the Mental Health Minimum Data Set but based on data provided by LPFT. However, it provides a further breakdown of similar data to that which is included in the MHMDS. As such it does not include data from any provider other than LPFT.
The maps on the following two pages show the rates per 100,000 of 18+ population, by MSOA, for discharges from LPFT and for outpatient first attendances at LPFT. The rates are an average of three years data from 2007/08 up until 2009/10. This allows analysis of which areas of Leeds have higher levels of access to services at LPFT. The thick orange lines show the boundaries of deprived Leeds to show whether there are higher levels of access in more deprived areas of the city.
23
Section 2: Psychiatric Morbidity

The Adult Psychiatric Morbidity Survey provides data on the prevalence of both treated and untreated psychiatric disorder in the English adult population. The 2007 survey was conducted by the National Centre for Social Research in collaboration with the University of Leicester for the NHS Information Centre for health and social care. The survey used a robust stratified, multi-staged probability sample of households and assesses psychiatric disorder where possible to actual diagnostic criteria. The Information Centre for health and social care: http://www.ic.nhs.uk/pubs/psychiatricmorbidity07 Age group Sex F F F F F F F M M M M M M M 16 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 Total 16 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 Total Leeds Total 63,979 64,841 55,045 48,928 40,994 30,779 304,566 59,210 69,237 61,834 52,124 41,715 28,289 312,409 616,975 Rate 210 218 184 234 161 122 119 133 133 138 102 67 158 No. 13,436 14,135 10,128 11,449 6,600 3,755 59,503 7,046 9,209 8,224 7,193 4,255 1,895 37,822 97,325 Rate 27 24 27 22 22 4 3 15 15 7 6 3 16 No. 1,727 1,556 1,486 1,076 902 123 6,871 178 1,039 928 365 250 85 2,844 9,715 Rate 29 17 32 49 22 16 15 27 26 26 15 4 24 No. 1,855 1,102 1,761 2,397 902 492 8,511 888 1,869 1,608 1,355 626 113 6,459 14,970 Population 16-74 * Any neurotic All phobias Depressive episode Generalised anxiety disorder Rate No. 53 3,391 43 2,788 59 3,248 80 3,914 55 2,255 36 1,108 16,704 19 1,125 41 2,839 47 2,906 41 2,137 27 1,126 29 820 10,954 45 27,657 Mixed anxiety depression Rate 123 141 97 143 90 86 82 74 74 81 68 39 95 No. 7,869 9,143 5,339 6,997 3,689 2,647 35,684 4,855 5,124 4,576 4,222 2,837 1,103 22,716 58,401 Obsessive compulsive disorder Rate No. 30 1,919 15 973 10 550 16 783 7 287 4 123 4,635 16 947 15 1,039 12 742 7 365 4 167 2 57 3,316 13 7,952 Panic disorder Rate 8 23 14 11 14 1 14 9 13 8 6 10 12 No. 512 1,491 771 538 574 31 3,917 829 623 804 417 250 283 3,206 7,123
* GP registered population Source: Estimating from the Psychiatric Morbidity Survey 2007. National rates applied to the local population The rates are provided by the 2007 Psychiatric Morbidity Survey and used to calculate actual numbers of people within Leeds with the conditions listed. The populations used are the GP registered populations at April 2010. As these are national rates applied to local populations it is not possible to compare Leeds to the national average, or to other similar PCTs, as the rates used will be the same. The national data shows that the highest rate per 100,000 for any neurotic disorder would be expected in Females aged 45 to 54. The highest rate in Males would also be expected in 45 to 54 year olds however, there would only be expected to be 59% of the number of females within this age range. When applied to Leeds populations the most people with any neurotic disorder would be expected to be within the 25 to 34 year age range for both Males and Females which are also the age ranges with the largest population registered with NHS Leeds. The Any neurotic section is a composition of the individual diagnoses, however due to co-morbidities the individual parts may add up to more than the Any neurotic total. 26
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Calculated number of Leeds GP registered patients with any Neurotic Disorder from national rates (2007 Psychiatric Morbidity Survey).
Figure 6
65to74
Anyneurotic(M)
55to64
Anyneurotic(F)
45to54 Age 35to44 25to34 16to24
2,000
4,000
6,000
8,000 People
10,000
12,000
14,000
16,000
National rates per 100,000 of patients with any Neurotic Disorder (2007 Psychiatric Morbidity Survey).
Figure 7
65to74
Anyneurotic(M)
55to64
Anyneurotic(F)
45to54 Age 35to44 25to34 16to24
50
100 150 Rateper100,000population
200
250
The charts for the individual diagnoses show similar overall patterns with higher numbers of diagnoses in females than in males for almost all disorders in all age groups with the main exceptions being in the 25-34 age group for Depressive episode, Generalised anxiety disorder and Obsessive compulsive disorder. 27
Section 3: Primary Care Mental Health Presentations

Source: GP Data Audit Queries. New diagnoses only. Note: The data has the following constraints Over 18s only Patient has been registered for at least a year prior to the first day of the quarter being studied Patient has NOT had a mental health code in the year prior to the first day of the study quarter There are two practices within Leeds who have not signed up to the audit collections and, as such their data is not included in the analysis. There are also occasions when data has not been available from one or two other practices during a quarter. As there are 113 practices within Leeds, missing data for a practice should not create too much of a discrepancy, and the population of that practice will be removed for the rate calculation. As such, All Leeds Practices are all practices for which data is available for the specific quarter. Number of new diagnoses, in Leeds GP practices, of disorders by quarter Q2 2009 to Q3 2010
Count
Presenting Disorder Anxiety Anxiety with depression Depression Obsessive compulsive disorder Panic disorders Phobic disorders Post traumatic stress disorder
Rate per 100,000 population
Q2 09/10 531 1,387 2,952 49 290 194 54
Q3 09/10 500 1,358 3,013 54 272 126 57
Q4 09/10 403 1,144 2,845 41 227 102 52
Q1 10/11 410 1,179 2,645 45 193 118 40
Q2 10/11 423 1,142 2,721 55 231 130 40
Q3 10/11 450 1,016 2,545 45 214 106 42
Total 2,717 7,226 16,721 289 1,427 776 285
Q2 09/10 84.84 221.60 471.64 7.83 46.33 31.00 8.63
Q3 09/10 79.72 216.52 480.40 8.61 43.37 20.09 9.09
Q4 09/10 63.87 181.29 450.86 6.50 35.97 16.16 8.24
Q1 10/11 64.82 186.39 418.14 7.11 30.51 18.65 6.32
Q2 10/11 66.31 179.02 426.53 8.62 36.21 20.38 6.27
Q3 10/11 70.92 160.11 401.07 7.09 33.72 16.70 6.62
The data included in this section is from queries included in the quarterly GP audit data collections. The data was first collected in Q2 2009/10 and as such there is yet data available for a full year (Q1-Q4). Included are the number of new diagnoses made each quarter for anxiety, anxiety with depression, depression, obsessive compulsive disorder, panic disorder, phobic disorders and post traumatic stress disorder. The data does not give a prevalence of any of these within the population, just the incidence of new diagnoses. The highest number of new diagnoses across Leeds each quarter from Q2 0910 to Q3 1011 were for depression, which showed over twice the second number of diagnoses, for anxiety with depression. These high levels of depression reflect what is been seen as a growing trend in the population. The lowest number of diagnoses each quarter were for obsessive compulsive disorder and for post traumatic stress disorder. Diagnoses of Depression and Anxiety with depression account for over 80% of all the diagnoses (included in the audits). While the total count of people with any of the above presenting disorders can be compared across organisations using data from IAPT returns, there is no breakdown of presenting disorder available to compare these across the organisations or with the Yorkshire & Humber SHA and England. This will therefore not show if there are similar patterns of disorders to in Leeds. 28
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Number of new diagnoses, in the 42 Leeds Target GP practices, of disorders by quarter Q2 2009 to Q3 2010
Count
Rate per 100,000 population
Q2 09/10 184 443 941 16 109 59 23
Q3 09/10 150 334 868 16 96 34 21
Q4 09/10 153 353 971 15 95 33 26
Q1 10/11 143 319 809 16 51 37 17
Q2 10/11 152 345 901 21 82 37 19
Q3 10/11 136 276 820 12 74 37 20
Total 918 2,070 5,310 96 507 237 126
Q2 09/10 94.76 228.15 484.62 8.24 56.14 30.39 11.85
Q3 09/10 79.00 175.91 457.15 8.43 50.56 17.91 11.06
Q4 09/10 78.75 181.70 499.81 7.72 48.90 16.99 13.38
Q1 10/11 73.60 164.19 416.38 8.24 26.25 19.04 8.75
Q2 10/11 78.35 177.83 464.41 10.82 42.27 19.07 9.79
Q3 10/11 70.38 142.83 424.35 6.21 38.29 19.15 10.35
Comparing the rates of the target practices (see page vi for definition) with the rates across all the practices shows that the rates of new diagnoses of the listed disorders are very similar in the subset to the whole. The charts in figure 8 show that the only disorder which has a higher rate of new diagnoses in the target practices during all available quarters is Post Traumatic Stress Disorder (PTSD), however, this disorder has the lowest number of new diagnoses of all the disorders listed, across all the practices and all quarters. There are high levels of PTSD in the migrant population (though not exclusively) who are more likely to be resident in more deprived areas of Leeds and thus showing higher levels in the target practice population.
29
Figure 8
Anxiety
100 80 60 40 20 0 Q209/10 Q309/10 Q409/10 Q110/11 Q210/11 Q310/11 TargetPractices AllLeedsPractices 250 200 150 100 50 0
AnxietywithDepression
Q209/10 Q309/10 Q409/10 Q110/11 Q210/11 Q310/11 TargetPractices AllLeedsPractices
Depression
600 500 400 300 200 100 0 Q209/10 Q309/10 Q409/10 Q110/11 Q210/11 Q310/11 TargetPractices AllLeedsPractices 12 10 8 6 4 2 0
ObsessiveCompulsiveDisorder
PanicDisorders
60 50 40 30 20 10 0 Q209/10 Q309/10 Q409/10 Q110/11 Q210/11 Q310/11 TargetPractices AllLeedsPractices 35 30 25 20 15 10 5 0
PhobicDisorders
PostTraumaticStressDisorder
16 14 12 10 8 6 4 2 0 Q209/10 Q309/10 Q409/10 Q110/11 Q210/11 Q310/11 TargetPractices AllLeedsPractices
30
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population New diagnoses, in Leeds GP practices, of affective disorders Q2 2009 to Q3 2010 by Consortium and percentage of over 18 population. Presenting Disorder Anxiety Population Percentage Anxiety with Depression Population Percentage Depression Population Percentage Obsessive Compulsive Disorder Population Percentage Panic Disorder Population Percentage Phobic Disorders Population Percentage Post Traumatic Stress Disorder Population Percentage Calibre
493 0.39% 1,644 1.30% 2,332 1.85% 58 0.05% 225 0.18% 192 0.15% 60 0.05%
Church Street Group

87 0.75% 59 0.51% 381 3.29% 2 0.02% 37 0.32% 11 0.09% 3 0.03%
H3+
1,038 0.43% 2,723 1.13% 7,115 2.97% 118 0.05% 566 0.24% 303 0.13% 98 0.04%
Independent
376 0.34% 1,254 1.15% 2,690 2.46% 41 0.04% 227 0.21% 88 0.08% 54 0.05%
Leodis Healthcare
723 0.45% 1,546 0.96% 4,203 2.62% 70 0.04% 372 0.23% 182 0.11% 70 0.04%
Grand Total
2,717 0.43% 7,226 1.14% 16,721 2.64% 289 0.05% 1,427 0.22% 776 0.12% 285 0.04%
The practices in the Consortia have changed during the period used and as such the practices used to make up each Consortium are the ones that made up that Consortium at the end of the period. The Consortia population has been taken as a total of the practice populations within that Consortium at the end of the period. Maps showing the locations of the practices within each Consortia and the coverage of their boundaries are included on the next pages.
The Calibre Consortium has the lowest overall percentage of new diagnoses in the specified time period. The Church Street Group has the highest percentage of new diagnoses; however, the consortium is much smaller than any of the other consortium. The second highest, just behind the Church Street Group, is H3+ consortium. It seems there may be some overlap between the separate codes for Anxiety and Depression, and the combined code for Anxiety & Depression. Calibre had the lowest percentage of population diagnosed with depression and the lowest diagnosed with anxiety, of all the consortia, but has the highest percentage diagnosed with combined anxiety and depression. Church Street Group has the highest percentage of population diagnosed with depression and the highest diagnosed with anxiety, of all the consortia, but has the lowest percentage diagnosed with combined anxiety and depression. This trend continues with the consortia in between.
Figure 9
3.50% 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% Calibre

Anxiety AnxietywithDepression
ChurchStreet Group
Depression
H3+
Independent
PanicDisorder
LeodisHealthcare
PhobicDisorders
GrandTotal
ObsessiveCompulsiveDisorder
PostTraumaticStressDisorder
31
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Referrals to IAPT Services 2009/10 Figure 10 shows the referral rates, per 1,000 of the 18+ population, into IAPT services for each practice in 2009/10. The charts shows that there is no real correlation between higher referral rates and target practices as the target 2 practices are relatively evenly spaced throughout the whole range of referral rates and the R value is only 0.0311 2 2 (R =0 shows no correlation, R =1 shows strong correlation). As such there is no evidence that a high rate of referrals come from deprived Leeds. This does not however necessarily mean that the practices near the top of the list have a higher prevalence of mental health issues than those near the bottom of the list as IAPT services are not the only services to which people with mental health issues can be referred. As such, it could be that those practices with lower referral rates are choosing to refer their patients to a different service.
Figure 10 50 45 40
Rateper1,000population
35 30 25 20 15 10 5 0
GPPractice
The Black columns are practices within the 42 target practices in Leeds the Blue columns are practices which are not in this group of 42 target practices. For definition of target practices see page vi.
60 R=0.0311 50 Rateper1,000population 40 30 20 10 0 0 5 10 15 20 25 30 35 40 45
Deprivation 34
Section 4: Suicide & Self Harm

