Wellbeing and Adult Mental Health

Executive Summary

This chapter compares data for Surrey to both England and its group of 15 nearest neighbours, using the CIPFA model that measures similarities between local authorities(1) . For more detail broken down by Surrey CCGs see the recently published Mental Health Five Year Review Dashboard (2) and NHS Rightcare CCG datapacks .(3)

Surrey has lower rates than most of the key risk factors than the England average and among its comparator group – apart from loneliness and social isolation in adult carers – which is higher. In terms of higher risk/hard to reach groups, Surrey generally has lower proportions of people in these than England and its comparator group.

In terms of wider determinants of mental health: there are pockets of deprivation that have significantly higher scores than Surrey overall; most councils have seen a rise in homelessness applications in the last few years which has led to a shortage of temporary accommodation; Surrey has a slightly higher percentage than England of people claiming incapacity benefit and Employment Support Allowance for a mental health diagnosis. For factors supporting recovery, Surrey has: a higher percentage point gap between employment of those receiving secondary mental health services and the employment rate of the overall population – than England and most of its comparator group; and a lower percentage of adults in contact with secondary mental health services who live in stable and appropriate accommodation than for England and is mid way among its comparator group.

Surrey has similar levels of self-reported wellbeing to England and better than most of its comparator group, although it is highest in the group for people with a high anxiety score.

National data shows there is a considerably higher prevalence of mental health problems among the population than those diagnosed or receiving treatment – in large part due to the stigma that can make it harder for people to seek help from services. Several data sources show that in Surrey: levels of common mental health problems are lower than England; although highest in its comparator group for generalised anxiety and panic disorder and higher than most in the group for depressive disorder (older data); all CCGs have a lower referral rate to IAPT than England; levels of severe/enduring mental illness are also lower than England; but Surrey has a slightly higher (not significantly)excess mortality rate in adults with serious mental illness (SMI); and all CCGs have a significantly lower percentage of SMI patients who received the complete list of health checks than England; Surrey has significantly lower rates of emergency admissions for neuroses, schizophrenia and intentional self-harm than England and most of its comparator group; Surrey has a similar suicide rate to England and lower than most of its comparator group – although national data shows that the numbers of people who have thought about suicide is much higher.

Recommendations where improvements can be made and to address service gaps, are made in the following areas: mental health promotion, prevention and anti-stigma; wider determinants of mental health, lifestyle behaviours and physical health; higher risk/priority groups; detection/ under reporting and under diagnosis; services; self-harm and suicide

Introduction

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Visualisation of data used in this chapter

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Mental health problems often begin in childhood: it is known that 50% of mental illness in adult life (excluding dementia) starts before age 15 and 75% starts by age 18 (4). Therefore tackling problems when they first emerge is both important and cost effective. Early treatment is important as mental health problems in childhood have been shown to be associated with poor outcomes in adulthood.

Mental illness has wide-reaching effects on people’s education, employment, physical health, and relationships. Although many effective mental health interventions are available, people often do not seek the help they need due to the various types of stigma that still surround mental illness. Hence the importance of widely available self-help information and anti-stigma interventions within prevention programmes, as well as taking action to reduce risk factors.

Who’s at risk and why?

There are many factors that increase the risk of mental health problems/illness – only the minority of which are fixed and the majority are modifiable. The key ones are listed in Table 1.

Table 1: Factors that increase the risk of mental health problems.

Wider Determinants Lifestyle Risk Factors Fixed Risk Factors Family Factors
Deprivation Alcohol use Genetics & family history Parental mental illness & poor infant attachment
Unemployment Substance misuse Age Parental substance misuse
Social isolation / exclusion Smoking Ethnicity Family break up
Financial difficulty & debt Inactivity High Risk/ Hard to Reach Groups Being a looked after child (LAC)
Poor housing, homelessness, residential care Poor nutrition Victims of abuse, violence Adverse Life Events/
Circumstances
Crime & fear of crime Lack of social support People with long term conditions Marital/Relationship breakdown/divorce
Co- Morbidity Carers Physical illness
Ante-natal & post natal MH problems Black & Minority Ethnic groups Physical/sexual/ emotional abuse
Long Term Physical Health Condition (LTC) Lesbian, gay, bisexual, transgender Bereavement
Learning Disability Veterans & their families Work related stress
Cognitive Impairment People in the criminal justice system
Asylum seekers

Who’s at risk and why?

More information on risk factors and why they increase risk for mental health – see data visualisation

Wider Determinants

Deprivation

Overall Surrey has significantly lower deprivation than England, both for overall IMD score 9.4 vs 21.8 (2015)(5) and for the population living in areas defined as being in the 20% most deprived areas in England 0.4% vs 20.2%(6) (2014). Surrey ranks lowest among and significantly better than its 15 CIPFA group (CIPFA range: 0.4% – 13.0%).

However there are pockets of deprivation with the following lower super output areas having statistically significantly higher Index of Multiple Deprivation summary scores than the 9.4 for Surrey overall(7) , ranging from 36.1-29.5 in descending order: * Guildford 012D, Reigate & Banstead 008A, Woking 004F, Guildford 007C, Waverley 002E, Epsom & Ewell 007A, Woking 005B, Spelthorne 001B, Surrey Heath 004C, Mole Valley 011D. See data visualisation

Unemployment

Surrey has a significantly lower percentage of people in long term unemployment than England 0.09% vs 0.37% 2016) (8). and ranks 2nd lowest among the 15 CIPFA group – significantly better than most in the group (CIPFA range: 0.07 – 0.31).

There was a larger increase in unemployment in Surrey than England in the years 2001-2011 – a 71% rise compared to a rise of 43% in unemployment across England. However, as Surrey has a low rate of unemployment, the increase in the actual number of people unemployed was broadly similar to the increase across other parts of England over the same time period (Surreyi). Spelthorne, Woking and Reigate & Banstead have the highest rates of unemployment in Surrey (in descending order). See Surreyi dataset

Mental Health Benefit Claimants

Incapacity benefit is a measure of the level of severity of mental illness in the community and a direct measure of socio-economic disadvantage in those ‘not in work’ because of mental illness. Severe mental illness restricts a person’s capacity to fully participate in society, in particular the employment market. Unemployment rates are higher amongst people with severe mental illness.

The highest proportion of incapacity benefit and Employment Support Allowance claim in both Surrey and nationally is for mental health diagnosis (49.6% and 48.5% respectively). See Surreyi dataset

Surrey has a slightly higher percentage of mental health incapacity benefit claimants than England. Surrey wards with the highest proportion of Employment Support Allowance claimants for mental health reasons are (in descending order): Maybury and Sheerwater, Merstham and Westborough.

Homelessness

Surrey has a significantly lower level of statutory homelessness acceptances per 1,000 households than England (2015/6) 1.3 vs 2.5 and 5th lowest in its 15 CIPFA group. Surrey has a significantly lower level of statutory homelessness households in temporary accommodation per 1,000 households than England (3.1) with Surrey’s data too low to report.(9) Surrey ranks: lowest among the 15 CIPFA group. Statistical significance: Significantly better than almost all of the group (CIPFA range: 0.2 – 2.4).

Among all the Surrey boroughs, Spelthorne ( 2.8 per 1,000 households) had the highest statutory homelessness, higher than 7 of the Surrey boroughs but similar to the compared to the England average. Runneymede, Woking and Reigate and Banstead are also in the top three compared to other Surrey boroughs. See data visualisation.

Most councils in Surrey have seen a rise in homeless applications. There were 983 homeless applications in Surrey in 2013-14, which increased by 11% (to 1088) in 2014 -15. An increase of 12% is projected by the end of March 2016. The highest number of applications were received in Reigate & Banstead, Spelthorne, then Epsom & Ewell. The sharp rise in homelessness has also led to a shortage of temporary accommodation within the County and some homeless people are now being placed in bed and breakfast accommodation outside of Surrey, which means they can become disconnected from their health, care and support services. The housing JSNA chapter shows that mental health issues are overtaking substance and alcohol issues in this group.

Research has shown that the impact of homelessness is the most profound amongst rough sleepers. A report issued by CRISIS and Sheffield University(10) has shown that rough sleepers have a significantly lower life expectancy (average age at death of just 47 years for men and 43 years for women), and are nine times more likely to die by suicide.

Housing

The percentage of adults in Surrey in contact with secondary mental health services who live in stable and appropriate accommodation – independently, is lower than for England 45.3% vs 59.7% (2014/15) (statistical significance is not calculated), and (11)ranks 6th lowest among the 15 CIPFA group (CIPFA range: 24.8 – 81.8). Surrey has a significantly lower percentage of houses that are overcrowded than England 3.4 vs 4.8 (2011, although the fourth highest among its 15 CIFA nearest neighbours). Housing support data suggests a large variation in capacity compared to population. Spelthorne appears to have high occupancy compared to other boroughs, but this data is difficult to interpret as it includes both short term support and more stable tenancies (Mental Health PVR 2012)(12) .

The percentage of households experiencing fuel poverty in Surrey is lower than England 9.7% vs 14.6% (Census 2011)(13) . Surrey ranks: 3rd lowest among and significantly better than the 15 (CIPFA group. CIPFA range: 8.6 – 19.6).