Suicide Rate per 100,000 population for suicides by gender and age group, Leeds 2006-2008 Age Band 1-4 5-14 15-34 35-64 65-74 75+ Total Female 0.0 0.8 2.9 4.3 2.2 2.0 3.0 Male 0.0 0.0 10.3 17.5 5.0 6.5 10.7
For the three year average data from 2006-2008 the overall rate of suicide was higher for males than females with over 3 times as many males committing suicide as females. The rate is also higher for males in all age bands except the 5-14 age group. The highest suicide rate for both males and females is within the 35-64 age group. The male rate is approximately 4 times higher than the female rate in this age group. This is the largest percentage difference between genders in any of the age groups.
Figure 11
20 18
16 14 12 10 8 6 4 2 0 14 514 1534
Female
3564
AgeGroup
Male
6574
75+
Total
Rate per 100,000 population for suicides by age group, Leeds 2004-2006 to 2006-2008 Age Band 1-4 5-14 15-34 35-64 65-74 75+ Total 2004-2006 0.0 0.0 6.0 10.2 4.1 4.4 6.3 2005-2007 0.0 0.0 6.1 10.4 4.1 2.5 6.3 2006-2008 0.0 0.4 6.7 10.8 3.5 3.7 6.7
The overall suicide rate has risen slightly, by 0.4 per 100,000 population, over the three three year average periods. The main cause of the overall increase is within the 15-34 and 35-64 age ranges, while the rates for 65+ have fallen from 2004-2006 to 2006-2008. The highest suicide rate was in the 35-64 age range in each three year average periods. 36
Figure 12
12
10 8 6 4 2 0 14 514 1534 3564

AgeGroup
20042006 20052007 20062008
6574
75+
Total
Rate per 100,000 population for suicides by age group, Leeds, Yorkshire & Humber and England 2006-2008 Age Band 1-4 5-14 15-34 35-64 65-74 75+ Total Leeds 0.0 0.4 6.7 10.8 3.5 3.7 6.7 Yorkshire and Humber 0.0 0.2 6.4 9.8 5.1 7.0 6.7 England 0.0 0.1 5.8 9.3 3.6 4.6 6.1
The total suicide rate per 100,000 population in Leeds was the same as for Yorkshire and the Humber for the 20062008 period. Both of these rates were slightly higher than the rate for England as a whole. The rates in the under 65 age groups were higher for Leeds than both Yorkshire and the Humber and England, however were lower than both of these rates in the other 65 age ranges. The Yorkshire and the Humber rate was higher than England in all age ranges. The highest rates for all three areas were in the 35-64 age range.
Figure 13
12
10 8 6 4 2 0 14 514 1534 3564

AgeGroup
Leeds YorkshireandHumber England
6574
75+
Total
37
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population In 2006 a local suicide audit was undertaken by NHS Leeds to establish a baseline data set for ongoing regular audits and monitor suicide deaths in Leeds. This data then informed the suicide prevention group and compared local results with nationwide patterns. The main findings from the Leeds audit were; Over 10% males who had completed suicide had accessed their GP within 7 days prior to death, and under 20% males had been to see their GP within a month. Over 30% of women had accessed their GP within 7 days of completing suicide and slightly less within a month of seeing their GP Suicide methods for men was predominantly by hanging, and for women the method was predominantly self poisoning Over 40% had no known previous contact with mental health services Within 2 weeks of death 5 people had changed their medication It is recommended that a new and updated Suicide Audit and a citywide Suicide Strategy are completed for Leeds. Self Harm Patient age profile Inpatients at Discharge
Figure 14
98 91 84 77 70 63 56 49 42 35 28 21 14 7 0 30 20 10 0 10 20 30 40 50
Patientage
Numberofindividuals Males Females
There were 1,601 patients discharged from hospital following a self-harm related admission in 2009/10. These are shown in Figure 14, split by age and gender. This shows that from the age of 30 onwards, the numbers of males and females who had one of more self-harm related inpatient spell during the year were roughly equal (460 women compared to 422 men). By contrast for the under 30s nearly twice as many females had one of more self-harm related inpatient spells compared to males (478 women compared to 241 men). The data also shows that women self-harm at a younger age than men. There are significant numbers from 13 years of age for females but 17 years for males (16 males under 17 compared to 102 females).
Self harm related Inpatient activity 38
Figures 15 and 16 show a time series of self-harm related inpatient spells for the period Apr-07 to Jun-10 by discharge month. These data demonstrate that over this period self-harm related hospital spells have remained relatively stable, averaging 184 per month. The data in Figure 17 shows a clear gender bias with females accounting for 59% of all self-harm related hospital admissions, as is consistent with the age profile of this group of patients. The time series also shows a weak seasonality with admissions peaking in the autumn, although short-term fluctuations in admissions largely mask this pattern. This is shown in Figure 15.
Figure 15
160 140
SelfharmrelatedIPspells
120 100 80 60 40 20 0
Figure 16
250
200
150
100
50
April
July
September
December
February
August
October
2007/08
2008/09
2009/10
November
2010/11
January
March
June
May
2007 04 2007 06 2007 08 2007 10 2007 12 2008 02 2008 04 2008 06 2008 08 2008 10 2008 12 2009 02 2009 04 2009 06 2009 08 2009 10 2009 12 2010 02 2010 04 2010 06
Females Males
39
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Figure 17 shows a frequency plot of the numbers of self-harm related IP spells that the cohort of 1,601 patients had during 2009/10. This plot demonstrates that the vast majority of patients (83.4%) only had one self-harm related IP spell during this period. A small minority had multiple self-harm related IP admissions (with 4.0% of the group of patients having 4 or more self harm related IP admissions during this period). A similar pattern is seen with males and females.
Figure 17
1,600
100.0%
1,400 1,200 1,000 800 600 400 200 0 1 3 5 7 9 11 13 15 17 19 21 23 25 75.0% 85.0% 80.0%
90.0%
Annualno.ofselfharmrelatedIPspells Females Males Cum.%
The cumulative percentage (green line) shows the percentage of people who had up to and including that number of inpatient spells.
Self Harm Related Diagnoses The most common primary diagnosis for self harm related inpatient spells recorded during 2009/10 was poisoning, accounting for 1,960 inpatient episodes. The highest percentage of poisonings were recorded as Poisoning by 4Aminophenol derivatives, approximately 40%. Injuries, mainly to the arms, wrists and hands accounted for 273 inpatient spells, while 29 episodes where recorded as Other Mental health diagnoses including depression and alcohol related. There were 26 episodes assigned to Other Conditions.
Ethnic Origin The vast majority of patients are reported as being of British origin (91% of the total). This percentage is higher than that for all Leeds residents (82%) suggesting some ethnic groups are less likely to seek medical treatment for selfinflicted injuries or are less likely to disclose that their injuries are self inflicted. The gender split varies significantly between ethnic groups, with South Asian, Southern European and East Asian ethnic groups showing the largest bias toward females. This may reflect cultural factors that influence uptake of healthcare for self-inflicted injuries by males.
Cumulativepercentage
95.0%
40
Section 5: Mental Health Audit Data (Severe Mental Illness Register)

The mental health audit is part of the quarterly GP data collection and includes the same codes as the QOF severe mental illness register data but also provides further breakdown by age, gender, deprivation and actual diagnosis. The data used is from the Quarter 2 2010/11 audit run in October 2010 but provides prevalence data so will include people diagnosed prior to this quarter. The audit only pulls out the most recent diagnosis, so, for example, if a person is diagnosed with a depressive disorder and then with a bipolar disorder the audit will only pull out the recording of the bipolar disorder. As this information is collected by NHS Leeds directly from the Leeds GP practices it is not directly comparable with other PCTs as identically sourced data is not available. However, the data from the severe mental illness register is also available from the Quality and Outcomes Framework (QOF) data for both NHS Leeds and other PCTs as well as the Yorkshire and Humber SHA and England. QOF data cannot be broken down by age and gender, or by diagnosis and as such cannot be used as a comparator in this section, however, Section 6 (pg. 28) contains comparisons of QOF data for Leeds and the Core Cities. Female 18-64 890 127 32 67 15 1,252 ** 2,386 Male 18-64 627 92 35 70 16 2,000 ** 2,845 Total >65 121 29 17 26 ** 327 ** 526 1,908 294 109 198 38 4,177 16 6,740
Bipolar disorder Depressive disorder Hypomania Mania Other and unspecified affective psychoses Psychotic disorder Unknown local code Total
<18 ** ** ** ** ** ** ** **
>65 268 45 25 35 6 588 ** 970
<18 ** ** ** ** ** ** ** **
(Note: figures under 5 have been suppressed to prevent identification of individual persons (replaced with **). As such, the columns may not add up to the column totals)
The majority of people with severe mental disorders, as picked up in the audit, are within the 18-64 age range, with 71% of females and 81% of males falling within this range. The male-female split is even with only 18 different between the two; however there are a higher percentage of females of an older age than males. Psychotic disorders and bipolar disorders account for 90% of all the diagnoses (62% and 28% respectively).
Figure 18 Female
<18 1864 >65
500
1,000 People
1,500
2,000
2,500
41
Figure 19 Male
<18 1864 >65
500
1000 People
1500
2000
2500
MSOA Deprivation Quintile 1 - Most 2 3 4 5 - Least Leeds
Count 1,863 1,577 1,087 881 946 6,740
Population 159,666 165,922 130,630 127,811 155,384 739,413
Rate 1.17% 0.95% 0.83% 0.69% 0.61% 0.91%
The audit data shows that, when grouped into quintiles of deprivation by Medium Super Output Area (MSOA), that the more deprived the area is the higher the prevalence of severe mental health issues. This is based on the deprivation of where the people actually live rather than on the deprivation scores of the practice as used in the QOF section. This would suggest a direct link between deprivation and Severe Mental Illness.
Figure 20
1.4%
1.2%
1.0%
Leeds
0.8%
0.6%
0.4%
0.2%
0.0% 1 Most 2 3 MSOADeprivationQunitile 42 4 5 Least
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Deprivation Deprived Leeds Non-Deprived Leeds Leeds Total Count 1,863 4,491 6,740 Population 159,666 579,747 739,413 Rate 1.17% 0.77% 0.91%
As expected from the MSOA deprivation quintiles, the rate in the Lower Super Output Areas (LSOA) that fall in Deprived Leeds is higher than the rate in the rest of Leeds (Non-deprived Leeds).
Figure 21
DeprivedLeeds
NonDeprivedLeeds
LeedsTotal
0.00%
0.20%
0.40%
0.60%
0.80%
1.00%
1.20%
1.40%
Comparison with Psychiatric Morbidity Report 2007 national prevalence rates Age group Population 16-74 * 128,820 55,045 48,928 40,994 30,779 304,566 128,447 61,834 52,124 41,715 28,289 312,409 616,975 All Psychotic Disorders PMR 2007 % No. 0.3 386 1.0 550 0.9 440 0.6 246 0.1 31 1,654 0.4 514 0.7 433 0.3 156 0.2 83 0.1 28 1,215 2,355 Audit Actual Numbers No. 400 542 656 543 397 2,538 710 743 653 528 283 2,917 5,455
Sex
F 16 to 34 F 35 to 44 F 45 to 54 F 55 to 64 F 65 to 74 F Total M 16 to 34 M 35 to 44 M 45 to 54 M 55 to 64 M 65 to 74 M Total Leeds Total
Note: The Psychiatric Morbidity Report 2007 data is Probable Psychosis and the disorders used are based on the World Health Organisation International Classification of Diseases chapter on Mental and Behavioural Disorders Diagnostic Criteria for Research (ICD10). They consist of two main types: Schizophrenia and affective psychosis, such as bi-polar disorder. For the measure of probable psychosis the following approach was used: For those who screened positive for psychosis at phase one and had a SCAN assessment, the results of the SCAN were used. For those who screened negative for psychosis at phase one, it was assumed that these were true negatives regardless of whether or not a SCAN assessment was completed. For those who screened positive for psychosis at phase one but did not have a SCAN assessment (e.g. due to refusal or non-contact) those meeting just one psychosis screen criterion at phase one were assigned a negative probable psychosis outcome, and those meeting two or more psychosis screening criteria were assigned a positive outcome. The GP audit data separates this into two individual sections with Schizophrenia under the heading of Psychotic Disorder and Affective psychosis under Bipolar disorder.
43
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population The national rates from the Psychiatric Morbidity Report 2007 show that more females than males would be expected to have a psychotic disorder within the 16-74 age range. The audit data shows that, within Leeds, more males than females are recorded as having a psychotic disorder. It also shows that almost double the number of people in Leeds are recorded as having a psychotic disorder compared to what would be expected from the national rates. The main difference in females is in the older age ranges from 45 and above, while in males there is a consistently higher number across all age ranges. Ethnicity Data Severe Mental Illness
Ethnicity Background Known Background Unknown Not Stated Unknown Not Recorded Grand Total Prevalence 4,533 2,207 52 101 2,054 6,740 Percentage 67.26% 32.74% 0.77% 1.50% 30.47%
Split of Recorded Ethnicity

Ethnicity White Background White British White Irish Other White Background Asian Background Bangladeshi or British Bangladeshi Indian or British Indian Pakistani or British Pakistani Other Asian Background Black Background Black African Black Caribbean Other Black Background Mixed Background Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Caribbean Other Mixed Background Chinese and Other Background Chinese Other Ethnic Background Known Total Prevalence 3,890 3,574 47 269 318 20 85 163 50 204 89 73 42 68 15 18 25 10 53 14 39 4,533 Percentage 85.82% 78.84% 1.04% 5.93% 7.02% 0.44% 1.88% 3.60% 1.10% 4.50% 1.96% 1.61% 0.93% 1.50% 0.33% 0.40% 0.55% 0.22% 1.17% 0.31% 0.86%
The data shows that, within GP practice, the ethnicity of 32.74% of people on the severe mental illness register is unknown. This may introduce a bias into any further analysis of the ethnicity data as it is not possible to say whether the people with unknown ethnicity follow a similar prevalence to those which are unknown. Of the peoples ethnicity which was known nearly 86% were from a white background, leaving just over 14% from Black and Minority Ethnic (BME) groups. Mosaic Origins software has been used to try and calculate the ethnicity of every person registered with a GP in Leeds based on their first and surnames. For 2011 the software gives an estimated ethnic breakdown of nearly 87% leaving just over 13% from BME groups. This shows that the breakdown of White compared to BME, for those whose ethnicity is recorded, on the Severe Mental Illness register is reasonably representative of Leeds as a whole. The breakdown within the BME groups does not correlate as well with only 1.3% of the Leeds population been calculated as from a Black background and a higher proportion of the population falling in to Other Ethnic Background.
44
Section 6: Quality & Outcomes Framework (QOF)

Prevalence of Patients on the Severe Mental Illness Registers by Consortia and GP Practice 2009-2010 Consortium Calibre Church Street Group H3+ Independent Leodis Healthcare Leeds Total Yorkshire and Humber England Core Cities Bristol PCT Liverpool PCT Manchester PCT Newcastle PCT Nottingham City PCT Sheffield PCT Patients on the Mental Health Register 1,761 153 2,335 1,128 1,742 7,119 40,951 424,223 3,927 5,283 5,807 2,521 2,834 4,297 List size 168,107 14,725 287,149 134,435 206,701 811,117 5,436,921 54,836,561 462,105 486,919 545,577 281,160 338,093 565,861 Prevalence 1.05% 1.04% 0.81% 0.84% 0.84% 0.88% 0.75% 0.77% 0.85% 1.08% 1.06% 0.90% 0.84% 0.76%
The Core Cities also includes Birmingham however this is not served by a single PCT and as such is not included in the above chart.
Leeds falls in the middle of the Core Cites PCTs with 3 PCTs having a lower prevalence of Severe Mental Illness and 3 PCTs having a higher prevalence (not including data for Birmingham).
Figure 22
3.0%
Calibre
2.5%
Church Street Group
H3+
Independent
Leodis
2.0% Prevalence
1.5%
1.0%
England Leeds
0.5%
0.0% GPPractice
The practices with the highest prevalence of patients on a mental health register are within the Church Street Group and the Independent practices, while the practices with the lowest prevalence are within H3+ and, again, the Independent practices. There is a variation in prevalence between these across all the consortia, however, the variation is lowest in the Calibre practices where all the practices have prevalence from approximately 0.5% to 1.5%. 46
Figure 23
3.0%
Target
2.5%
NonTarget
2.0% Prevalence
1.5%
1.0%
0.5%
0.0% GPPractice
The 10 practices with the lowest prevalence of patients on a mental health register are all non-target practices, so have less than 30% of their population living in areas of Leeds ranking in the top 20% of deprivation nationally. Likewise the 6 practices with the highest prevalence are all target practices, and so have more than 30% of their population living in areas of Leeds ranking in the top 20% of deprivation nationally. The scatter plot below shows that there is only a slight correlation between deprivation and prevalence of patients 2 2 2 recorded on a mental health register (R = 0.2453 - R = 0 shows no correlation, R = 1 shows strong correlation). This doesnt necessarily show that deprivation and severe mental health issues are not connected as it may be that recording of severe mental health issues is not as good in more deprived areas.
Figure 24
3.0% R=0.2453 2.5%
2.0% Prevalence
1.5%
1.0%
0.5%
0.0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
PercentageofpracticelivinginDeprivedLeeds 47
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Review and care plan status Patients without a recorded review in the previous 15 months Number Percentage 170 9.60% 15 9.80% 160 6.85% 159 13.54% 133 7.63% 637 9.18% Patients not followed up for non-attendance of review Number Percentage 12 7.10% 13 76.47% 11 3.91% 52 33.55% 20 10.53% 108 8.62% Patients without a care plan documented Number 169 17 256 152 190 784 Percentage 9.60% 11.11% 10.96% 12.95% 10.91% 10.90%
Consortium Calibre Church Street Group H3+ Independent Leodis Healthcare Leeds Total
Within Leeds as a whole under 10% of patients who are on a GP severe mental illness register have not had a st recorded review in the previous 15 months as at 31 March 2010. However, this still equates to 637 people who are on a register and have not had a review recorded in that time. The highest percentage of patients without a review was in the Independent practices where 13.5% had no recorded review. Again within Leeds the percentage of patients who are on a GP severe mental illness register and not followed up for non-attendance of a review is down below 10%. However, there is a large variation across the Consortia with only 3.9% not followed up in H3+ while 76.5% were not followed up in the Church Street Group (though the total number is low for Church Street Group). The percentage of patients who are on a GP severe mental illness register in Leeds and dont have a care plan documented is just under 11%. There is little variation across the consortia with Calibre having the lowest percentage at 9.6% and the independent practices having the highest at approximately 13%. Severe Mental Illness registers need to be in place, updated and reviewed on a regular basis to address this.
48
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Prevalence of Patients on Depression Registers by Consortia and GP Practice 2009-2010 Consortium Calibre Church Street Group H3+ Independent Leodis Healthcare Leeds Total Yorkshire and Humber England Core Cities Bristol PCT Liverpool PCT Leeds PCT Manchester PCT Newcastle PCT Nottingham City PCT Sheffield PCT Patients on the Depression Register 13,444 718 21,604 10,719 17,677 64,162 447,725 4,648,287 49,507 50,746 64,162 48,638 26,576 25,799 48,544 List size (18+) 132,847 11,887 239,031 107,395 162,259 653,419 4,092,514 50,703,846 362,441 363,075 640,427 408,139 222,912 258,958 443,795 Prevalence 10.12% 6.04% 9.04% 9.98% 10.89% 9.82% 10.94% 10.91% 13.66% 13.98% 10.01% 11.92% 11.92% 9.96% 10.94%
For Core Cities data the list sizes have been extracted from the ADS2010 and reconciled to ONS mid 2009 estimates for local authorities by the Information Centre (minus special populations) - special populations HAVE NOT been added back in. The Core Cities also includes Birmingham however this is not served by a single PCT and as such is not included in the above chart.
All the Depression Register figures are taken from the QOF 2009-2010 data however, as the Depression register count only includes people aged 18 and over the QOF data doesnt give populations or prevalence rates for any geographical areas below England. As such, the population figures used are from different sources. The Consortia, Leeds Total and Yorkshire and the Humber figures are from local data sources while the Core Cities data is taken from the ADS2010 (Attribution Dataset). Leeds has been included in the Core Cities data also due to the slight difference in the two population sources and thus the prevalences. Leeds is at the lower end of the Core Cities with only Nottingham PCT having a lower prevalence of GP recorded depression. It should be noted that this is GP recorded depression and will not necessarily cover everybody who has depression.
Figure 25
30%
25%
Calibre
Church Street Group
H3+
Independent
Leodis
20%
15%
England
10%
Leeds
5%
0%
50
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population The practices with the highest prevalence of patients on a mental health register are within the Leodis and the Independent practices, while the practices with the lowest prevalence are within Calibre and, again, the Independent practices. There is a variation in prevalence between these maximum and minimum across all the consortia, however, the variation is lowest in the Calibre and Church Street Group practices where all the highest prevalence is approximately 15%.
Figure 26
30%
25%
Target
NonTarget
20% Prevalence
15%
10%
England NHSLeeds
5%
0% GPPractice
The 4 practices with the highest prevalence of patients on the depression register are all target practices, so have less than 30% of their population living in areas of Leeds ranking in the top 20% of deprivation nationally. There is only slight difference between the prevalence in the lowest target practice and the prevalence in the lowest non-target prevalence. The scatter plot below shows that there is a very slight negative correlation between deprivation and prevalence of 2 2 2 patients recorded on a mental health register (R = 0.0297 - R = 0 shows no correlation, R = 1 shows strong correlation). This doesnt necessarily show that deprivation and depression are not connected as it may be that recording of depression is not as good in more deprived areas.
51
Figure 27
30% R=0.0297 25%
20% Prevalence
15%
10%
5%
0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
PercentageofpracticelivinginDeprivedLeeds
Figure 28
12.0% 10.89% 10.12% 10.0% 9.04% 9.98% 9.82% 10.94% 10.91%
8.0% Prevalence 6.04% 6.0%
4.0%
2.0%
0.0% Calibre Church Street Group H3+ Independent Leodis Healthcare NHSLeeds Yorkshire andHumber England
GP recorded depression is lower in Leeds than in both the Yorkshire & Humber SHA and England, with the prevalence in Yorkshire & the Humber being slightly higher than in England as a whole. Prevalence varies across the consortia from 6% in the Church Street Group to 11% in Leodis Healthcare.
52
Section 7: Prescribing
Items prescribed by year in Leeds - General Practice only Items Antidepressant Anti-psychotic Antimanic Dementia Hypnotics and Anxiolytics Total 2007/2008 453,934 106,383 24,764 24,539 198,023 807,643 2008/2009 475,512 113,036 26,554 28,405 198,591 842,098 2009/2010 522,613 119,313 28,579 33,626 199,141 903,272
The highest number of items prescribed each year in Leeds General Practice are Antidepressants while the lowest number prescribed varies between Antimanic drugs and Dementia drugs differing between the two in different years. This is to be expected as depression is a much more common disorder and is more likely to be managed in primary care. The numbers of Hypnotics and Anxiolytics prescribed has remained constant during the three years while the numbers prescribed for all other types of drugs have increased. Figure 25 shows that the largest numerical increase was in Antidepressant drugs with an increase of nearly 70,000 over the three years. However, by taking log10 of the count of items shows proportional increase and that the largest percentage increase was in Dementia drugs with a 37% increase over the same period. This relates to an increase in the number of dementia diagnoses and also that dementia drugs are now more commonly prescribed in primary care. This information, whilst useful, should not be used as standalone data. The data comes from the national e.PACT database and doesnt necessarily relate to quantities dispensed.
Figure 29
600,000
500,000
400,000
Itemsprescribed
300,000
200,000
100,000
0 2007/2008
Antidepressant Antipsychotic
2008/2009
Antimanic Dementia
2009/2010
HypnoticsandAnxiolytics
54
Figure 30
5.8 5.6 5.4

log10(itemsprescribed)
5.2 5.0 4.8 4.6 4.4 4.2 2007/2008

2008/2009
Antimanic Dementia
2009/2010
Cost of items prescribed by year in Leeds - General Practice only Items Antidepressant Anti-psychotic Antimanic Dementia Hypnotics and Anxiolytics Total 2007/2008 2,085,650.89 3,216,002.36 72,131.99 1,248,878.37 803,614.38 7,426,277.99 2008/2009 1,659,493.59 3,228,619.70 80,591.75 1,404,554.42 824,192.83 7,197,452.29 2009/2010 1,615,902.23 3,133,295.72 80,591.75 1,589,318.51 791,640.13 7,210,748.34
The highest total cost for items prescribed each year in Leeds General Practice are for Anti-psychotic drugs. The lowest total cost is for Antimanic drugs which corresponds to the fact that less people are prescribed Antimanic drugs than any of the other items shown. The overall cost of drugs prescribed over the three years has fallen slightly with the largest fall in Antidepressant drugs. Many of the commonly used antidepressants have recently come off patent and are now available generically. This may explain the reduction in costs. Also patients are now more regularly reviewed as per nice guidelines which may also have an effect on the costs. There was, however, a rise in cost of Dementia drugs. Dementia drugs are currently still under patent and the increase in costs correlates to the increase in diagnoses of dementia. The log10 figures used in Figure 27 also confirm that the largest percentage increase was in the cost of Dementia drugs while the largest percentage decrease was in Antidepressant drugs.
55
Figure 31
3,500,000 3,000,000 2,500,000