Crime

Surrey has a significantly lower rate of violent crime per 1000 population than England 13.9 vs 17.2 (2015/6) (14) and ranks: mid-way among the 15 CIPFA group. Statistical significance: Significantly better than half in the group (CIPFA range: 8.6 – 18.6).

Surrey has a lower rate of violent offences (including sexual violence) per 1000 than England 1.3 vs 1.7 (15) (2015/16). Surrey has a significantly lower rate of emergency hospital admissions per 100,000 population for violent crime (including sexual violence) than England 25.1 vs 47.5 and ranks 4th lowest among the 15 CIPFA group (2012/13 – 2014/15) – significantly better than half of the group CIPFA range: 14.1 – 39.4.

Social Isolation

The percentage (%) of adult social care users in Surrey that have as much social contact as they would like ( 2015/16) is similar to England 45.5 vs 46.4 and Surrey ranks 6th lowest among the 15 CIPFA group – not statistically different from most of the group (CIPFA range: 39.9 – 51.4)(16) . However, Surrey has a significantly lower percentage of adult carers who have as much social contact as they would like than England 35.8 vs 38.5 (17) (2014-5) and ranks. 6th lowest among the 15 CIPFA group – not statistically different from most of the group (CIPFA range: 26.8 to 46.8).

Lifestyle Behaviours and Physical Health

Poor mental health can lead to a poor lifestyle and increased risk taking behaviours such as excessive drinking, smoking, poor nutrition and lack of exercise. These are risk factors for serious physical illness, particularly coronary heart disease and cancers. The prevalence of these modifiable risk factors is much higher for people with mental health problems and increases with the severity of the mental health problem . (18) People with common and more serious mental health needs have lower life expectancy and a 0.7 and 3.6 times higher mortality rate (respectively), than those without mental health needs. People with schizophrenia and bipolar disorder die an average 15-20 years earlier than the general population – they have 4.1 times overall risk of dying prematurely; have 3 times the risk of dying from CHD(19) and a 10 fold increase in respiratory disease deaths.
(20) See JSNA chapter; Improving health behaviours.

Alcohol

Synthetic estimates (2008-9) for the 16+ population show that the overall prevalence of increasing/higher risk drinking in Surrey is similar to England 21% vs 22.3 and 5th highest –although similar to its CIPFA comparison group (21). Whilst similar, these estimates suggest that more than one in four adults who drink alcohol in Surrey, do so above the recommended levels.

Alcohol-related hospital admissions in Surrey have risen by 24% since 2009/10 (22). This upward trend is evident across the Surrey and Sussex area and the country as a whole. However the level in Surrey is significantly lower than England and similar to that of the Surrey ranking: 5th lowest among its 15 CIPFA neighbours (CIPFA range: 1631.5 – 3,746.7 no significance calculated).
See JSNA chapter; Improving health behaviours. In Surrey, there is limited data on the prevalence of alcohol misuse and mental health issues, however 18% (n=289) of clients in treatment for alcohol misuse in 2012-13 were reported as having a dual diagnosis (Halo System 2013).

Substance Misuse

Data from PHE shows that Surrey has: a similar percentage of people in contact with mental health services when they access services for substance misuse to England, 20.4 vs 21 (2014-15) and 7th highest among its 15 CIPFA nearest neighbours (CIPFA range: 7.3 – 29.5, significantly better than 6 neighbours).(23) ; and a significantly lower rate per 1 000 pop of adults in treatment at specialist drug misuse services than England 2.4 vs 4.8 (2014/15) and 4th lowest rate among its 15 nearest neighbours (CIPFA range: 2.0 – 3.7) (24) . Data from Surrey drug and alcohol services show a slightly lower number of clients both recorded with and in treatment for dual diagnosis with mental health problems in 2013/14 as compared to 2011/12. For more information on hospital admission for dual diagnosis. See JSNA chapter; Substance misuse.

Physical activity

Surrey is statistically significantly better than England 62% vs 57% (2015) on the percentage of physically active adults (25) and ranks 2nd highest among and similar to most of the 15 CIPFA group. (CIPFA range: 57.5 – 62.8, similar to most neighbours). Surrey also has a higher percentage than England of people using outdoor space for exercise/health than England (24.9 vs 17.9%) and ranks third highest among its 15 CIPHA nearest neighbours but not significantly different from most of them (CIPFA range: 11.3 – 31.8, similar to most neighbours) (26).
See JSNA chapter; Improving health behaviours.

Smoking

Smokers with mental health problems are more dependent on nicotine than the population(27) as a whole, with levels about three times those observed in the general population (28). In 2015, a Public Health England and NHS England survey revealed that 33% of people with a mental health condition smoke compared to 18.7% of people in the general population . Smoking rates are even higher among people with severe and enduring mental health problems. GP data 2009-10 reported smoking prevalence as high as 47.1% in patients with personality disorders, 44.6% in patients with schizophrenia/schizotypal/delusional disorders, and 36.7% in patients with bipolar affective disorder(29). See data visualisation. (Some of these figures will be slightly elevated as a person with multiple diagnoses will be registered as a smoker across several of them). However, using this data, it has been estimated that there are approximately 2.6 million smokers in the UK with a common mental condition and around 3 million with a mental condition of any kind.

Surrey has a significantly lower smoking prevalence in adults with SMI than England 32.5 vs 40.5 and the lowest in the 15 CIPFA group (significantly lower than 13) (CIPFA range: 32.5 – 42.1, better than almost all of its neighbours).(30)
See JSNA Chapter; Improving health behaviours.

High Risk Groups

People with Long Term Conditions/ Physical Illness

Surrey has an overall statistically significantly lower percentage of the population with a limiting long term illness or disability that limits their day to day activities than England 13.5% vs 17.6% (2011) (31) and Surrey ranks: 2nd lowest among the 15 CIPFA group – significantly better than most in the group CIPFA range: 13.4 – 20.3. The proportion of the population reporting a health problem that limits their day to day activities is highest in Spelthorne (14.9%), then Tandridge (14.8%), Mole Valley (14.7%) and lowest in Elmbridge (12.1%).

The overall proportion reporting a health problem that limited their day to day activities in the 2011 Census, was very similar to the previous Census in 2001. The percentage rises sharply in older people with 78% of people over 85 and 51% of people aged 75 to 84 reporting a health problem that limited their day to day activities.

Carers – LiNK to Carer’s JSNA

Surrey has a significantly lower percentage of unpaid carers than England 1.63% vs 2.37% (2011)(32) and the lowest percentage of all its 15 CIFA nearest neighbours (CIPFA range: 1.63 – 2.49). Surrey has higher expected numbers of carers of people with a Learning Disability than in other parts of the country, due to a historic, disproportionately high LD population. We can estimate that in 2016 there are 115,216 carers of all ages living in Surrey (taking the number of carers from the 2011 census as a percentage of the population and applying that to future population projections).

Carers support organisations (jointly funded by Adult Social Care and CCGs), reported helping over 28,000 carers during the year 2015/16.

Surrey has a significantly higher percentage of carers of clients with mental health problems receiving community services – advice or information(33) (although PHE express some concerns about the quality of this data). Surrey has a significantly higher rate (per 100 000) of assessments for carers of adults with a mental health condition than England 76.7 vs 64.3, and the fifth highest rate among its 15 CIPFA nearest neighbours (CIPFA range: 5.4 – 184.7) (34) (although PHE express some concerns about the quality of this data).

Black and Ethnic Minority Groups (BME)

Rates of mental health vary by ethnicity. The Data visualisation shows that Black males are more likely to be diagnosed with a psychotic disorder; Asian Females are more likely to be diagnosed with a common mental health disorder (CMD) and White females and other mixed and multiple ethnic groups are more likely to experience suicidal thoughts.

The majority of the Surrey adult population (83.5%) reported their ethnic group as “White British” in the 2011 Census; other white ethnic groups; “Irish, “Gypsy or Irish Traveller” and “Other White” (6.9%), then “Indian” (1.8%) followed by Pakistani (1.0%). Surrey has a significantly lower than England percentage of mixed/multiple 2.08.2.25, Asian or Asian/British 5.6 vs 7.8, Black of Black/British 1.1 vs 3.5 and other ethnic groups 0.8 vs 1.0 (2011) and ranks 3rd highest among its CIPFA neighbours ( CIPFA range: 2.5 – 14.6) (35). For other ethnic groups Surrey is the highest among its CIPFA nearest neighbours. Hence. Surrey likely to have more ethnic groups suffering with mental health issues.

Within Surrey, Woking is the most diverse local authority and North West Surrey is the most diverse clinical commissioning group (CCG) and Guildford & Waverley is the least diverse. For a more detailed breakdown see the data visualisation.

Although Surrey has a significantly lower rate of migrant GP registrations per 1 000 than England 11.2 vs 12.6 (2015)(36) , the rate is the third highest of all its CIPHA neighbours (CIPFA range: 4.8 – 21.2, significantly higher than most of its neighbours).