Prescribingcost
2,000,000 1,500,000 1,000,000 500,000 0 2007/2008

2008/2009
Antimanic Dementia
2009/2010
Figure 32
7.0
6.5
log10(prescribingcost)
6.0
5.5
5.0
4.5 2007/2008
2008/2009
Antimanic Dementia
2009/2010
56
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Prescribing vs. Cost Despite the 22% rise in Antidepressant costs there has been a 23% fall in the cost of these drugs. The average cost per unit for Antidepressants in 2007/2008 was 4.59. This fell by 1.50 to 3.09 in 2009/20010, the biggest decrease being in the first year to 2008/2009 with a fall of 1.00 per unit. Despite there being a 27% increase in the total cost of Dementia drugs the increase in items prescribed was even higher at 37%. Thus even here there has been a fall in unit cost of 3.63, from 50.89 to 47.26. Items per Head Prescribed by Consortium The chart shows that the practices with the highest prescribing rate per head are in the H3+ consortium and the Independent group of practices. These two groups also contain the two practices with the lowest prescribing rates per head. All Consortia have a range of practices from lower to highest prescribing rates per head, however the practices within the Church Street Group Consortium are all in the higher end of the range of prescribing rates.
Figure 33
2.5
2.0
Calibre
Church Street Group
H3+
Independent
Target
Leodis
Target Target
Itemsperhead
Target
Target
1.5
Target Target Target
Target
Target Target
0.0 GPPractice
HypnoticsandAnxiolytics Antipsychotic Antimanic Antidepressant
For definition of target practices see page vi.
Target
0.5
Target
Target
Target Target Target Target
1.0
Target Target Target Target Target Target Target Target
Target Target Target
Target
Target Target Target Target Target Target Target
Target
Target
Target Target Target Target
57
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Items prescribed and total costs per patient by Consortium for Leeds (2009-2010)
Items 2009/2010 Items 2009/2010 Antidepressant Consortium Calibre Church Street Group H3+ Independent Leodis Healthcare Leeds Population 168,107 14,725 287,149 134,435 206,701 811,117 Number 110,702 11,782 166,462 81,984 151,683 522,613 Per patient 0.66 0.80 0.58 0.61 0.73 0.64
Anti-psychotic Per Number patient 27,634 0.16 2,473 0.17 39,552 0.14 20,039 0.15 29,615 0.14 119,313 0.15
Antimanic Number 7,177 487 10,006 4,218 6,691 28,579 Per patient 0.04 0.03 0.03 0.03 0.03 0.04
Dementia Number 7,294 668 13,480 4,695 7,489 33,626 Per patient 0.04 0.05 0.05 0.03 0.04 0.04
Hypnotics and Anxiolytics Per Number patient 48,985 0.29 4,007 0.27 63,922 0.22 28,433 0.21 53,794 0.26 199,141 0.25
Consortium Calibre Church Street Group H3+ Independent Leodis Healthcare Leeds
Population 168,107 14,725 287,149 134,435 206,701 811,117
Cost 2009/2010 Antidepressant Per Number patient 371,585.02 2.21 37,237.58 2.53 502,803.18 1.75 247,940.66 1.84 456,335.79 2.21 1,615,902.23 1.99
Anti-psychotic Per Number patient 703,114.16 4.18 66,064.38 4.49 1,041,192.12 3.63 546,026.78 4.06 776,898.28 3.76 3,133,295.72 3.86
Antimanic Number 20,531.56 2,239.93 34,698.90 13,795.99 17,809.20 89,075.58 Per patient 0.12 0.15 0.12 0.10 0.09 0.11
Dementia Number 344,086.98 31,123.88 621,331.95 225,277.78 367,497.92 1,589,318.51 Per patient 2.05 2.11 2.16 1.68 1.78 1.96
Hypnotics and Anxiolytics Per Number patient 184,313.63 1.10 14,184.83 0.96 260,763.40 0.91 101,366.94 0.75 231,011.33 1.12 791,640.13 0.98
Average annual items prescribed and total costs for Leeds (2007-2010) Items Antidepressant Anti-psychotic Antimanic Dementia Hypnotics and Anxiolytics Total Cost () Antidepressant Anti-psychotic Antimanic Dementia Hypnotics and Anxiolytics Total Annual Items 484,020 112,911 26,632 28,857 198,585 851,004 Annual Cost 1,787,015.57 3,192,639.26 77,771.83 1,414,250.43 806,482.45 7,278,159.54 % 57% 13% 3% 3% 23% 100% % 25% 44% 1% 19% 11% 100% Church Street Group has the overall highest number of units prescribed per patient for 2009/10 while H3+ has the lowest number of units prescribed per unit. Again Church Street Group has the highest prescribing cost per patient while the Independent practices have the lowest prescribing cost per patient. There are many compounding factors to take into account in comparing the prescribing across consortia, such as the prevalence of diseases/disorders in each practice within the consortium, and also the deprivation levels within the consortium. Anti-psychotic drugs account of only 13% of all items prescribed over the three years, however, they cost 44% of the total prescribing cost for that time. Likewise Dementia drugs are only 3% of the total amount of drugs prescribed, but cost 19% of the total. Antidepressants and Hypnotics & Anxiolytics combined give a total of 80% of all drugs prescribed within the three year period however they are only responsible for 36% of the overall cost.
58
Comparative Data
The bar charts below compare the prescribing habits of NHS Leeds for drugs used in mental health to other PCTs within the SHA. The line graphs compare only the West Yorkshire PCTS and Sheffield. The graphs are provided by the Regional Drug and Therapeutics Centre in Newcastle. Hypnotic Prescribing
Hypnotics are used to induce sleep in patients suffering from insomnia. They should be prescribed for short courses only to avoid patients developing dependence.
Figure 34
Yorkshire&TheHumberPCTs:Weightedprescribingcostsof'Hypnotics' baseline period*comparedwithApr Jun'10

NorthEastLincolnshireCareTrustPlus Kirklees NorthofEngland EastRidingofYorkshire NorthYorkshire&York HullTeaching England Calderdale Barnsley Yorkshire&TheHumber Leeds WakefieldDistrict NorthLincolnshire Bradford&Airedale Rotherham Doncaster Sheffield 0 5 10
20.79 19.30 20.71 19.36 20.44 19.37 19.26 17.66 18.83 17.43 18.65 17.31 18.28 17.65 18.18 15.91 17.28 16.24 17.13 17.37 17.05 17.55 16.83 15.82 14.77 13.26 13.92 12.50 13.31 12.70 12.68 11.43 25.61 23.01
15
20
25
30
ActualCostper100Patients
*baselineperiodisFY2009/10dividedby4
Hypnotics Q110/11
Hypnotics Baseline
Figure 29 shows the prescribing costs of hypnotics in Apr June 2010, compared to a baseline within 2009/10. The figures are weighted for population. Over the last few years, NHS Leeds has made a considerable effort to reduce the use of these drugs and is one of only two PCTs that have demonstrated a reduction in cost, which is indicative of reduced usage.
59
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Z-Drug Prescribing
Z-drugs are non-benzodiazepine hypnotic drugs which are significantly more expensive than benzodiazepines.
Figure 35
Yorkshire&theHumberSHA:Weightedprescribingfrequencyofzaleplon, zolpidemandzopiclone,April2006 March2010

650
600
550
500 ADQs/1000patients
450
400
350
300
250
200 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 06/07 06/07 06/07 06/07 07/08 07/08 07/08 07/08 08/09 08/09 08/09 08/09 09/10 09/10 09/10 09/10 Bradford&Airedale Leeds Yorkshire&TheHumber Calderdale Sheffield NorthofEngland Kirklees WakefieldDistrict England
NICE issued guidance on the use of these drugs in 2004, recommending there was no advantage in using these over other hypnotics. PCTs are therefore encouraged to reduce the expenditure on these drugs. NHS Leeds has consistently been a low prescriber of these drugs and continues to work with the GPs to maintain this.
60
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Low Dose Antipsychotic Prescribing
Antipsychotic drugs are often used inappropriately for the management of behavioural and psychological symptoms in dementia. within the care home environment. This is often
Figure 36
Yorkshire&TheHumberPCTs:Weightedprescribingfrequencyoflowdose antipsychotics baselineperiod*comparedwithApr Jun'10

HullTeaching NorthEastLincolnshireCareTrust Plus Calderdale Kirklees EastRidingofYorkshire Bradford&Airedale Barnsley WakefieldDistrict Leeds NorthLincolnshire Sheffield Rotherham NorthYorkshire&York Doncaster 0 500 1000
2312.9 2254.0 2296.6 2271.8 2290.4 2386.9 2238.9 2177.4 2234.4 2256.3 2204.6 2278.6 2019.6 2102.8 2016.1 1994.5 1961.6 2025.2 1825.0 1790.7 1807.0 1858.6 1648.3 1607.3 1395.4 1446.2 3777.8 3717.1
1500
2000
2500
3000
3500
4000
DDD/100dementiapatients Lowdoseantipsychotics Q110/11 Lowdoseantipsychotics baseline
*baselineperiodisFY2009/10dividedby4
Figure 31 compares the prescribing costs of low dose antipsychotics within the SHA. This is important because of the 1 DoH Bannerjee report published in 2009 . A core recommendation of this report is that each PCT should commission a service that supports primary care in its work in care homes and the community. NHS Leeds has committed a significant amount of time to facilitate GPs to tackle this prescribing, but the need for dedicated care home support is an area for further development.
1. The use of antipsychotic medication for people with dementia: Time for action. November 2009 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_108303
61
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Atypical Antipsychotic Prescribing
These drugs are relatively newer antipsychotics with more favourable side-effect profiles than the older ones. NICE recommend that they should be considered as an option when prescribing antipsychotics.
Figure 37
Yorkshire&theHumberSHA:Weightedprescribingfrequencyofatypical antipsychotics,April2006 March2010

65
60
55
DDDs/mentalhealthpatient
50
45
40
35
30
25 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 06/07 06/07 06/07 06/07 07/08 07/08 07/08 07/08 08/09 08/09 08/09 08/09 09/10 09/10 09/10 09/10 Bradford&Airedale Leeds Yorkshire&TheHumber Calderdale Sheffield NorthofEngland Kirklees WakefieldDistrict England
Figure 32 shows the prescribing of atypical antipsychotics within the West Yorkshire PCTs and Sheffield. Both LPFT and NHS Leeds are compliant with the NICE guidance relating to these drugs whilst maintaining a low prescribing incidence.
62
Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Antidepressant Prescribing
This marker includes all classes of antidepressant drugs.
Figure 38
Yorkshire&TheHumberSHA prescribingcost:antidepressantsantipsychotics, April2007toSeptember2010

40 38 36 34 32 30 28 26 24 22 20 18 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 07/08 07/08 07/08 07/08 08/09 08/09 08/09 08/09 09/10 09/10 09/10 09/10 10/11 10/11 Bradford&Airedale Leeds Yorkshire&TheHumber Calderdale Sheffield NorthofEngland Kirklees WakefieldDistrict England
Figure 33 illustrates antidepressant prescribing across the West Yorkshire PCTs and Sheffield. This has shown a gradual decline due to reductions in the prices of generic drugs and the work by PCTs to improve cost-effective prescribing. NHS Leeds shows an average usage of antidepressants within the region.
NIC()/100AntidepressantSTARPU
63
Section 8: Projecting Adult Needs & Service Information (PANSI) and Projecting Older People Population Information (POPPI)
The predicted figures from PANSI and POPPI are based on the last available rates for each area applied to the Office of National Statistics (ONS). As such increased and decreases in levels of mental health/dementia issues depend on projected changes in population. It gives an idea of the number of issues that will be faced in future years if the rates in the population remain the same as current. Dementia People aged 30-39, 40-49, 50-59 and 60-64 predicted to have early onset dementia, projected to 2030 2010 9 22 78 62 2015 11 22 86 56 2020 13 21 94 62 2025 14 23 92 69 2030 13 29 89 70
People aged 30-39 People aged 40-49 People aged 50-59 People aged 60-64
Based on the Alzheimer's Society report, Dementia UK - the full report. This 2007 report into the prevalence and cost of dementia was prepared by the Personal Social Services Research Unit (PSSRU) at the London School of Economics and the Institute of Psychiatry at King's College London, for the Alzheimer's Society.
In 2010 the predicted highest number of cases of early onset dementia were in people aged 50-59 (however the group contains twice as many ages as the 60-64 age group which has the second highest number), while the lowest numbers were in the 30-39 age range. The number of cases in all age ranges is predicted to be higher in 2030 than in 2010 however these do not show a constant rise between the beginning and end years. The highest number of cases in any age range is predicted to be in the 50-59 year age group after which the number of cases in this age group is predicted to begin to fall in 2025 and then 2030. Cases in other age ranges will, however, continue to rise after 2020. The predicted number of cases in the 30-39 and 40-49 age groups combined is less in any of the years than either the 50-59 or 60-64 age groups.
Figure 39 100 90 80 70 60 50 40 30 20 10 0 2010 2015
People aged 30-39 People aged 40-49
2020
People aged 50-59
2025
People aged 60-64
2030
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Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population People aged 65 and over predicted to have dementia, by age band (65-69, 70-74, 75-79, 80-84 and 85 and over), projected to 2030 2010 373 743 1,316 1,996 3,783 2015 448 743 1,397 2,108 4,285 2020 403 898 1,410 2,307 4,951 2025 448 815 1,721 2,381 5,954 2030 503 910 1,572 2,941 6,905
People aged 65-69 People aged 70-74 People aged 75-79 People aged 80-84 People aged 85 and over
The most recent relevant source of UK data is Dementia UK: A report into the prevalence and cost of dementia prepared by the Personal Social Services Research Unit (PSSRU) at the London School of Economics and the Institute of Psychiatry at Kings College London, for the Alzheimers Society, 2007. The prevalence rates have been applied to ONS population projections of the 65 and over population to give estimated numbers of people predicted to have dementia to 2030.
The predicted numbers of cases of dementia in 2010 increased with age for each 5 year age group. About 50% of all cases of dementia in over 65s in the 85 and over age group, with the percentage been just under 50% in 2010 but rising to just over 50% by 2030. The numbers are predicted to rise each year for all over 75s except in the final year when the 75-79 age group will fall slightly. For those between 65 and 74 the predictions fluctuate over the years but are higher at the end of the period than at the beginning.
Figure 40 7,000
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Mental Health and Wellbeing in Leeds: An Assessment of Need of the Adult Population Mental Health People aged 18-64 predicted to have a mental health problem, by gender, projected to 2030 Mental health - all people People aged 18-64 predicted to have a common mental disorder People aged 18-64 predicted to have a borderline personality disorder People aged 18-64 predicted to have an antisocial personality disorder People aged 18-64 predicted to have psychotic disorder People aged 18-64 predicted to have two or more psychiatric disorders 2010 86,337 2,412 1,886 2,145 38,648 2015 91,207 2,543 2,024 2,265 40,952 2020 94,773 2,639 2,126 2,353 42,644 2025 97,943 2,725 2,215 2,431 44,144 2030 101,690 2,827 2,315 2,523 45,891
Based on the report: Adult psychiatric morbidity in England, 2007: Results of a household survey, published by the Health and Social Care Information Centre in 2009. Common mental disorders (CMDs) are mental conditions that cause marked emotional distress and interfere with daily function, but do not usually affect insight or cognition. They comprise different types of depression and anxiety, and include obsessive compulsive disorder. The report found that 17.6% of the population surveyed met the diagnostic criteria for at least one CMD, with women (19.7%) more affected than men (12.5%). Psychiatric co-morbidity - or meeting the diagnostic criteria for two or more psychiatric disorders - is known to be associated with increased severity of symptoms, longer duration, greater functional disability and increased use of health services. Disorders included the most common mental disorders (namely anxiety and depressive disorders) as well as: psychotic disorder; antisocial and borderline personality disorders; eating disorder; posttraumatic stress disorder (PTSD); attention deficit hyperactivity disorder (ADHD); alcohol and drug dependency; and problem behaviours such as problem gambling and suicide attempts.
The predicted numbers are based on the proportion of 16-64 year olds who reported having mental health problems in the Adult Psychiatric Morbidity in England, 2007 report and are applied to the population projections from the Office of National Statistics (ONS). The population of Leeds is predicted to increase over time and as such the number of people with mental health problems is also predicted to increase at the same level. By 2030 it is predicted that there will be approximately 15,000 more people living in Leeds with a common mental health problem than in 2010 and approximately 7,000 more people who have two or more psychiatric disorders. The numbers with personality disorders and psychotic disorder are predicted to rise by approximately 400 for each disorder.
Figure 41
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Figure 42
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There are no projected numbers for the 65 and over age group with mental health problems available from this source. Figures can be calculated if current rates of mental health problems in 65 and overs are available based on future 65+ population projections for Leeds. Mortalities of people aged 18-64 from suicide, by gender, projected to 2030 2010 Males aged 18-34 predicted to commit suicide Males aged 35-64 predicted to commit suicide Females aged 18-34 predicted to commit suicide Females aged 35-64 predicted to commit suicide Total population aged 18-64 predicted to commit suicide 14 21 3 6 44 2015 16 22 3 6 46 2020 16 24 3 6 49 2025 16 27 3 6 52 2030 16 29 3 7 54
Based on information contained in the Clinical and Health Outcomes Knowledge Base, a source of information on health outcomes generated by NCHOD (the National Centre for Health Outcomes Development), http://www.nchod.nhs.uk/.
The predicted number of suicides in 2010 was nearly four times as many in males than in females. Due to the relative low numbers of suicides in females there is only a predicted rise of 1 by 2030 taking the total to 10. The rise in male suicides is predicted to be higher rising by 10 between 2010 and 2030 to 45
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Figure 43
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There are no projected numbers for the 65 and over age group for mortalities from suicide available from this source. Figures can be calculated if current rates of suicide in 65 and overs are available based on future 65+ population projections for Leeds.
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3. Qualitative Data Key Themes and Issues 3.1 Summary This section of the report attempts to bring together available qualitative information on mental health and wellbeing needs for the Leeds population, as well as some headline commentary on local issues. The content has been themed around those population groups and key conditions/programme areas which this data was focused upon. This data does not claim to be conclusive or complete, but is intended to complement the quantitative data in its content and provide some local context and commentary. 3.2 Setting the context 3.2.1 Leeds the City The Leeds Metropolitan District covers 552 square kilometres (217 square miles) and is the second largest Metropolitan District in England. It is recognised as one of Britains most successful cities having transformed itself from a mainly industrial city into a broadly-based commercial centre regarded as the most important financial, legal and business service centre in the country outside London. Leeds census The city includes a vibrant city centre and the built up areas that surround it together with more rural outer suburbs and several small towns, all with their own very different identities. Two-thirds of the district is designated green-belt. Despite the success of the city as a whole there are still unacceptably wide health gaps between those areas that are wealthy and thriving and those that suffer high levels of multiple deprivation, which the city and its partners are committed to tackling through the narrowing the gap agenda. Narrowing the gap A measuring tool called Index of Multiple Deprivation (IMD) provides a detailed analysis of the range and extent of deprivation across England and it is measured by using small local areas known as super output areas (SOAs) and domains of deprivation which are explained in more detail in the data pack. Although Leeds as a whole is ranked as 85th most deprived area out of 354 in the 2007 Index of Multiple Deprivation, 95 out of the 476 indicators show the area to be in the most deprived 10% in England. The majority of these are located in the inner city and just under 150,000 people (20% of the resident population) live in these areas. A quarter of all children in the city live in these most deprived areas together with 18% of the citys older people. These are the areas are defined as deprived Leeds. This needs assessment refers to these areas throughout the report and will discuss complex issues that highlight unmet need for some individuals and communities who live and work here. The number of people living in deprivation in Leeds is significantly above the national average; about one in five people in Leeds live in neighbourhoods that are among the 10% most deprived in the country. (Please refer to Map 1 in the data pack)
All Age All cause Mortality (AAACM) is an overarching measure for a number of the mortality data sets often used to measure public health trends. The AAACM rate for Leeds is around the national average, and in line with national trends, is continuing to fall, however the trajectory for narrowing the gap between Leeds overall and deprived Leeds is of significant concern. The deprived areas of Leeds have AAACM rates significantly higher than Leeds, parts of Yorkshire and Humber region and the national average. Life expectancy is increasing for both genders, with an average life expectancy now for people now being 79. However there remains a marked gap between the life expectancy of males and females. Leeds is a culturally diverse population with nearly 11% of the total resident population comprising of people from Black and Minority Ethnic (BME) Communities, though slightly lower than the national average. 3.2.2 So what has this got to do with Mental Health? Our most deprived communities nationally and locally have the poorest mental and physical health and wellbeing. Improving the mental health and wellbeing of our population will require action across all sectors, locally and nationally and reflects why the new No Health without Mental Health strategy for mental health is a cross government strategy where mental health and wellbeing is everyones business. Many mental health problems start early and are associated with a combination of known risk factors, including socio-economic status, cultural factors and inequality within and between communities. Poor mental health and wellbeing are associated with a broad range of adverse outcomes, including higher levels of health risk behaviours such as alcohol and drug misuse, smoking, and experience of violence and abuse. 3.3 Acxiom Data Some Key Messages around Wellbeing We have mapped local data from a national survey (Acxiom household survey) distributed twice a year in January and September. Sent out nationally, over 1 million responses are received back each year. Data is collected both by post and online across different age groups, which ensures a representative demographic profile of responders. Using Acxioms APE (Acxiom population estimates) product, responses are weighted to ensure they reflect the population profile, and mapped back to the annual population estimates. Acxiom are confident that this means a national survey can be interpreted at small areas (on average 1 in 30/35 households complete the survey). The results are available within the same year. We have lifted relevant data from Leeds to begin to understand how people feel about living in their neighbourhoods and some of the day to day issues local communities are facing. This information was shared by Leeds City Council. Local households in Leeds were asked specific questions including how they felt about where they lived. The following data is from 2010 and gives us a sense of how wellbeing impacts on our everyday lives.
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Acxiom data maps: The map on p.72 highlights the areas where people generally responded that they like the area that they live in. The map shows that positive responses were generally received from people who do not live within deprived Leeds. Instead people who like their area tend to come from more affluent SOAs where there are more open and greener spaces, better housing stock and less apparent poverty The map on p.73 shows the response to the same question but highlights does not like their area responses. Note however a smaller range of responses with this map therefore we cannot compare exactly, yet those that do not like their area appear to almost overwhelmingly live in deprived Leeds, which as we know links to inequality which has strong links to poor mental wellbeing. The map on p.74 shows the positive response to the question Has your area improved or got worse? The responses show a mixed spread of positive answers across Leeds and deprived Leeds. P.75 shows the more negative responses of those who felt their area had got worse. It is again interesting to note that more of those who felt that their area got worse live in deprived Leeds P.76 Are you struggling to pay bills? Notice the higher numbers of those respondents who reported struggling in Leeds to pay their bills again live in deprived Leeds. Debt and poverty are interlinked with poor mental health and this is well evidenced and complex. We need to understand this data better, to tackle the root causes of poor mental health and wellbeing across the city. The map on p.77 reflects the impact of the current economic climate. It indicates those households who report that they have been affected by financial pressures. This spread suggests that whilst many households in deprived Leeds are being affected, there is a high response rate across Leeds which suggests people in better off areas are also feeling the impact of the economic climate. We need to understand this better and what impact the economic downturn is having across the social gradient and not just in deprived Leeds. P.78 shows the spread of response to Do you feel that you can influence local decisions? Those who answered and responded as definitely disagree or tend to disagree are shown to be spread across Leeds with people living in the areas around some of the boundaries of Leeds and deprived Leeds feeling this way. Again we need to understand some of this data in more detail. Asked Are you struggling with food Shopping? on p.79. Between 20-40% of respondents reported to be struggling with food shopping. We know from other neighbourhood data that food access issues are a real issue to local communities who lived in deprived Leeds. Larger supermarkets are often located in areas less accessible to some communities and local shops have suffered from the competition the larger supermarkets offer.
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Whilst this data only begins to scratch at the surface of some of the issues for the people who live in Leeds we need to understand this data better and ask more questions about liveability of an area, city, and our region. We need to explore how this impacts on our mental health and wellbeing. Programmes and services for mental health and wellbeing should be delivered within the context of how people live within their communities and include insight from communities themselves. This mapping information supports evidence that how we think and feel about the area in which we live can have an impact on our mental health. In turn if we are happy with where we live, it has a huge positive impact on our mental wellbeing and thus impacts on local services and service provision. 3.4 Health Inequalities Model of Vulnerability The health inequalities model of vulnerability arose as a result of confusion and different understanding of the concepts of vulnerable groups, seldom heard groups and even the terminology used when trying to describe vulnerability. In the context of health and wellbeing and health inequalities there was no agreed definition or framework capturing the complexities of this issue. In Leeds, we have begun to use the following model of vulnerability to understand the complexities of how health inequalities are linked to vulnerability and that vulnerability is complex and affects our mental wellbeing. There are a plethora of factors around vulnerability that can increase or contribute to the risk of being vulnerable to poor health and thus poorer health outcomes. The model below highlights how these different elements interact to reflect the experiences of population groups and individuals.
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4. Findings from local qualitative intelligence around mental health and wellbeing in Leeds In conducting this needs assessment, we reviewed local evidence in the form of qualitative reports and intelligence, which offer insight into understanding specific issues within a local context. A number of local reports have been reviewed to understand expressed and unexpressed mental health need in Leeds. This following section aims to highlight the main issues by offering qualitative information on current provision and reviews recommendations made in these reports which are meaningful to Leeds health economy. 4.1 Review of Needs Assessments in Leeds A review of local needs assessments (2007-2010) against Joint Strategic Needs Assessment (JSNA) gaps and priorities was produced for the JSNA steering group in 2010. This information has also been included in this section as the findings help to underpin the findings of this report JSNA power point link. The relevant aims of the paper were to undertake a content review of recently completed needs assessments against the priorities and data gaps identified by the JSNA. Themes and priorities arising from the needs assessments were then identified. Overall 22 needs assessments were reviewed.
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Mental health emerged as the single most cited area covered by the 22 needs assessments reviewed. A recurring theme was the need for increased screening for and awareness of mental health problems within other service settings. In 11 of the assessments mental health was either the fundamental driver of the work or important co-morbidity (e.g. alcohol, maternity services, young offenders, prison health, obesity, student health). Also the importance of early interventions was a consistent theme throughout the reviewed needs assessments. The prominence of the need to address mental health across a wide range of services and programme area is not surprising given the wide spectrum of mental health problems and high prevalence across all age groups and social strata. Also nationally this supports what we know; one in six adults has a mental health problem at any one time, over half of all adult mental health problems are present by the age of 14, and 10% of children have a diagnosable mental health condition. The report highlights the need to risk assess young people in a variety of settings (GP, A&E, universities, prisons, and community services) to identify risky and potentially harmful behaviours. Specific examples of early intervention included the following; ! ! ! ! ! improving early identification of drug taking to reduce drug related deaths screening for prisoners at entry for alcohol and mental health problems early identification of mental health problems for new mothers identifying mental health issues for the LGB community in non mainstream settings expanding screening in brief interventions for harmful/ hazardous drinking in GP and A&E departments
Some of these issues are already being addressed across Leeds, and there are several examples of good practice. In addition, it was recognised that there is a need for increased collaboration between many physical health and mental health programmes. We know that people with mental health problems are more likely to have poor physical health. This is due in part to higher rates of health risk behaviours such as smoking, and alcohol and substance misuse. Increased smoking is responsible for most of the excess mortality of people with severe mental health problems. Adults with mental health problems including those who misuse alcohol or drugs smoke 42% of all the tobacco used in England, smoking and mental health Some people with mental health problems have poor diets, may not be physically active and may be overweight, though the reasons for this are complex. (Refer to map viii around food access issues and deprived Leeds) Mental health problems such as depression are also much more common in people with physical illness and having both physical and mental health problems delays recovery from both. People with one long term condition are two to three times more likely to develop depression than the rest of the population. Another recurring theme was the need for new or extended screening for mental health problems in services in other settings (e.g. maternal health, alcohol services, student health). The reviewed reports call for clear and functioning pathways from these settings into mainstream mental health services, with specialist mental health services recommended for some groups (e.g. LGBT community, sensory impairment, and adults with Autism)