Asylum Seekers

Surrey is not a dispersal area for asylum seekers therefore there is no data on the number of asylum seekers in Surrey. However on average nine unaccompanied and former unaccompanied children are placed in Surrey every month. High levels of mental health need are reported in this group. See JSNA Chapter: Unaccompanied (and former unaccompanied) Asylum seeking children

Lesbian, Gay, Bisexual, Transgender (LGBT)

The data visualisation shows there are an estimated 11 286 people who are gay or lesbian and 5 643 people who are bisexual in Surrey, based on the England estimates. There is no equivalent data for people who are transgender. For more information see JSNA Chapter: Lesbian, Gay, Bisexual and Transgender. The evidence base shows that people who LGB&T are at higher risk of mental disorder, suicidal ideation and attempts, drug and alcohol use, deliberate self-harm (37) and more likely to report psychological distress than their heterosexual counterparts.

Victims of Domestic Abuse

Surrey has a significantly lower rate of domestic abuse incidents per 1000 population recorded by the police, than England 15.5 vs 20.4 (2014/5) (38) and the third lowest rate out of its 15 CIPHA nearest neighbours (CIPFA range: 13.0 – 22.7).

Within Surrey – Elmbridge, Guildford, R&B and Spelthorne have the highest rates of Domestic Violence Incidents (although this could be due to better reporting in these areas and different population sizes) See Surreyi dataset. See also JSNA chapter; Domestic abuse

People with Learning Disabilities

People with learning disabilities are at a high risk of developing a mental health need. It is estimated that between 25% and 40% of people with a learning disability have a mental health need(39) . Factors such as medical condition, social circumstances, loss of control, poor communication and lack of opportunities can often cause poor mental health.

In Surrey there are:

  • 647 of 16-17 year olds with learning disabilities and 98 with autism
  • 21,400 adults 18 + with learning disabilities and 8,921 with autism – of whom 4510 adults with learning disability and 2014 with autism are over 65 (40)

PHE data (2013-14) shows that Surrey has a: significantly lower prevalence of adults with learning disabilities 0.43 vs 0.48 and significantly lower than eight out of its 15 CIPFA comparator group (CIPFA range: 0.37 – 0.59)(41) . Surrey has a significantly lower percentage of people with learning disabilities known to GPs than England 0.4 vs 0.5 and the same as nine out of 15 of its CIPFA nearest neighbours (CIPFA range: 0.4 – 0.6).

Veterans

There are significant problems estimating the size of the veteran population (due to differently perceived definitions of veterans and no single reliable data source). According to estimated national data, veterans make up approximately 9% of the population. Surrey County Council’s Mental Health Public Value Review (2012) estimated that approximately 6% of Surrey’s 16-64 residents are veterans/ current army personnel. The Surrey Health Needs Assessment of the Armed Forces Community (2013) (42) estimated the number of veteran households in 2010 as 94,784 and the number of veterans born post 1960 as 34,467. There is no more recent data. National prevalence estimates (in previous Mental Health JSNA) shows that common mental health disorders are the highest among veterans 19.7%, then alcohol misuse 13% then Post Traumatic Stress Disorder 4%. See data visualisation.

People in Criminal Justice System

Data from the Prisons reform trust shows that prisoners have much higher rates of self-harm, anxiety, depression, symptoms indicative of psychosis and attempted suicides compared to the general public (3-7 times higher for different mental health issues) See data visualisation
.
Surrey has a significantly lower rate of first time offender rate (per 100 000 population) than England 191.3 vs 242.4 and is midway among its 15 CIPFA nearest neighbours (CIPFA range: 87.1 – 241.2)(43) . The prisoner population count (2014) shows that Surrey has 2 433, which is the 2nd highest of its 13 nearest neighbours (with data available, no significance data available) (44) – Surrey has five prisons. However PHE express significant concerns re the quality of this data).

The data visualisation shows the expected percentages and numbers of female and male prisoners in Surrey with mental health conditions – respectively for 2016. For both female and male prisoners, the highest number (in descending order) have personality disorders, then anxiety and depression, attempted suicide, then symptoms indicative of psychosis. Female prisoners have three times as high levels of previous psychiatric admission before they entered prison than males.

Adverse Life Events/Circumstances

Marital breakup

Surrey has a significantly lower percentage of marital break ups than England 10.4 vs 11.6 (2011) and is the second lowest of its 15 CIPFA nearest neighbours (CIPFA range: 10.2 – 13.4) and a significantly lower percentage of lone parent households than England 4.7 vs 7.1 (2011) and of all its 15 nearest neighbours (CIPFA range:4.7 – 6.8).
(45)

Work Related Stress

Although there is no Surrey data, estimates from the national Labour Force Survey (2014/5) show :
(46)

The total number of working days lost due to stress in 2014/15 was 9.9 million days – an average of 23 days lost per case; stress accounted for 35% of all work related ill health cases and 43% of all working days lost due to ill health; and stress is more prevalent in public service industries, such as education; health and social care; and public administration and defence.

The level of need in the population

Self-reported Wellbeing

Surrey has good levels of self reported wellbeing (Public Health Outcomes Framework 2014-5) :

  • significantly lower than England percentages of people with a low satisfaction score 3.3 vs 4.8 and 4th lowest among its 13 CIPFA nearest neighbours (with data available) (CIPFA range: 2.9 – 5.1, similar to all of its neighbours) (47)
  • significantly lower than England percentages of people with a low happiness score 7.0 vs 9.0 and third lowest among its 15 CIPFA nearest neighbours (CIPFA range: 5.5 – 10.1, similar to all of its neighbours) (48)
  • similar to England percentage of people with a low worthwhile score 3.6 vs 3.8 and midway among its 7 CIPFA nearest neighbours (with data available) (CIPFA range: 2.4 – 4.3, similar to all of its neighbours) (49)
  • similar to England percentage of people with a high anxiety score 19.6 vs 19.4 and fourth highest among its 15 CIPFA nearest neighbours (CIPFA range: 14.0 – 21.2, similar to all of its neighbours)
    (50)

Post Natal Depression

About 10%-20% of women are affected by mental health problems at some point during pregnancy or the first year after childbirth.(51) Depression and anxiety are the most common mental health problems during pregnancy, and also affect 15–20% of women in the first year after childbirth. Postpartum psychosis affects between 1 and 2 in 1000 women who have given birth. Women with a history of mental health problems before becoming pregnant are at increased risk of certain mental health conditions during pregnancy and the year after childbirth. Women with pre existing bipolar type 1 disorder are at particular risk, but post-partum psychosis can occur in women with no previous history of mental health problems .(52)
Between 2009-2012 there were 0.67 maternal deaths per 100,000 maternal deliveries in the UK that were a result of psychiatric causes; this is an increase from 0.55 in the UK 2009-2011 ).(53)

The risk factors (such as domestic abuse, teenage pregnancy, stillbirth and infant mortality rates) and the rate of mental health problems in the Surrey population, are at a lower level than the national average and so we would not expect to see a higher level of maternal mental health problems than the national average. The estimated number of women with mental health problems during pregnancy and after childbirth for Surrey and NE Hampshire are shown here. The data visualisation shows the prevalence of perinatal mental health needs and infant mental health needs in Surrey (2007) and projected needs (2026) using a benchmarking tool from NICE .
(54,55) See JSNA chapter; Perinatal mental health

Surrey has a higher rates of live births in older mothers (aged 35+) compared to the rest of the country. Risks and complications within pregnancy and birth increase with maternal age. Surrey also high level of gypsy roma and travellers who tend to have more children compared to their age-sex matched counterparts, with high rates of infant and child deaths. Perinatal mental health services to be developed locally therefore need to cater for a more complex population.

Common Mental Health Problems

Incidence Adult Mental Health Problems

The national Adult Psychiatric Morbidity Survey (APMS)(56) is one of the only data sources to assess/ screen for prevalence of both treated and untreated mental disorders in England. This includes both people with diagnosed disorders and people who have not received a formal diagnosis. (This explains why the prevalence reported in the APMS is higher than those based on service data below). The APMS demonstrates there is considerably higher prevalence of mental health than problems among the general population, than those receiving treatment. Often the stigma that surrounds mental health can make it harder for people to seek help from services, hence the importance of widely available self-help information and anti-stigma interventions.

The latest APMS (2014) shows the high incidence of common mental health problems:

  • One adult in six (17.0%) had a CMD, an overall rate that hasn’t changed much since 2000), but of these only about a quarter (26.8%) had received a diagnosis. CMD rates were higher in women than men 20.7% vs 13.2% (about one in five vs one in eight men).
  • Comorbidity relates to the presence of more than one disorder. In the last 12 months just over a quarter of adults (27.7%) reported having at least one of the five chronic physical conditions considered in the report, in addition to a mental health disorder. High blood pressure was the most common, followed by asthma, diabetes, and cancer.
  • Self-harm – In the 2000 survey, one in fifteen young women aged 16 to 24 years reported in the face to face part of the interview that she had self-harmed (6.5%); this increased to one in nine in 2007 (11.7%) and one in five in 2014 (19.7%).
  • The data visualisation shows the percentage of people with various mental health disorders (based on the Adult Psychiatric Morbidity Survey (2014) and the estimated numbers of adults in Surrey with these disorders (calculated by applying this percentage to the Surrey population aged 16+ (2015 mid-year estimates from ONS). In comparison to the previous 2007 APMS, there is approximately 1% reduction in prevalence of people with common mental disorder.