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Finally an important cited issue is the part the Voluntary and Community Sector (VCS) play in providing a safety net for individuals slipping through mainstream mental health services. However the VCS is currently as vulnerable as publicly funded services and reports greater regulation in having to justify continued funding, when compared to the public sector. In summary, this review highlights the case for a whole-systems approach to addressing mental health and wellbeing, which is integrated into a wide range of public health programmes and health and social care services whose primary focus is not mental health, as the two are inter-related in their effect on communities and individuals. Developing this integrated approach will enable us to co-produce better mental health and physical health with the people of Leeds. 4.2 Ethnicity There is clear evidence that mental health services do not always meet the needs of certain groups. These include Black and Minority Ethnic (BME) individuals, communities and older people. The government states in the latest mental health strategy No health without mental health that it is committed to delivering equity of access to treatment, prevention and promotion of interventions as well as equality of experience and outcomes across all protected groups. The evidence on the incidence of mental health problems in BME groups is complex. The term BME covers many different groups with vastly different cultural backgrounds and experiences in wider society. People from BME groups often have different presentations of problems and different relationships with health services. Some BME groups have admission rates around three times higher than average, with some research indicating that this is an illustration of need. African Caribbean individuals are particularly likely to be subject to compulsory treatment under the Mental Health Act. There are higher rates of mental health problems for some migrant groups and subsequent generations. We know that migrant groups and their children are at two to eight times greater risk of psychosis than the general population. National research also indicates that South East Asian women are less likely to receive timely, appropriate mental health services. The Race Equality Action Plan: A Five-year Review looks back at the work of the delivering Race Equality in Mental Health Care programme and describes some of the key challenges, successes and learning. Delivering Race Equality (DRE) was a five-year plan to improve services for people from BME communities. The DRE action plan extended its coverage to all people of minority ethnic status in England... [and] does not only refer to skin colour, but to people of all groups who may experience discrimination and disadvantage, such as those of Irish origin, Mediterranean origin and East European migrants. In addition, the DRE action plan also covers specific populations, including Refugees and Asylum Seekers, older people, and children and young people. The DRE action plan was designed to reduce inequalities relating to how people from a range of communities access, experience and achieve outcomes from mental health services. Five year review
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The relationship between ethnicity and deprivation is significant in relation to local mental health and wellbeing needs. As highlighted above, around one in five people in Leeds live in neighbourhoods that are amongst the 10% most deprived in England. A significant number of BME communities reside in these deprived neighbourhoods. For example, in Leeds, fifty percent of the Asian-British / Asian-Pakistani residents live in the 10% most deprived areas of Leeds. This deprivation is a significant factor in relation to health inequalities and poor mental health and wellbeing. The lack of reliable local data in relation to ethnicity and mental illness in Leeds has historically been limited, and was identified as a key priority for progressing the work of the JSNA. In addition to quantitative data, there was also recognition for the need for agencies to build relations with communities to better understand and meet their needs in a culturally sensitive way, particularly as cultural stigma and stereotypes around mental health issues are complex and can give an inaccurate picture of need. There are some examples of current practice in working with local communities. For example, a local voluntary sector partner, Touchstone was commissioned by NHS Leeds to undertake local research to address some of these issues and to identify models of service delivery that were likely to be most effective in meeting the prioritised needs. They were tasked to make recommendations about the best use of the ring-fenced resources and to work on behalf of the commissioners and in partnership with the BME Advisory Group of the Leeds Mental Health Modernisation Team. The research focused on Chapeltown and Harehills, which are areas within the city which have diverse Black and Minority Ethnic (BME) communities: from traditionally established groups from the Caribbean, Africa, South East Asia and Ireland, to newer migrants from Eastern Europe and Asylum Seekers and Refugee communities. Chapeltown and Harehills suffer high levels of deprivation in areas of income, health, education, housing, crime and living environment in comparison to the national average (Office of National Statistics). http://www.touchstoneleeds.co.uk/files/touchstone/TouchstoneBMEResearchapril08.pdf Needs and issues in the research included; ! ! ! ! Older people from BME communities need better support to access primary care professionals, particularly GPs. Conditions like Dementia and Alzheimers are experienced by older people, but are not often understood by carers. There were little or no mental health specific services for teenagers and young people. Little work is in place around the needs of BME carers. Needs data shows they need clarity and support around pathways to services when a family member is experiencing mental health distress or crisis. Supporting the mental health of Asylum Seekers and Refugees falls to too few over subscribed and under-funded services.
Recommendations included ! ! ! The unique importance of building based services to BME Communities The importance of non-specialist mental health support The importance of a representative BME workforce for some communities
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! ! !
GPs need to know the resources available to them The importance of non-medical language Improving generic services
Community Development Workers are currently employed by Touchstone to work closely with BME communities across the city and are a beacon of good practice. They have been instrumental in developing resources such as a pacesetters training manual , and Fairness scheme 4.3 Employment and Worklessness A total of 1.18 million people in the UK are in contact with secondary mental health services. Of these, 136,000 have a serious mental health condition and may require support to gain and keep paid employment. Fact file Lack of work is detrimental to health and well being, and re-employment leads to improvement in health and well being. There is no evidence that work is harmful to the mental health of people with serious mental health conditions. A total of 2.3 million people are off work with mental health conditions, on benefits or out of work. 1.3 million of these have a serious or enduring mental health condition. Mental health is the most common reason for claiming health related benefits; some 42% of the 2.6 million people claiming health related benefit are doing so because of a mental health condition. Many others have a secondary mental health condition that contributes to their inability to work or return to the workplace. The annual growth rate in mental health-related unemployment benefit claims since 2000 is 5.4% compared with 0.8% for total incapacity benefit claimants. Over a third (34%) of people with mental health problems rate their quality of life as poor, compared with 3% of those without. The financial costs of the adverse effects of mental health problems on peoples quality of life are estimated to be 41.8 billion per year in England. An estimated 40% of Incapacity Benefit claimants (850,000 people) are registered as having a mental health issue, and a further 10% having mental health issues as a secondary problem. An estimated 40% of Incapacity Benefit (IB) claimants (or 850,000 people) have a mental health problem. In addition 10% of other claimants cite a mental health issue as a secondary issue The Confederation of British Industry (CBI 2004) estimates that time off work for depression, anxiety and stress costs employers around 4b annually. Reducing the length of time someone is off sick is key to the chances of returning to work. It is well known that being off work for longer than 12 months significantly reduces the chances of returning at all, and proportionately as time progresses. The introduction of the fit to work scheme through GPs is one attempt to stem the flow of people on sick notes as a way of coping with difficulties at work and working more constructively with employees and employers to make the necessary adjustments to support people through difficulties.
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In Leeds unemployment in some Inner-city wards is seven times higher than in some outer wards although this can hide pockets of high unemployment throughout the wider Leeds district. At 28.7% the benefit claimant rate in the Leeds deprived areas is more than double the rate for the city, whilst across the city 6.5% of the working age population are claiming Incapacity Benefit, rising to 12.4%, nearly twice the city average in the deprived areas. Almost 71,000 households in the city (23%) are in receipt of local authority administered benefits, almost 12,500 of which are lone parent households, whilst in the deprived area the benefit take-up rate is 44% almost double the average for the city. The Yorkshire and Humber regional strategy on employment for people with mental health needs reported that Leeds: ! has one of the highest rates of people on Incapacity Benefit due to mental ill health in the region ! broken down by gender, work rates were significantly below the national average for women service users in Leeds ! Data captured through the Mental Health Minimum Data Set in 2008/9 for LPFT indicated that 5.2% of people (115 out of 2,260) on Care Programme Approach (CPA) were in employment. In the 2009 Care Quality Commission (CQC)National Patient Survey 2009 for LPFT ! 14% of patients said currently in paid work ! 10% would have welcomed help with finding work but had not received it this was an increase from the previous year report of 7% ! 52% said they could not work The challenge of the current economic climate and the new governments expectation of reduced state provision creates an even greater urgency to re-focus our investment in order to improve the long term outcomes for service users. However, the challenge of improving the employment rates for users of secondary is not be under-estimated. The immediate reduction in jobs through the change of investment profile in local areas will inevitably reduce the range of employment options. This has the potential to disadvantage those people who are already distanced from the job market. However, creating solid foundations, raising aspirations, changing attitudes, and improving skill levels are essential to achieve longer term outcomes; and this should be the focus alongside hard job outcomes whilst the economy recovers and employment options increase. Even without full employment, the quality of life improves for those individuals who feel that they are developing skills, confidence and work readiness whilst undertaking meaningful activity. In Leeds it is estimated by Job Centre Plus that in 2010 50% of current Incapacity Benefits (IB) claimants have a mental health problem. A large number of these people will not be in touch with secondary mental health services, the majority will be supported by either their GP or will not be in touch with services. In Leeds mental health services there are approximately 2,500 people on the Care Programme Approach in touch with LPFT as well as other services, and it is likely that the majority of these will be on IB.
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All IB claimants are being re-assessed for work fitness over the next three years. Following a recent national pilot, it is estimated that about 25% of people on IB will move onto Job Seekers Allowance and be ready for work, whilst the remainder will go onto Employment Support Allowance. The recently proposed overhaul of the benefit system signals the government drive to reduce the number of people on benefits, and create expectations of return to work. This direction of travel matches the shift in focus for mental health services to be recovery focussed in order to reduce social exclusion. There are specific local examples of the relationship between worklessness and poor mental health, e.g. in relation to male suicide (see suicide section of this report) This local data highlights the inter-relationship between employment and mental health and wellbeing. The current policy context around reducing worklessness and reducing uptake of welfare payments including incapacity benefit presents further challenges. Increasing employment opportunities and reducing the impact of worklessness should be taken into account when developing and commissioning local programmes to improve mental health and wellbeing. 4.4 Ageing Population The range of mental health problems experienced in later life is very wide. Nationally one in four older people living in the community have symptoms of depression that are severe enough to warrant intervention. Only a third of older people with depression ever discuss it with their GP, yet depression is the most common mental health problem in older people. Some 25% of older people in the community have symptoms of depression that may require intervention. Only half of older people are diagnosed and treated, primarily with antidepressants, even less are referred to talking therapies. Older people with physical ill health, those living in care homes and socially isolated older people are at higher risk. (Craig R and Mindell J (eds) (2007) Health Survey for England 2005: Health of older people. Leeds: NHS Information centre.), yet these problems often go unnoticed and untreated. Depression is the leading risk factor for suicide. Older men and women have some of the highest suicide rates of all ages in the UK yet it is generally under-reported. Studies show that only one out of six older people with depression discuss their symptoms with their GP and less than half of these receive adequate treatment. (Chew-Graham C, Burns A and Baldwin R 2004 Treating depression in later life: we need to implement the evidence that exists. British Medical Journal 329) As well as the impact on quality of life, untreated depression in older people can increase need for other services, including residential care, however, older people can respond very well to psychological and medical treatments. This includes carers of people with dementia, so that they are better supported to manage challenging behaviours. The Department of Health will complete the nationwide roll-out of psychological therapy services for adults who have depression or anxiety disorders, and will pay particular attention to ensuring appropriate access for people over 65 years of age. People who remain healthy into older age are more likely to continue in employment if they wish, and to participate actively in their communities.
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With demographic changes alone we will see significant increases in the prevalence of depression at a population level, both nationally and within Leeds. The number of older people in our population is increasing, with a corresponding increase in those at risk of depression. Recommendations from Leeds Partnership for Older Peoples Programme (POPP) on later life mental health. Leeds people include: ! ! ! ! ! ! ! ! ! Prevention at the Acute/Mental Health Interface Intermediate Care Resource Centres Mental Health Rapid Response Intermediate Care (MH RRICT) Community Support Team (CST) Hospital After-Care Carer Support Community Support A focus on Prevention
A national report from Age Concern Improving services and support for older people with mental health problems also discusses the complexities of issues facing older people and reflects some of the issues the local POPP highlighted. Age concern Recent data from Older Peoples Mental Health prevalence for in Leeds based upon PSIGE IAPT report For people aged 65 or over in Leeds,there are: ! 27,500 people with a diagnosable mental illness ! 14,850 people with depression (12,485 receiving no treatment) ! 9,000 people with dementia (6,000 not diagnosed) ! 7,150 people with other mental illness
4.5 Young People (including young adults) We know that a good start in life and positive parenting promote good mental health, wellbeing and resilience throughout life. A lot of mental health problems start early and are associated with certain risk factors, including inequalities. Leeds data informs us that one fifth of all children in the city live in families where no-one in the household are in work. In deprived Leeds over 40% of children live in workless households double the city average. The scope of this study does not include data for children under 16. The mental health needs of children and young people are clearly critical in a life-course approach and central to understanding whole-population needs. Much work is currently in place to join up our understanding of mental health and wellbeing needs across the whole population. We will need to specifically explore if there is value in further work to understanding the needs of children and young people.
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Leeds has a significantly higher proportion of 15-29 year olds (26% compared to a national average approaching 20%), including a significant student population with more than 60,000 students studying in the two universities in the city. This also contributes to Leeds having a particularly transient population with students, many of whom will live and study in the area during term time, moving away during the holiday periods. A student health needs assessment in Leeds showed that collecting reliable data on the spectrum of student mental health issues provided difficult, however the percentage of students reporting levels of distress similar to a clinical population is comparable to levels found in previous studies. http://www.emua.ac.uk/downloads/LSHNA.pdf Evidence informs us that a high proportion of young people who have mental health problems do not wish to access traditional mental health services. They are often inappropriate and do not meet the needs of younger people, however early interventions, particularly with vulnerable children and young people can improve lifetime health and wellbeing, prevent mental illness and reduce costs incurred by ill health, unemployment and crime. These interventions not only benefit the individual during their childhood and into adulthood, but also improve the capacity to parent, so their children in turn have a reduced risk of mental health problems. 4.6 Refugees and Asylum Seekers (RAS) and Homeless People Inclusion Health has recognised the importance of equitable access to healthcare for homeless people. The complexity of homeless peoples lives makes it difficult for them to follow traditional care pathways; frequently resulting in missed appointments and wasted healthcare resources. In relation to homeless people there is evidence that rough sleepers and those living in hostels have significantly higher levels of premature mortality as well as mental and physical ill health than the general population. Many homeless people demonstrate tri-morbidity of physical illness, mental health problems and substance misuse. Research by London charity St. Mungos found approximately half their residents have mental health problems including schizophrenia, psychological disorders and depression. The research also found that 32% had alcohol dependency and that 63% had a drug problem. It is recognised that ill health can be both a cause and consequence of homelessness. Expert opinion suggests that majority of serious chronic health problems amongst homeless people pre-exist their homelessness, but will be exacerbated by the person being homeless. Homelessness is a complex problem which for many people results from a complex interaction of environmental and mental health factors. There is emerging evidence that psychological disorders strongly predict homelessness, particular youth homelessness and rough sleeping. This is particularly associated with Personality Disorder, Post Traumatic Stress Disorder (PTSD) and complex trauma. It is estimated that up to 60% of people within the hostel population in England may suffer from Personality Disorder (PD). The most common presenting problems for the homeless population after mental ill health is physical trauma, skin problems, respiratory illness, infections and drug/alcohol dependence.
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There are barriers to the homeless population registering with mainstream GPs including: ! ! ! Requirement of proof of address for registration Poor engagement and chaotic lifestyle make them poor at keeping appointments Tend not to seek assistance until their health is critical
They are also known to be high users of A&E for alcohol related health issues, and physical injury. Additionally a number of offenders leaving prison end up homeless. There needs to be strong links between prison health and the specialist primary care team. Asylum seekers are recognised as having varied and often complex health needs based on their country of origin and their reason for seeking asylum which can include escaping violence, torture or abuse. The majority will experience loss of family through death or separation which adds to the psychological pressures of being in the asylum process. Evidence from primary care sites in the UK shows consistently that consultations by asylum seekers and refugees include a predominance of minor illness such as upper respiratory tract infections, dental health problems, and skin conditions. Mental health symptoms of psychological distress problems are most commonly presented by this group. Mental health symptoms are frequently presented as the physical sequel of torture or violent trauma which may result in mal-united fractures, epilepsy or deafness from head injury. The reported prevalence of major physical illness/chronic disease is low, possibly reflecting the relatively young age of most refugees and asylum seekers. In Leeds the No Fixed Abode (NFA) team monitoring has shown a steady reduction in presentations to A&E by their registered patients as a result of working relationships between the services. In 2009 Leeds piloted the Homeless Link Health Needs Audit tool being developed as a national tool for authorities to use in order to contribute the needs of homeless people to the annual JSNA. The needs audit is targeted at clients supported by street outreach agencies and hostels. Key findings from the review were: ! ! ! ! ! ! 82% (n125) of clients have used a GP at least once during the past 6 months 34% used a dentist at least once 37% of clients attended A&E in the past 6 months 3 clients with 22 visits between them 22% had used an ambulance in the past 6 months (the Holies hostel being the place of highest call out) 61% reported a mental health problem with 45% reporting taking medication or receiving treatment Roughly and quarter and a third have received vaccinations or accessed screening. HIV being the most widely accessed.
The majority of clients falling into the target group are male.
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Similar to other large cities Leeds has a diverse and changing population that will include a number of transient vulnerable adults. Homeless figures vary according to source, how people present to services, and how homelessness is defined. There are fewer rough sleepers now than 10 years ago but there are still a number of people who consider themselves vulnerably housed through staying with friends, or being unable to maintain tenancies as evidenced by the current demand on services. Additionally there are a significant number of asylum seekers in the appeals procedure but living in destitution; estimated by research by Joseph Rowntree Charitable Trust (JRCT) to be up to 3,000 in Leeds in 2008. This number should fall as decisions are finally made on their application. As a large city Leeds it will always attract a range of transient people seeking to settle here and there is no evidence that this movement will cease. Up until 2010 Leeds has benefited from the services of two specialist teams; ! The well established No Fixed Abode (NFA) primary care team for the past 20 years with in February 2009 a registered list size of 742 of which 184 were destitute asylum seekers, and 86 were refugees. In March 2010 the majority of those with housing status recorded (n 473) were staying with friends and 104 were rough sleeping. Housing status changes frequently and so accuracy of data from NFA is inevitably hard to capture. The Health Access Team for asylum seekers was established in 2000 when Leeds became a dispersal site for newly arrived asylum seekers. It was a gateway service to local health and support services to ensure that asylum seekers gained access to appropriate healthcare. It also provided an educative function for other professional staff on the experience and entitlements of asylum seekers and refugees. In that time there has been considerable changes in the United Kingdom Boarder Agency (UKBA) asylum process, local arrival numbers, and understanding and capability within mainstream health services. Numbers are currently dropping, and the speeded up asylum process means that asylum decisions are being made much faster than in the past, resulting in faster turn around. This has brought with it a rise in the numbers of RAS experiencing destitution in Leeds as reported in two JRCT independent reports. This has led to a change in the focus of the work of the Health Access Team, and brought some overlaps with the work of the NFA Team. The key four top countries of origin of refugees and asylum seekers in Leeds are Zimbabwe, Iraq, Iran and Eritrea and top four languages as English, Arabic, Farsi and Tigre. 70% are male and the majority aged 26 34. The number of individuals in the asylum process in Leeds is falling. The total number dropped by 21% from 2008 to 2009 from 2129 for year ended June 2008 to 1687 for year ended June 2009. Figures from July 2009 to March 2010 would indicate that this trend is continuing. New arrivals had dropped from 1499 to 488 from June 08 to June 09.
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Total referrals to the Health Access Team from March 09 Oct 09 was 1575 which will include a mixture of new arrivals and people who have been in the asylum system for some time. There is a growing established community of different refugee groups in Leeds and a number of asylum seekers who are Section 4 funding.
In September 2010 UKBA closed the Initial Accommodation Centre in Leeds, due to a national reorganisation of provision. There is currently a national fall in the number of new asylum seekers, and UKBA decisions on outstanding applications for long standing claimants are being resolved. Leeds retains a large number of refugee communities, as well as a significant number of asylum seekers who have chosen to fall outside the system for fear of an enforced return. These changes in the national and local profile, and the increasing overlap between the work of the two teams is the rationale for now merging the functions of the NFA and HAT teams into one primary care team for vulnerable transient adults that will have the capacity to respond flexibly to demographic changes and local trends. 4.7 Prison Population in Leeds The prison population in Leeds have significant and often complex, multiple health needs and poor mental and physical health. This group is often invisible especially when we are using a geographical public health approach. Some 90% of all prisoners are estimated to have a diagnosable mental health problem (including personality disorder) and or substance misuse problem. The current Leeds prison population is approximately 2,500 people. Many prisoners nationally do not receive the support they need to overcome their mental health and substance misuse problems. The public sector duty in the Equity Act 2010 means that public bodies will have to be compliant and mindful of how the inclusion and equitable treatment of all protected groups is incorporated and measured. http://www.opsi.gov.uk/acts/acts2010/ukpga_20100015_en_1 This act also complements the report from Lord Bradley on improving mental health and learning disability outcomes for offenders which states that they should have the same access to mental health services as the rest of the population, and that mental health issues should be picked up as early as possible in their interaction with the criminal justice system. http://www.opsi.gov.uk/acts/acts2010/ukpga_20100015_en_1 The national mental health strategy No Health without Mental Health suggests that collaboration around diversion services by key stakeholders will identify a number of diversion pathfinders from existing services that will help to shape best practice, quantify the benefits and develop appropriate quality standards and begin evaluating work by 2012. Many offenders are from deprived communities with low educational attainment and multiple disadvantage. Before being sent to prison half of offenders are not registered with a GP, however once incarcerated, prisoners tend to consult primary care doctors three times as often as young adults in the community; for other health care workers it is roughly one to two hundred times as often.
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There have recently been health needs assessments undertaken in Leeds prisons. HMP Wealstun in identified the following (2010); There is a lack of complete figures for primary mental health as the team have only been functional since mid November 2009. However using prescribing figures: ! ! ! ! ! ! Around a quarter were on antidepressants 3% were on antipsychotic medication 2-3% were on medication for anxiety 1% were receiving counselling 5% were waiting for assessment by primary mental health 1% were on an open Assessment, Care in Custody and Teamwork (ACTT) document
The following gaps and recommendations in services have been identified; ! ! ! ! ! A screening validated questionnaire for mental health and learning disabilities needed at reception Provision of services around dual diagnosis Psychological interventions for sleep disorders to avoid hypnotic prescribing Psychological skills training, such as cognitive behavioural skills training, activities to improve self-esteem, anger management Prison officer training in mental health
Wetherby Young Offenders Health Needs Assessment (2008) Identified needs included ! ! ! Awareness by staff that it is a time of change for young people and need specific approach (to children and young people with complex needs rather than adult approach) and the importance of positive role models amongst all staff including HR. Security/ safety are foremost in staff minds with care coming second due to environment. Important to provide appropriate mental health awareness training for all staff and work closely within system to get on board the right staff who can promote this culture and champion. Engendering that training is relevant - improving understanding of how addressing the emotional health and well-being of young people is likely to have a positive impact on relationships, behaviour, emotional and social development, learning and achievement. Consider having a day unit for the most vulnerable young people, to reduce the likelihood of them being isolated on the wing for long periods of time which in turn would reduce the need for them to become in-patients in health care and reduce the risk of self harm and or complete suicide. Improve access with families as per recommendation in HNAs
HMP Leeds In July 2005 the Howard League for Penal Reform published statistics showing that Leeds Prison had the second highest suicide rate of all prisons in England and Wales. 25 inmates had committed suicide at the prison between 1995 and 2004.
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Suicide among prisoners is: ! ! About eight times more common than in the communities they come from Less common in sentenced prisoners than those on remand
4.8 Long Term Conditions Mental health problems are more common in people with physical illness, particularly depression and having both physical and mental health problems delays recovery from both. People with one long term condition are two to three times more likely to develop depression than the rest of the population. www.nice.org.uk/nicemedia/pdf/CG91NICEGuideline.pdf Adults with both physical and mental health problems are much less likely to be in employment. At the time of the 2001 Census there were over 128,000 people living in Leeds who considered themselves as having a limiting long-term illness (18% of the total resident population). Of these people 57,732 were of working age. Geographic analysis of the Census data has shown that people with a Limiting Long term illness are concentrated in particular geographic areas of the city that we have referred to as deprived Leeds. We need to understand the needs for people with long term conditions better and work collaboratively across the city especially in relation to the impact that long term conditions has on mental health and wellbeing. 4.9 Dual Diagnosis The term dual diagnosis is commonly used to describe individuals who have co-existing mental health and substance misuse difficulties. The nature of the relationship between these two conditions is complex and can include: ! a primary psychiatric illness precipitating or leading to substance misuse ! substance misuse worsening or altering the course of a psychiatric illness ! alcohol or drug dependence leading to psychological symptoms ! Substance misuse or withdrawal leading to psychiatric symptoms or illnesses. A clear association exists between mental illness and drug and alcohol dependence. People experiencing mental ill health have a higher risk of substance misuse. Like mental health problems, behavioural problems including substance misuse, frequently start early in life. For young people, emotional and behavioural disorders are associated with an increased risk of experimentation with, misuse of and dependence on drugs and alcohol. Young Minds A new drug strategy to tackle drug dependence and promote a recovery-led approach to help people rebuild their lives was published in December 2010.Drugs strategy The approach adopted by this strategy, of promoting mental wellbeing, preventing mental illness and early intervention as soon as the problem arises, will also help to reduce the risk of substance misuse across the population.
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It is important that the appropriate services are available locally in the right settings including the provision of fully integrated care, when this is appropriate, to meet this breadth of need. The Government will continue to actively promote and support improvements in commissioning and service provision for this group, their families and carers. The Public Health Outcomes Framework includes a proposed indicator on alcohol-related hospital admissions. The new strategy will set out proposals to tackle the burden of illness, injury, and death from alcohol misuse. The National Dual Diagnosis Programme (NDDP) was established in 2004/05. The main aim of the programme has been to actively promote and support the development of improvement in commissioning and service provision for people with a dual diagnosis, their families and carers.,It also aims to promote and embed the philosophy of mainstreaming across mental health services to ensure that dual diagnosis is seen as everyones business across health, social care and the criminal justice system. In support of developing its dual diagnosis policy the Department of Health also commissioned an epidemiological study known as COSMIC. This study (Weaver et al., 2003) found that 44% of service users in Community Mental Health Teams had a past year drug or alcohol misuse diagnosis (see Table 1) and that nearly 13% of these individuals were dependent users. The most commonly used substances encountered by mental health services were alcohol, cannabis, and stimulants and few of these service users would fit eligibility for substance misuse services priority, set centrally, is given to opiate and cocaine users. In Leeds there has been a Dual Diagnosis strategy group, practitioner network, website, and training developed since 2007. The aim is to support local services in the development of effective, embedded and sustainable care provision for people with DD. Leeds Partnership Foundation NHS Trust have recently developed a DD framework to develop their practice and increase staff capability. The number of people presenting to secondary mental health services with DD is increasing with a trend of about a third of new admissions being assessed for substance misuse problems. It is recognised that the prevalence and complexity of DD is increasing locally and the link between the two work streams of mental health and substance misuse service increasingly needing to work more closely together to achieve the best outcomes for service users.
4.10 Severe and Enduring Mental Health issues It is useful to see mental illness and enduring problems as being at one end of a mental health continuum. The majority of people move up and down at the other end (common mental health problems) and middle (more severe but temporary problems) part of the continuum. It is a minority who have an enduring diagnosable mental illness such as schizophrenia or bi-polar disorder. This minority, in terms of prevalence, represent about 1% of the adult population.
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For this group we know that despite new treatments, approximately 30% of people will experience significant and ongoing difficulty and disability, and a further 30% of people will have episodes of difficulty. We know that an effective mental health plan must ensure that services are in place to treat, support and assist people to manage their lives with an enduring mental health condition, while focusing on early intervention and fast access to effective treatment. Nationally the quality of mental health care has improved significantly in recent years. Skilled and committed front line staff have developed services that are internationally recognised including Early Intervention in Psychosis teams (EIP) and the improving access of psychological therapies (IAPT). The policy shift within mental health services is to ensure that more people, whatever their diagnosis, are in receipt of a recovery focussed service that enables them to recover the quality of life they seek. People with severe mental illness die on average 20 years earlier than the general population. Diagnosis is not, however, a predictor of ability, coping or outcome. Some people with bipolar or schizophrenia work full time, and lead full and active lives with periods of interruption when their symptoms of mental health become severe whilst others are unable to integrate into regular social settings or employment structures. Other people can be significantly disabled by extreme anxiety or phobias. In other words the response to mental ill health is individual, and can be dependent on a number of other factors particularly support structures, lifestyle etc. Mental health problems are usually defined and classified to enable professionals to refer people for appropriate care and treatment. But some diagnoses are controversial and there is much concern in the mental health field that people are too often treated according to or described by their label. This can have a profound effect on their quality of life. Nevertheless, diagnoses remain the most usual way of dividing and classifying symptoms into groups.
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Glossary
Bipolar disorder A severe mental illness with a long course, usually characterised by episodes of depressed mood alternating with episodes of elated mood and increased activity (mania or hypomania). However, for many people the predominant experience is of low mood. In its more severe forms, bipolar disorder is associated with significant impairment of personal and social functioning. The independent regulator of health and social care in England. It regulates care provided by the NHS, local authorities, private companies and voluntary organisations. A type of therapy that aims to help people manage their problems by changing how they think (cognitive) and act (behavioural), which can help them to feel better about life. The process of assessing the needs of a local population and putting in place services to meet those needs. Groups of GPs that will in future lead the commissioning of most healthcare services across England. GP consortia are to be statutory bodies accountable for commissioning. A programme that aims to improve access to evidence-based psychological therapies in the NHS through an expansion of the workforce and services. An assessment that provides an objective analysis of the current and future health and wellbeing needs of local adults and children, bringing together a wide range of quantitative and qualitative data, including user views. Up until now, each areas assessment has been produced by the local authority in collaboration with the primary care trust. GP consortia and local authorities, including directors of public health, will in future have an obligation to prepare the assessment, and to do so through the arrangements made by their local health and wellbeing board. The entirety of a persons cognitive and emotional resources. It includes their cognitive ability, how flexible and efficient they are at learning, and their emotional intelligence, such as their social skills and resilience in the face of stress. It therefore conditions how well an individual is able to contribute effectively to society, as well as their ability to enjoy a high quality of life. A broad term covering mental illness, learning disability, personality disorder and substance misuse. It is more formally defined as mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind.
Care Quality Commission
Cognitive behavioural therapy
Commissioning
GP consortia
Improving Access to Psychological Therapies Joint Strategic Needs Assessment
Mental capital
Mental disorder
Mental health
Good or positive mental health is more than the absence or management of mental health problems; it is the foundation for wellbeing and effective functioning both for individuals and for their communities.
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Mental Health Minimum Dataset
A nationally defined framework of data on adult patients, held locally by mental health trusts. It is designed to show in detail the patterns of care received by patients looked after by specialist mental health care providers in England. A phrase used in this strategy as an umbrella term to denote the full range of diagnosable mental illnesses and disorders, including personality disorder. Mental health problems may be more or less common and acute or longer lasting, and may vary in severity. They manifest themselves in different ways at different ages and may present as behavioural problems (for example, in children and young people). Some people object to the use of terms such as mental health problem on the grounds that they medicalise ways of thinking and feeling and do not acknowledge the many factors that can prevent people from reaching their potential. We recognise these concerns and the stigma attached to mental ill health; however, there is no universally acceptable terminology that we can use as an alternative. A term generally used to refer to more serious mental health problems that often require treatment by specialist services. such illnesses include depression and anxiety (which may also be referred to as common mental health problems) as well as schizophrenia and bipolar disorder (also sometimes referred to as severe mental illness). conduct disorder and emotional disorder are the commonest forms of childhood mental illness. An independent organisation that provides advice and guidelines on the cost and effectiveness of drugs and treatments.
Mental health problem
Mental illness
National Institute for Health and Clinical Excellence NHS Commissioning Board
A proposed new body that will have powers devolved to it directly from the secretary of state for health. It will be responsible for allocating and accounting for NHS resources and for supporting the GP consortia and holding them to account in terms of outcomes, financial performance, and fairness and transparency in the performance of their functions. Any disorder in which an individuals personal characteristics cause regular and long-term problems in the way they cope with life and interact with other people and in their ability to respond emotionally. A measure of the proportion of the population with different levels of mental health at any one time. The spectrum ranges from mentally ill and languishing through to moderately mentally healthy and flourishing. Psychosis affects a persons mind and causes changes to the way that they think, feel and behave. A person who experiences psychosis may be unable to distinguish between reality and their imagination. They may have hallucinations or delusions. Psychosis is not a condition in itself; it is a symptom of other conditions. The most common causes of psychosis are mental health conditions such as schizophrenia or bipolar disorder. A new body which, subject to passage of the health and social care Bill, will be established within the department of health in 2012 and will set the overall outcomes Framework for public health. It will be accountable to the secretary of state for health.
Personality disorder
Population mental health
Psychosis
Public Health England
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Public mental health
The art and science of promoting wellbeing and equality and preventing mental ill health through population-based interventions to: reduce risk and promote protective, evidence-based interventions to improve physical and mental wellbeing; and create flourishing, connected individuals, families and communities. Reports on the quality of services published annually by providers of NHS care. Quality Accounts are intended to enhance accountability to the public. A set of specific, concise statements that act as markers of high-quality, costeffective patient care, covering the treatment and prevention of different diseases and conditions, and published by NICE. This term has developed a specific meaning in mental health that is not the same as, although it is related to, clinical recovery. It has been defined as: A deeply personal, unique process of changing ones attitudes, values, feelings, goals skills and/or roles. It is a way of living a satisfying, hopeful and contributing life, even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in ones life.95 An important aspect of wellbeing and mental health: the ability to cope with adverse circumstances, either as an individual or in a community. A major psychiatric disorder, or cluster of disorders, characterised by psychotic symptoms that alter a persons perceptions, thoughts, affect and behaviour. Each person with the disorder will have a unique combination of symptoms and experiences. More severe and long-lasting mental illness associated with functional impairment. Someone with a severe or serious mental illness may nevertheless also have long periods when they are well and are able to manage their illness. (Sometimes referred to as mental wellbeing or emotional wellbeing.) For the purposes of this strategy the following definition has been developed: A positive state of mind and body, feeling safe and able to cope, with a sense of connection with people, communities and the wider environment.
Quality Accounts
Quality Standards
Recovery
Resilience
Schizophrenia
Severe (or serious) mental illness
Wellbeing
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Leeds Mental Health Needs Assessment 2011