Index of Multiple Deprivation – Mental Health Indicator of Common Mental Illness (57)

This Mental Health Indicator is a measure of adults under 60 suffering with common mental health illness (suffering from mood or anxiety disorders, based on prescribing, suicides, and health benefits data). The Indices are used widely to analyse patterns of mood and anxiety disorders by Lower Super Output Area (LSOA)* . The value of zero represents the average population across all SOAs in England. A score above zero indicates that more mental health problems are evident in an area than expected, given the age and gender distribution. A higher score for the indicator represents a higher level of deprivation.

For 2015 the England range is from 3.09 to -2.85 and the Surrey range is from 1.07 to -2.34. Overall common mental health needs in Surrey are relatively low compared to England. The data visualisation shows the five Surrey wards with the highest and lowest levels of common mental illness (in green), as measured by the IMD Mental Health Indicator (2015). Three of the wards with the highest levels are in Reigate and Banstead, one each in Waverley and Guildford. In descending order they are: Reigate and Banstead 018E, Waverley 003B, Reigate and Banstead 016E, Guildford 01A and Reigate and Banstead 008A.

Primary care Quality and Outcome Framework (QOF) data report the prevalence of depression, psychoses and dementia diagnosed in people registered with GPs. While covering the majority of the UK population, QOF data may not fully represent all groups and relies on accurate registers and diagnosis of mental health problems. We know through feedback from service users, that not everyone with common and/or severe mental illness is on their local QOF register. As a result, prevalence of health conditions represented by QOF data should be viewed with caution as a higher prevalence does not necessarily mean that the condition is genuinely more prevalent within that area but rather that the GP practices are better at recording it.

In the data below, the CCG charts have been aggregated from actual GP data and local authority QOF prevalence has been modelled.

Depression (18+)

The data visualisation shows that Surrey CCG total area has a statistically significantly lower percentage prevalence of depression among adults aged 18+ than England (6.2% vs 7.3%) (2014-5). All the Surrey CCGs have a significantly lower prevalence than England except the combined prevalence of the 5 GP practices in North East Hampshire and Farnham CCG within the Surrey County border – which is statistically significantly higher than England. (It should be noted however that this is just for Surrey residents registered in this CCG, not the entire CCG).

The data visualisation shows that: Epsom and Ewell (93.3), Waverley (82.6) and Mole Valley (69.9%) local authorities have statistically significantly higher modelled prevalence of depression per 1,000 population than for the Surrey PCT area as a whole (66.1) and England (73.2) (2014-5).

The GP Patient Survey is an independent survey run by Ipsos MORI on behalf of NHS England, is sent out to over a million people across the UK and designed to give patients the opportunity to comment on their experience of their GP practice and answer questions about their health. The data visualisation shows patients’ responses on their state of health for anxiety and depression. N.B this is self-report data and does not use clinical/diagnostic measures, therefore is liable to sizeable individual differences in the meanings of anxiety and depression; CIPFA comparators not available.

According to the 2014-5 GP Survey(58,59), all Surrey CCGs have lower than the England 12.4% of patients reporting they feel moderately/extremely anxious or depressed (East Surrey 8%, Surrey Health 8.5% Surrey Downs 9% NE Hampshire & Farnham 9.8%), in a GP survey .NHS Guildford and Waverley had the highest percentage for those slightly anxious or depressed 9.3% – although just above the England average this is not statistically significant.

Modelled prevalence data from PHE from 2012 (which they express some concerns over its quality and significance data is not available)(60), , shows that the estimated percentage of the population (aged 16-74) with depressive disorder, mixed anxiety and depression, generalised anxiety, phobias, panic and obsessive compulsive disorder is lower in Surrey than England(61) : Although Surrey is the highest among its CIPFA comparators for generalised anxiety and panic disorder, and higher than most of them for mixed anxiety and depressive disorder and depressive disorder.

  • Estimated percentage of population with depressive disorder is lower in Surrey than England 1.93 vs 2.48% and higher than 10 of its 15 CIPFA nearest neighbours (CIPFA range: 1.21 – 2.97)
  • Estimated percentage of population with mixed anxiety and depressive disorder is lower in Surrey than England 7.76 vs 8.92 and higher than 10 of its 15 nearest neighbours (CIPFA range: 6.18 – 10.57)
  • Estimated percentage of depression and anxiety reported by social care users is lower in Surrey than England 49 vs 52.8 and lower than two thirds of its 15 nearest neighbours (CIPFA range: 47.1 – 57.0)
  • Estimated percentage of population with generalised anxiety disorder is lower in Surrey than England 3.7 vs 4.5 and 4th highest among its 15 nearest neighbours (CIPFA range: 3.0 – 4.2)
  • Estimated percentage of population with all phobias is lower in Surrey than England 1.14 vs 1.77 and lower than 9 of its 15 nearest neighbours (CIPFA range: 0.98 – 1.85)
  • Estimated percentage of population with obsessive compulsive disorder is lower in Surrey than England 0.72 vs 1.10 and about midway among its 15 nearest neighbours (CIPFA range: 0.62 – 1.17)
  • Estimated percentage of population with panic disorder is higher than England 0.73 vs 0.65 and joint 3rd highest among its 15 nearest neighbours (CIPFA range: 0.13 – 1.05)

PHE express significant concerns over the quality of the data for these next two disorders:

  • Estimated percentage of population with eating disorders in Surrey is higher than England 6.89 vs 6.73 and joint 2nd highest among its 15 nearest neighbours (CIPFA range: 6.6 – 6.9)
  • Estimated percentage of population with post traumatic stress disorder is higher in Surrey than England 3.11 vs 3.02 and 3rd highest among its 15 nearest neighbours (CIPFA range: 3.0 – 3.2).

Severe/Enduring Mental Illness

According to the national Adult Psychiatric Morbidity Survey 2014 (which assesses/screens for prevalence of both treated and untreated mental disorders), In comparison to the previous 2007 APMS, there is an increase (between one-four percent) in prevalence in people of psychotic and personality disorders, suicide attempts, suicidal thoughts and self harm. The largest increases are in suicidal thoughts and self harm.

All Surrey CCGs have a statistically significantly lower percentage than England 5.1% of people reporting they have a long term mental health problem in the GP survey (Surrey Heath 2.8%, East Surrey 3.4%, Surrey Downs 4.1%, North West Surrey 4.6%, Guildford & Waverley 4.9%, NE Hampshire & Farnham 4.2% ).(62,63).

QOF Primary Care-Mental Health: Schizophrenia, Bipolar Disorder and other Psychoses

Primary care Quality and Outcome Framework (QOF) data for people with schizophrenia, bipolar disorder and other registered with GPs, shows that the Surrey CCG total prevalence of patients with schizophrenia, bipolar affective disorder and other psychoses is significantly lower than England (2014-5). The CCG with the highest prevalence is East Surrey – which is statistically significantly higher than Surrey as a whole. (See data visualisation)

All Surrey local authorities have a lower modelled prevalence than England. Waverley, Reigate and Banstead and Mole Valley have a modelled prevalence of schizophrenia, bipolar affective disorder and other psychoses significantly higher than Surrey (2014-5). The data visualisation shows that Surrey has a similar premature mortality (<75) age standardised rate per 100 000 population among adults with serious mental illness to England 1399 vs 1319 and is in the bottom third of its 15 nearest neighbours (CIPFA range: 1200 – 1682, similar to its CIPFA neighbours) .
(64)

Surrey has a slightly higher (not significant) excess mortality (<75) mortality rate in adults with serious mental illness than England 356.1 vs 351.8 (benchmarking significance level is not available) and is in the upper two thirds of its 15 nearest neighbours (65) (CIPFA range: 266.3 – 437.1, similar to its CIPFA neighbours) . (ratio of observed number of deaths in adults in contact with secondary mental health services to the expected number of deaths in the general population –hence a health inequality).

Factors supporting recovery

  • Surrey has higher percentage point gap in employment of those in contact with secondary mental health services and the overall employment rate, than England 68.3 vs 66.1 and the joint third lowest among its 15 CIPFA nearest neighbours (CIPFA range: 59.3 – 76.4) (66)
  • Surrey has a similar percentage of adults on CPA in employment (2012-13) 8.1 vs 8.8 but is in the bottom third among its 15 CIPFA nearest neighbours (CIPFA range: 5.2 – 20.2) .
    (67)
  • Surrey has a significantly lower percentage of adults in contact with secondary care mental health services in settled accommodation (2012-13) 44.4 vs 58.5 and has the 5th lowest percentage among its 15 CIPFA nearest neighbours (CIPFA range: 27.6 – 81.5) .
    (68)
  • Surrey has a significantly lower percentage of social care mental health clients on self directied support – receiving direct payments or that have a personal budget, than England 14.5 vs 28.4 and is in the bottom third amongst its 15 CIPFA nearest neighbours (CIPFA range: 4.5 – 96.2, significantly lower than half of its neighbours) (69)

Mental Health Hospital Admissions
The data visualisation shows that the boroughs with highest rate of mental health related acute hospital admissions per 1,000 population (2015-6) are: Reigate and Banstead (36.4), Tandridge (35.1) and Spelthorne (33.5).