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Leeds Mental Health Needs Assessment 2011

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Mental Health and Wellbeing in Leeds: An Assessment of Need in the Adult Population

Cover Image (by Dawn Smallwood) - Hyde Park Leeds

Victoria Eaton FFPH Consultant in Public Health, NHS Leeds

Mental Health Needs Data Pack

Leeds Population Data

Population 171,922 621,803 793,725 18,028 252,836 558,917 811,753

% of Reg. Pop 21.18% 76.60% 97.78% 2.22% 31.15% 68.85%

% of Leeds Pop 21.66% 78.34%

Deprived Leeds Population Pyramid

Non-Deprived Leeds Population Pyramid

Section 1: Mental Health Minimum Data Set (MHMDS) 2009-2010

Outpatient and community activity; 2009-2010

LPFT Contracting Data; 2007/08 2009/10

Section 2: Psychiatric Morbidity

45to54 Age 35to44 25to34 16to24

45to54 Age 35to44 25to34 16to24

100 150 Rateper100,000population

Section 3: Primary Care Mental Health Presentations

Q2 09/10 531 1,387 2,952 49 290 194 54

Q3 09/10 500 1,358 3,013 54 272 126 57

Q4 09/10 403 1,144 2,845 41 227 102 52

Q1 10/11 410 1,179 2,645 45 193 118 40

Q2 10/11 423 1,142 2,721 55 231 130 40

Q3 10/11 450 1,016 2,545 45 214 106 42

Total 2,717 7,226 16,721 289 1,427 776 285

Q2 09/10 84.84 221.60 471.64 7.83 46.33 31.00 8.63

Q3 09/10 79.72 216.52 480.40 8.61 43.37 20.09 9.09

Q4 09/10 63.87 181.29 450.86 6.50 35.97 16.16 8.24

Q1 10/11 64.82 186.39 418.14 7.11 30.51 18.65 6.32

Q2 10/11 66.31 179.02 426.53 8.62 36.21 20.38 6.27

Q3 10/11 70.92 160.11 401.07 7.09 33.72 16.70 6.62

Q2 09/10 184 443 941 16 109 59 23

Q3 09/10 150 334 868 16 96 34 21

Q4 09/10 153 353 971 15 95 33 26

Q1 10/11 143 319 809 16 51 37 17

Q2 10/11 152 345 901 21 82 37 19

Q3 10/11 136 276 820 12 74 37 20

Total 918 2,070 5,310 96 507 237 126

Q2 09/10 94.76 228.15 484.62 8.24 56.14 30.39 11.85

Q3 09/10 79.00 175.91 457.15 8.43 50.56 17.91 11.06

Q4 09/10 78.75 181.70 499.81 7.72 48.90 16.99 13.38

Q1 10/11 73.60 164.19 416.38 8.24 26.25 19.04 8.75

Q2 10/11 78.35 177.83 464.41 10.82 42.27 19.07 9.79

Q3 10/11 70.38 142.83 424.35 6.21 38.29 19.15 10.35

Q209/10 Q309/10 Q409/10 Q110/11 Q210/11 Q310/11 TargetPractices AllLeedsPractices

Q209/10 Q309/10 Q409/10 Q110/11 Q210/11 Q310/11 TargetPractices AllLeedsPractices

Q209/10 Q309/10 Q409/10 Q110/11 Q210/11 Q310/11 TargetPractices AllLeedsPractices

Church Street Group

3.50% 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% Calibre

Section 4: Suicide & Self Harm

10 8 6 4 2 0 14 514 1534 3564

10 8 6 4 2 0 14 514 1534 3564

Numberofindividuals Males Females

Self harm related Inpatient activity 38

Annualno.ofselfharmrelatedIPspells Females Males Cum.%

Section 5: Mental Health Audit Data (Severe Mental Illness Register)

>65 268 45 25 35 6 588 ** 970

<18 1864 >65

<18 1864 >65

MSOA Deprivation Quintile 1 - Most 2 3 4 5 - Least Leeds

Count 1,863 1,577 1,087 881 946 6,740

Population 159,666 165,922 130,630 127,811 155,384 739,413

Rate 1.17% 0.95% 0.83% 0.69% 0.61% 0.91%

0.0% 1 Most 2 3 MSOADeprivationQunitile 42 4 5 Least