Although generally the highest mental health coding is for mood disorders and substance misuse, each borough has a different proportion of admissions for different diagnoses:

  • The highest proportion of Mood Disorder acute hospital admissions (in descending order) are: Reigate and Banstead, Tandridge and Woking.
  • The highest proportion of Neurotic Disorders acute hospital admissions are: Reigate and Banstead, Tandridge and Mole Valley.
  • The highest proportion of Psychoactive Substance Misuse Disorder acute hospital admissions are: Spelthorne, Reigate, Banstead and Runnymede.
  • The highest proportion of Personality Disorder acute hospital admissions are Guildford and Tandridge.

Surrey has a significantly lower rate of admissions for depression than England 16.1 vs 32.1 and the third lowest among its 15 CIPFA nearest neighbours (DSR per 100 000 population aged 15+ 2009/10-2011/12) (CIPFA range: 7.8 – 47.9). However this data is quite old.

Surrey has a significantly lower rate of admissions (per 100 000 population) for mental and behavioural disorders due to alcohol than England 41 vs 84 (2014/15) and joint second lowest (with three others) among its 15 CIPFA nearest neighbours (CIPFA range: 35 – 76) (70).

Surrey has a similar rate of admissions (DSR per 100 000 population) as a result of self harm to England 392.6 vs 398.8 and 6th lowest among its CIPFA group(71) (CIPFA range: 249.2 – 565.1).

Emergency Mental Health Hospital Admissions

Surrey has a significantly lower rate of emergency admissions for neuroses (2012-3) than England 9.5 vs 21.7 (indirectly age and sex standardised rate per 100 000 population), and the third lowest among its 15 nearest neighbours (CIPFA range: 6.7 – 26.0)(72) (although PHE express some concerns about the quality of this data).

Surrey has a significantly lower rate of emergency admissions for schizophrenia (per 100 000 2009/10-2011/2) than England 25 vs 57 and the second lowest rate among its 15 CIPFA nearest neighbours (CIPFA range: 7.0 – 54.0) (73) (although PHE express some concerns about the quality of this data.

Surrey has significantly lower emergency hospital admissions for intentional self-harm (directly age standardised rate 2014-5) than England 155.9 vs 191.4 and the 5th lowest rate among its 15 CIPFA nearest neighbours (CIPFA range: 126.4 – 255.5)(74) .

Section 136 Detentions

In the year April 2015-March 2016, there were 768 detentions under s136 of the MHA (which is a 19% increase in detentions in comparison to 2014/15) and 25 (3%) of the 768 individuals were taken to custody as a Place of Safety (which is a 2% decrease to the overall from 2014/15). In 80% (20) of incidents that went to custody, this was due to lack of available assessment suites and therefore not in accordance with the multi-agency protocol, Crisis Care Concordat, or Mental Health Act Code of Practice (MHA CoP). For more detail click here.

Self Harm

The Mental Health Five Year Forward Plan has published data on self-harm hospital admission rates for 2015/16. This is the most up to date data available and shows that: Surrey Heath has the highest rate of hospital admissions (per 100 000) for self-harm for persons aged over 18, at 88. This is significantly higher than the England rate of 47.7. See data visualisation

Suicide and Injury Undetermined

In general there has been a downward trend in suicides in the UK and in Surrey since 2000. Surrey has historically had a lower rate of suicides than the UK, except in 2009 and 2013 when the rate peaked to above the UK figure. (See data visualisation.)

The latest three year average data (age standardised rate per 100 000) shows that Surrey:

  • has a similar rate of mortality from suicide and injury undetermined as England 9.1 vs 10.1 and the 4th lowest rate among its 15 CIPFA nearest neighbours (CIPFA range: 6.6 – 12.0) (2013-5)
    (75)
  • has a significantly lower rate than England among males 12.8 vs 15.8 and the second lowest of its 15 CIPFA nearest neighbours (CIPFA range: 10.9 – 19.4) (2013-5) (76)
  • has a significantly lower rate of years of life lost due to mortality from suicide and injury undetermined among males, than England 41.7 vs 50.2 and the second lowest of its 15 CIPFA nearest neighbours (2012-14) (CIPFA range: 35.1 – 65.2) (77)

The Mental health Five Year Forward Plan dashboard October 2016(78) , publishes suicide rates at CCG level. North West CCG had the highest suicides rate compared to other Surrey CCGs 11.4 which is higher than the England rate of 10.1. This is new information and Public Health will be investigating this further with North West CCG.. Click here to view the 5 year forward plan. . However, the numbers for people who have thought about suicide are much higher. Data from the Adult Psychiatric Morbidity Survey (2014), which screens for prevalence of both treated and untreated mental disorders, shows one person in five (20.6%) has considered suicide (the question asked was: Have you ever thought of taking your life, even though you would not actually do it?)

The last suicide audit in Surrey was completed for the two year period 2012-13, in which there were 141 suicides recorded. An average of 70 suicides a year and nearly 6 a month. Key findings were:

  • 72% of suicides were amongst men and 28% women (previous audit 77% men, 23% women)
    This reflects the national picture of a much higher percentage of suicides among men
  • 39% of cases had contact with their GP within four weeks before their death
  • 50% of cases had a diagnosis or some form of mental illness mentioned in their notes
  • About a third (33%) had a clinical mental health diagnosis
  • 46% suffered with depressive illness and 21% had anxiety disorders
  • 29% were known to a secondary mental health service at some point in their life
  • 71% of people were unknown to secondary mental health services
  • 32.6% of cases had a history of alcohol misuse; 21% of cases a history of substance misuse
  • Only 5% of cases were known to drug and alcohol services
  • Self-harm was mentioned in a 25% of cases

Although the circumstances of every death are unique, through the audit we can begin to see factors in common across the cases, the key contributing factors mentioned in the notes were:

  • 35.5% of cases – relationship problem
  • 27.7% of cases – financial problems
  • 25.5% of cases – general health related problem

The identified high risk groups are:

  • People with long term and chronic health conditions
  • Ageing population
  • Males aged: 25- 44 and Males aged: 55-64
  • People who misuse alcohol and substances
  • People experiencing mental and emotional health crisis

Services in relation to need.

Universal population mental health promotion and prevention services are commissioned by Public Health in Surrey County Council. Adult mental health services are commissioned by both the CCGs and Surrey County Council and have providers from NHS, independent and voluntary sectors. Prison and criminal justice services are commissioned by NHS England.

  1. Tier 1 Universal Population Services – Need: approximately 1.2 million.
    The mental health promotion service – First Steps is currently provided by Virgin Care. The Time to Change Surrey programme is currently provided by local voluntary sector organizations and Virgin Care, and is overseen by a multi-agency steering group.
  2. Tier 2 Primary Community Services – Need: approximately 1 in 4 people.
    The majority of commissioned service is in the voluntary and charitable sector providing psychological therapy, community and supported employment services.
  3. Tier 3 Specialist Services – Need: approximately 1 in 100.
    The main local provider; Surrey and Borders Partnership NHS Foundation Trust and two small boundary trust contracts.
  4. Tier 4 Complex Specialist Services – Need: approximately 1 in 1 000.
    Limited services in the main local NHS trust, so services are commissioned via contracts or individual spot purchase basis with providers in the independent and NHS sectors

Tier 1. Universal Population Services

Mental health promotion and prevention– First Steps www.firststeps-surrey.nhs.uk Aims:

  1. Increase the capacity, knowledge and skills of staff to deal with mental health problems
  2. Deliver mental health promotion, and develop approaches to reach high risk groups
  3. Deliver CBT based self-help client interventions including: self help resources/information (web/paper based), psycho-education sessions for the public – Emotion Gyms
  4. Signpost people to relevant services (local and national)

Time to Change – Surrey

Aims to: improve understanding of and positive attitudes towards mental health; reduce the stigma and discrimination experienced by people with a mental health problem, their family and/or carers; and increase the confidence and ability of people with mental health problems, their family and carers to address discrimination. Time to Change – Surrey comprises:

  • An Ambassador Scheme: people with experience of mental health problems are supported and trained to speak with staff and members of the public at events.
  • Mental Health and Anti-Stigma Awareness Training – with statutory, private and third sector organisations/employers, delivered with input from Mental Health Ambassadors.
  • Drama scenes/plays and Forum Theatre: where the audience can stop and change what the actors say/do in order to improve outcomes – and thereby learn in an active way.

Tier 2. Primary Community Services (where there is an identified mental health need)

Parent and Infant Mental Health (PIMH) Service

Offers early intervention to parents who are identified as being at risk of poor attachment with their infant. It is delivered through the partnership of community health, CAMHS, early years and social care. Key components of the service include: raising the awareness of its importance across agencies and professionals working with families in Surrey; training and workforce development, and universal screening for early parent and infant relationship difficulties.

Tier 1 observation and targeted therapeutic infant massage from 0-19 teams and children centres

Tier 2 CAMHS intervention from specialist health visitors and primary mental health workers

Tier 3 interventions from Parent and Infant Psychotherapists/ Specialists in the CAMHS service.
For more information click here.

Perinatal Mental Health Service

Across Surrey and NE Hampshire there are very limited services for perinatal mental health, the nearest mother and baby in-patient services are located in Winchester, there is no local specialist perinatal mental health community service and not all of the acute trusts or community providers have perinatal mental health midwifes or health visitors. The mainstream services do all work with women in the perinatal period and some roles and pathways have been developed to respond as a priority such as IAPT services, PIMH and recruitment of specialist mental health midwives in maternity services. For more detail link to Perinatal Business Case.

Improving Access to Psychological Therapies (IAPT)

A service for mild to moderate mental health problems, using a stepped care model together with specialist employment support, based on NICE guidelines. Key aims are to: support the effective demand for secondary care – earlier/more appropriate interventions and fewer episodes requiring secondary care; recognise and work with the overlap between mental health, long term conditions and medically unexplained symptoms; and help people to have less time off work and retain/return to employment. Low intensity services include: telephone contact, guided self help and guided computer Cognitive Behavioural Therapy, with the option for face to face contact, groups and psycho-educational workshops. For those who do not respond to/who have higher severity/ complexity, high intensity treatment interventions range from 8-20 psychological therapy sessions.

Currently IAPT services are delivered via Any Qualified Provider. Access is via self referral or GP referral. For more information on the current providers click here . Contracts require people to start treatment within twenty eight days. Veterans and mothers with post natal depression get fast track access.

Community Connections

Universal access services for working age adults with self-defined mental health need that are jointly commissioned with the NHS and Surrey County Council. The services provide community based opportunities and ongoing support for people with mental health needs to promote mental and physical wellbeing. Examples of support available include self-help groups, access to training, volunteering, social and leisure/physical activities. There are currently five providers delivering Community Connections in different areas of Surrey: For more information on these, click here.

Other Community Based Services

These include: Specialist mental health CAB advisors for people with severe/enduring mental health problems, advocacy, supported employment, vocational training (Travel Matters), mental health football league, one to one arts interventions, volunteer appropriate adults in criminal justice system, support for people with autism and veterans mental health service http://www.firststeps-surrey.nhs.uk/serves/

Tier 3. Specialist/Secondary Care Services

For adults with severe and enduring mental health problems are currently provided by Surrey and Borders Partnership Foundation Trust – with specialist placements made to external providers if necessary. For more information see http://www.sabp.nhs.uk/services/mental-health

Community Mental Health Recovery Service (CMHRS)

Health and social care teams are based in the community and work with statutory services as well as independent and voluntary sector organizations to provide a cohesive package of care.

Assertive Outreach

For people with a diagnosis of bi-polar disorder or schizophrenia and a history of not engaging with services/refusing treatment. The team offer bespoke care and help people live in the community.

Early Intervention in Psychosis (EIP)

The service works with individuals and their families to help recovery from the early stages of psychosis. The multi-disciplinary teams provide a range of treatment and support.

Home Treatment Teams (HTTs)

Offer home visits to people suffering from a mental health crisis. These medical teams assess whether people require hospital admission or if they can be treated at home, offering alternative treatment to avoid admissions where possible. The service operates 24 hrs a day, 365 days a year.

Psychiatric Liaison services

Operate in all five acute hospitals help ensure people attending A&E departments have the appropriate mental health services that will keep them safe in the community.

Inpatient and Rehabilitation Services

Offered from: Abraham Cowley Unit, Epsom General Hospital, Farnham Road Hospital and the Ridgewood Centre, Frimley. Rehabilitation therapy services are offered to people admitted to these inpatient services and to those under the care of Home Treatment Teams. The service provides therapy groups and individual treatment and bespoke patient programmes.

Specialist Services

Mother and baby units, drug and alcohol services, eating disorder services, forensic mental health services and prison mental health services – now the responsibility of the NHS England Local Area Teams. The need in Surrey for specialist in-patient provision for mother and baby/eating disorders/ CAMHs Tier 4 service has not been of sufficient scale to have their own units. Therefore pathways/contracts have been developed with neighbouring trusts or the independent sector.

Tier 4. Specialist Complex Services

For inpatients and outpatients on the national prescribed list (including eating disorders, personality disorders) and criminal justice/forensic services, are now commissioned by NHS England.

Crisis Services

Safe Havens provide out of hours help and support to people experiencing a mental health crisis and their carers. They are open evenings, weekends and bank holidays and are designed to give people a safe alternative to going to A&E when in crisis. They are available in six town centre locations across Surrey and North East Hampshire and open to residents of any district/borough within this area. All Safe Havens are provided in partnership with local Clinical Commissioning Groups and third sector mental health specialists. For more information click here.

The Surrey-wide out of hours ‘crisis helpline’ provided by Surrey and Borders Partnership NHS Foundation Trust, advises people including G.Ps on how best to manage the crisis or signposts to an appropriate service. a telephone and sms/text number 5.00pm – 9.00am Monday – Friday, 24 hours at weekends including Bank Holidays. There are three Places of Safety offering five beds across the county which are used for people detained under section 136 of the Mental Health Act 1983.

Suicide Prevention

There is a Surrey multi-agency Suicide Prevention Plan (linked to the national strategy and local data from Suicide Audits. See Surrey suicide prevention plan.

Physical Health

Late in 2016 the Public Health team started to deliver annual health checks at people attending Community Connections services (no data is yet available).

Improving the physical health and wellbeing of people who use SABP services is a key aim for SABP and as a result of a CQUIN to reduce premature mortality in people with SMI: Cardio Metabolic Assessment and treatment for Patients with Psychoses, health improvement is routinely delivered and where necessary in collaboration with GP. 46% of people whose first attended appointment was in May 2016 had a physical health check completed after their referral date and within 3 months of their appointment. In Community teams Health Action Planning helps identify the physical health needs of people and to work collaboratively with primary care to help address them, supported by the roll out of the Community Hub Programme. The 24/7 wards wards have nurse led physical health clinics, health assessments, wellbeing/fitness Instructors and psycho-educational sessions to promote health awareness. Physical health related information and staff briefings are delivered regularly. SABP are working to a plan to go smoke free on all sites in 2017.

Surrey CCGs have a similar summary score for physical health checks for patients with SMI to the England (2013-4) summary score of 76 – with two scoring slightly lower and four slightly higher (range 74.1-78.6) (significance data not available)
(79)

All Surrey CCGs have a significantly lower percentage of patients with SMI who have received the complete list of health checks than England – Surrey range (17.5-30.7) vs 34.8 (2014-15)(80) . In descending order: N E Hants & Farnham 30.7, NW Surrey 31, Surrey Heath 27, East Surrey 25, Guildford & Waverley 24.5, Surrey Downs 17.5).

Older People

Mental health services for older people are the same as for other adults.

See also Dementia JSNA chapter (81) .

Other Services – commissioned elsewhere/not by NHS/Surrey County Council

Many other services help adress some of the contributory/risk factors for mental health problems – e.g.: Citizens Advice Bureau, Domestic Abuse Services, debt and benefit advice, family mediation

Benchmarking of Services by CCG

  • Initial assessment of mental health – all CCGs are ‘Performing Well’
    (82)
  • Improving Access to Psychological Therapies Recovery Rate – N E Hampshire & Farnham 53.4%, Surrey Heath 52.6%, Surrey Downs 50.8%, North West Surrey 49.3%,East Surrey 49.5%, – Guildford & Waverley 47%, (Surrey similar to most CCGs)
  • People with 1st episode of psychosis starting NICE-recommended treatment within 2 weeks of referral – Surrey Heath 100%, Guildford & Waverley 71.4%, North West Surrey 70%, East Surrey 66.7% Surrey Downs 62.5%, N E Hampshire & Farnham 50%, (other nearby CCGs range from 33%-100%
  • Crisis Care and Liaison Mental Health Services – N E Hampshire & Farnham 98%, Surrey Heath 98%, North West Surrey 95%, Surrey Downs 93%, Guildford & Waverley 90%, East Surrey 83% (other nearby CCGs range 33%-98%)
  • Out of area placements for acute mental health inpatient care – all CCGs at 100% except N.E Hampshire & Farnham 88%, (high as some CCGs have as low as 25%)

Improving Access to Psychological Therapies Data (2015-6)

IAPT referrals: Rate (quarterly) per 100,000 population aged 18+ show that all CCGs have a lower referral rate than England and in quarter 4 the referral rate is statistically significantly lower for all CCGs in comparison to England.
(See data visualisation)

Referral rates have increased over 2015/16 for all Surrey CCGs apart from North West Surrey.

The data visualisation shows people entering IAPT (in month) as % of those estimated to have anxiety/depression: East Surrey CCG is consistently higher than the other Surrey CCGs and has been so for the last 12 months. It reports values similar to England for this indicator.

IAPT use by BME groups: % of referrals (in quarter) which are for people of black and minority ethnic groups. The data visualisation shows that North West Surrey has been consistently higher than the other Surrey CCGs since 2013 and is close to the England value. This is consistent with the higher proportion of the North West Surrey and England populations from non-white British ethnic groups. Surrey Downs has increased its use by BME groups over the last 2 quarters. Surrey Heath CCG tends to be the lowest although Guildford and Waverley CCG has the lowest proportion of its population from non-white British ethnic groups.

All Surrey CCGs have a similar rate of recovery for IAPT treatment (% who have completed treatment) to England 46% vs 45.9%.(83)

Projected Population Change

Between 2016 and 2026 the ONS project that the Surrey population will increase by about 8.3%, which is 98,000 people. The greatest increase will be among children aged 10 – 19 and people over 55 years of age. By 2036 the adult population of 18-64 year olds in Surrey is expected to increase by about 6% (42,300 people) from in 2016 – to approximately 743,867.

There is an expected increase in the older population aged 65 of 7.1% in 2020 based on 2016 figures. By 2030, this number is expected to increase by 33.9% to 298,300 (source POPPI).

See JSNA chapter; Surrey context and places.

Taking the number of carers from the 2011 census as a percentage of the population, and applying that to future population projections, by 2025 it is estimated there will be 124,176 carers in Surrey (8% growth). This equates to 10% of the Surrey population, which although large, is lower than the 13% of the U.K population to have some sort of a caring responsibility.

Projected Mental Health Needs

The biggest estimated increases in projected perinatal mental health need (in decreasing order) are for: adjustment disorder, mild to moderate depressive illness and anxiety, then jointly severe depressive illness and PTSD.

PHE estimate that Surrey will have a lower estimated percentage of the adult population with mixed anxiety and depressive disorder in 2021 than England 7.7 vs 9.26 and sixth highest among its 15 CIPFA nearest neighbours (CIPFA range: 6.07 – 10.46). (This data is modelled to mid-year population estimates – PHE express some concern over the quality of this data).
(84)

Table 2: shows the projected numbers with mental health disorders among people aged 16-64 in Surrey from 2017 to 2020.

Number of people in Surrey aged 16-64 predicted to: APMS (2014) – % with condition 2017 2020 % change
have a common mental disorder 18.9% 138,558 140,403
have a borderline personality disorder 2.4% 17,595 17,829
have an antisocial personality disorder 3.3% 24,193 24,515
have psychotic disorder 0.7% 5,132 5,200
Estimated number predicted to have these conditions** 180,346 182,747 1.3%
Estimated population 16-64yrs 733,113 742,872 1.3%

**One person could have 1 or more of the conditions listed above

Source: APMS 2014 (proportions applied to population projections), ONS 2014 Based population projections

The rise in the adult population is likely to be reflected in higher numbers of people experiencing mental health problems, as shown by the projected primary care mental health register figures below. The highest increase in depression are expected in Runnymede (25.4%) followed by Reigate and Banstead (18.1%), Tandridge (15.3%), then Epsom and Ewell (15.1%). Whereas Woking and Elmbridge are expected to be 2.3% and 1.8% lower (respectively) by 2020, which can be seen in the data visualisation.

The highest increases in Schizophrenia, bipolar disorder and other psychoses expected by 2020 are in: Runneymede (25.7%), Epsom and Ewell (18.6%) and Tandridge (15.3%). With no boroughs/districts expected to have decreases in 2020. See data visualisation.

Older People

By 2020, the proportion of people in Surrey aged 65+ predicted to have depression and severe depression will increase by about 6.8% and 7.5% respectively. Women over 65 years are more likely to suffer from depression than men of the same age.

Table 3: Increases in people aged 65+ and those predicted to have depression by 2020 and 2030 from 2016.

Number of People in Surrey aged 65+ predicted to: 2016 2020 % increase by 2020 2030 % increase by 2030
Population 65+ 222,700 238,600 7.1% 298,300 33.9%
Have depression 19,231 20,542 6.8% 25,673 33.5%
Have severe depression 6,148 6,608 7.5% 8,497 38.2%

Current and Projected Costs
The data visualisation shows the current and projected future costs by mental health disorder, England 2007 and 2026 (85). This is based on a 20 year projection against eight disorders. The projected cost of all mental health will increase. The projected biggest cost increase by far will be for dementia (£34.8 billion), then for anxiety (£14.2 billion), personality disorders (£12.3 billion), depression (£12.2 billion) and bipolar disorder (£8.2 billion).

Policy Shifts

The Better Mental Health for All report (86) states the optimum prevention approach, is universal interventions to promote mental wellbeing across whole populations, with more progressively targeted interventions to address specific needs among more vulnerable and at risk groups.

The key policies are: the NHSE 5 Year Forward View and the Mental Health Implementation 5 Year Forward View (2016)(87) (priority areas: prevention and early intervention; better mental health care for people with physical health problems; and improved support for people with severe mental illness) A key organisational lever to deliver these policies areas has been coming together as a system to form Sustainability and Transformation Plans. Across Surrey there are three STP footprints with the main one being the Surrey Heartlands (Surrey Downs, North West Surrey and Guildford and Waverley CCGs) and the mental health objectives are to:

  • Create resilient communities through prevention & early intervention
  • Ensure the system is based on a person and family centred holistic model of total wellbeing
  • Build broader capability & wellbeing across the system wide workforce
  • Ensure delivery of a coordinated and connected system
  • Measure what matters to people focused on optimising value

We anticipate the increased use of early intervention and integrated mental and physical healthcare, will enable a reduced demand for acute services and result in a decrease in acute admissions/attendances which will result in £0.5m year on year efficiencies for the Surrey Heartlands system by 2020/21.

The Care Act (2014) (88) consolidates and modernises the framework of care and support law. It set out new duties for local authorities and partners, and new rights for service users and carers. It places new duties on local authorities to prevent, reduce and delay care and support needs. There is an emphasis on the wellbeing principle that underpins the Act and duties around integration and collaboration with other public sector organisations.

Unmet needs and service gaps

Perinatal services. A bid for funding was not successful this financial year. Mental Health Commissioners are now working on securing funds and developing a service for 2018/9.

Mapping and harnessing community capital and social value from services provided other than those commissioned by CCGs and SCC, e.g. community development, encouraging community and social fundraising.

A sustainable programme of suicide prevention training that meets the needs of the different professional groups (in recent years accredited courses have been bought from external providers)

Needs and Issues identified by the Surrey Independent Mental Health Network include:

  • Concern about increase in suicide and unexpected deaths
  • Need to tackle the wider determinants
  • Need to involve service users and carers in the monitoring by Social Care Commissioners of services provided by the NHS Trust
  • Need to monitor unintended consequences of service changes and commissioning decisions
  • Ensuring continued service user and carer involvement in monitoring strategy implementation
  • Need to ensure involvement in monitoring ‘Any qualified provider’ IAPT services in CCG areas

What works

The Joint Commissioning Panel for Mental Health has guides, which provide a description of what a ‘good’ service configuration should look like, supported by scientific evidence, service user and carer experience, and case studies of best practice. Service guides include: public mental health, primary mental health, acute care, community specialist, liaison mental health, perinatal mental health, rehabilitation, drug and alcohol, eating disorders, black and ethnic minority communities, and learning disabilities.

Review level evidence demonstrates that programmes promoting positive mental health, prevention and early intervention, are effective in: reducing the risk of mental health problems; improving health and social outcomes in clinical populations; reducing inequalities; improving physical health – life expectancy, health behaviours (reduced alcohol intake, smoking); economic productivity; social functioning and quality of life (89, 90) , and reducing violence, antisocial behaviour and crime. Intervening in adult hood and later life is also effective at reducing mental health problems, supporting recovery and preventing losses for those who are currently at risk.(91) . The report, states the optimum approach includes: universal interventions to promote mental well-being across whole populations; with more progressively targeted interventions to address specific needs among more vulnerable/at risk groups; and reducing stigma and discrimination (92). For more detail see this paper: The data visualisation shows that
Employment and accommodation are highlighted in 5 year forward view as being important for both prevention and recovery
(93).

NICE recommends that a stepped-care model is used to help people with common mental health disorders (94) – the least intensive intervention that is appropriate for a person is typically provided first, and people can step up or down the pathway according to changing needs and in response to treatment. This limits the burden of disease and costs associated with more intensive treatment. The evidence shows that psychological intervention services that provide stepped care have better service-user outcomes and improved recovery rates (95) . It also indicates a localised approach and integration with a range of other physical and mental health pathways is needed, that allows some flexibility in how interventions are provided (as in Surrey Community Connections and Safe Havens).
For evaluation reports click here. An effectiveness evidence summary for diagnosis and treatment of more severe/ enduring mental illness can be found in the early National Service Framework for Mental Health , albeit quite old.
(96)

For effectiveness data and examples of good practice of Crisis services click here.

Locally in Surrey, evaluation of innovative new partnership crisis services called Safe Havens show promising evidence of effectiveness. The full report can be found here and the executive summary can be found here.

New national guidance around suicide prevention – based on effectiveness evidence can be found here.

Recommendations for Commissioning

1. Mental Health Promotion, Prevention and Anti-Stigma
1.1 Increase cross-agency ownership/involvement in mental health promotion and prevention at all steps of the mental health pathway. Maintain Public Health committed spend on the Surrey mental health promotion, signposting and anti-stigma service First Steps
1.2 Increase the publicity and promotion of First Steps so that more people have access to self – help information, early intervention and signposting for common/mild problems.
1.3 Increase the targeting and promotion of First Steps, Community Connections, IAPT and Individual Placement and Support services (IPS), in areas of: higher deprivation; higher incidence of common mental disorders and higher number of unemployment/Incapacity Benefit claimants.

2. Wider Determinants of Mental Health
2.1 Encourage GPs/primary care, to be aware of wider determinants that often contribute poor wellbeing/mental health (e.g. financial problems/debt, unemployment, work and relationship problems), give out the red card and refer patients to services who can assist or signpost e.g. First Steps, Citizens Advice Bureau, IPS.
2.2 Take action to address mental health needs associated with increases in unemployment and the higher percentage of Mental Health Incapacity Benefit claimants in Surrey. Link people to supported employment services through secondary care and IAPT pathways.
2.3 Action to address higher rates of homelessness -especially in Spelthorne – by councils and homelessness organisations. Strengthen the links between boroughs/districts, housing providers, homelessness organisations – and mental health related providers (CAB, First Steps, Community Connections, IAPT, IPS), so as to increase provider responsiveness to those at risk of homelessness and reduce the negative impact on their mental health.
2.4 Organisations working with homeless people to identify and address both their mental and physical needs.
2.5 Action across health, social care and local districts/boroughs to improve the range and suitability of accommodation, with care and support options for people with mental health needs.
2.6 Planners and communities to increase green spaces – especially in areas of deprivation, inequalities and higher incidence of mental health problems. Mental health provider services to encourage patients/clients to engage in physical activity in green spaces.

3. Lifestyle Behaviours and Physical Health

3.1 Mental health providers to embed physical health improvement across the pathway:
(97, 98)

  • Use the Wheel of Wellbeing to raise client awareness of how to improve their wellbeing.
  • Staff to raise clients’ awareness of the negative impact on mental health of smoking, alcohol/substance misuse, poor diet and inactivity and offer brief advice.
  • Refer clients to relevant services e.g. smoking cessation, alcohol/substance misuse and weight management and advise them of the benefits of these for mental health/wellbeing.
  • Encourage and where possible make mandatory for their frontline staff/physical health champions to attend Making Every Contact Count (99) and brief advice training in these areas.
  • Use published toolkits to improve the physical health of people with mental health problems (100, 101)

3.2 All mental health service providers to work to help increase numbers of people with mental health problems accessing/being supported by Surrey Smoking Cessation Service.
3.3 Public Health to continue supporting SABP to implement smoke free grounds by 2018.
3.4 Smoke free grounds to be included in other mental health service provider contracts.
3.5 Increase the percentage of SABP patients receiving a physical health check (e.g. via the access standard in the 5 Year Forward Review and target people on SMI register).
3.6 Increase physical health care providers’ awareness of:

  • mental health and the negative impact of physical health problems and long term conditions (e.g. via First Steps training and internal continuing professional development training)
  • services that offer support for mental wellbeing/mental health that staff can signpost patients to (e.g. First Steps, Community Connections, IAPT).

4. Higher Risk/Priority Groups

4.1 . Ensure carers continue to have access to generic carers support for their own mental and emotional health and wellbeing. Carer’s support organisations (statutory and third sector), to help increase adult carers’ levels of social contact.
4.2 Additional support for and promotion of services for people with Long Term Conditions.
4.3 Commissioners and providers of mental health and substance misuse services have a joint responsibility to meet the needs of individuals with co-existing alcohol and drug misuse and mental health issues.
4.4 Providers of mental health, substance misuse services alcohol and drug and other services should have an open door policy for individuals with co-existing alcohol and drug misuse and mental health issues, and should Make Every Contact Count.
(102)
4.5 Action to address stigma among BME groups – especially in areas with higher numbers of people from these groups and (ADWOA LINK JSNA chapter BME breakdown by borough) increase tailored support for and uptake of services among BME groups.
4.6 Action to address the high levels of mental health problems, self-harm and suicidal ideation/attempts in the LGBT population.
4.7 For people with Learning Disabilities (LD):

  • Mental health awareness training for staff working in LD services
  • Mental health promotion is delivered via all services
  • Ensure that mental health questions are asked In annual health check
  • Ensure that mental Health promotion is included In LD health action plan
  • Ensure that support and information is offered to carers of people with LD

4.8 Ensure that community capacity and resilience – built by the SERVES contract around Veterans MH Champions and local support groups – is maintained in light of NHSE re-commissioning of MH Services for the Armed Forces (inclusive of Veterans). Consider updating the needs assessment for veterans.
4.9 Ensure that mental health awareness and suicide prevention is embedded in the criminal justice system, e.g. among: police custody, probation, prison and other support services.
4.10 Make a suggestion to update the prison mental health needs assessments (previously done in 2012), to Public Health England.
5. Detection/ Under Reporting and Under Diagnosis
5.1 CCGs/primary care to increase the numbers of people whose common mental disorder is detected and treated (as data shows only about 25% of people receive a diagnosis).
6. Services
6.1 Providers-primarily First Steps – to publicise/make easily available – accessible information on the range of services available and how to access them – including those people can self-refer to e.g. First Steps, Community Connections, IAPT, Safe Havens, as well as SABP services.
6.2 CCGs and primary care to take action to increase the referral rate to IAPT providers.
6.3 Commission a Perinatal Service that takes account of the increased risk/complication from Surrey’s higher percentage of older mothers and gypsy, roma and traveller mothers, and of the projected increases in various perinatal mental health problems.
6.4 Investigate and take action around the increased rate of serious mental illness in Surrey reported in the Adult Psychiatric Morbidity Survey.
6.5 SABP to share their activity data to help inform the JSNA.
6.6 Providers to check if mental health service uptake is higher in areas of higher prevalence of more severe/enduring mental health conditions and if not, take action to increase it.
6.7 Take action to address rising levels of self-harm – especially among young females.
6.8 Investigate prevalence data and plan appropriate action to help address panic and eating disorders and posttraumatic stress – as Surrey estimated prevalence is higher than England.
6.9 CCGs and SABP to increase percentages of people with first episode of psychosis starting NICE recommended treatment within two weeks of referral – where this is not already met.
6.10 Retain focus through multi agency working via the crisis care concordat, to maintain the reducing numbers of people detained inappropriately in custody under Section 136 (e.g. by enhancing resilience of the existing POS suites and exploring community based alternatives).
6.11 Build into future commissioning intentions, provision for the increased projected mental health needs by 2020 (by condition and geographical area) and the associated costs (in descending order – anxiety, personality disorders, depression, and bipolar disorder).
6.12 Map and harness community capital and social value around mental health– available from services/organisations other than those commissioned by CCGs and Surrey County Council, (e.g. community development, third sector) and encourage community and social fundraising.
7. Self Harm
7.1 Improve data on self-harm
7.2 Identify why Surrey Heath CCG has high rates of self-harm hospital admissions
7.3 Develop an adult self-harm working group
8. Suicide
8.1 Continue to implement the multi-agency Suicide Prevention Plan, ensuring it remains responsive to changes in local suicides (as identified by audit/coroner data) and reflects national guidance (e.g. soon to be updated Suicide Prevention Strategy).
8.2 Improve the real time monitoring of suicides.
8.3 Explore the recent CCG suicide data and investigate reasons for NW Surrey higher rates
8.4 Work with all relevant agencies to collect and improve data on attempted suicide.
8.5 Develop a sustainable programme of suicide prevention training that meets the needs of the different professional groups.
8.6 Develop the new service to support those bereaved by suicide.
9. Recommendations for Future Needs Assessment Work
9.1 Improve gathering of data on mental health and learning disabilities (e.g. via the new national access standard in the 5 Year Forward Review)
9.2 Consider the most useful geographical format for the data (e.g. STP/CCG/local authority)
9.3 Consider including key elements of the Five Year Forward View Dashboard data – published too late for inclusion in this JSNA

Key contacts

  • Surrey County Council
  • Maya Twardzicki – Public Health Lead (mental health) JSNA chapter coordinator, Surrey County Council Email: maya.twardzicki@surreycc.gov.uk
  • Jane Bremner – Senior commissioning manager – Adult Social Care, Surrey County Council
    Email: jane.bremner@surreycc.gov.uk
  • Diane Woods – Associate Director Commissioning, Mental Health & Learning Disabilities Surrey CCG Collaborative – NHS North East Hampshire & Farnham CCG
  • Janine Sanderson – Mental Health Senior Commissioning Manager
    Email: janinesanderson@nhs.net

Chapter References

1. The Chartered Institute of Public Finance and Accountancy (CIPFA) have created a model which seeks to measure similarity between Local Authorities. This is done by following the traditional ‘distance’ approach whereby a selection of variables (see below) is standardised (with a mean value of zero and a standard deviation of one) and the Euclidian distance between all possible pairs of local authorities is calculated1. These distances are then summed across every single subject and ‘rebased’ (by assigning a distance of 1 to the farthest neighbour meaning all overall distances will lie between zero and one) to calculate the final distance http://www.cipfastats.net/resources/nearestneighbours/
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Signed off by

Key contacts listed above.

Formal sign off by the Mental Health Partnership Board will be at the meeting end of January 2017