Newham Improving Access to
Psychological Therapies
a partnership between
Newham Primary Care Trust
East London NHS
Foundation Trust
Evidence Based Choices &
‘Complexity at the coalface’
Dr Ben Wright
Lead Clinician Newham IAPT
Three dimensions of complexity
• Complexity of context
– (Choice & Access)
• Complexity of systems
– (Treatment Choice)
• Clinical complexity
– (Choice outcome)
London Borough of Newham
Very Diverse
• 61% BME
• 130+ Languages
Deprived
• 44% live in poverty
• 20% intense poverty
40% greater demand for mental health services
Access - Pathways into Service
Resident
in
Newham
Self
Referral
Routine
screening
of new IB
claimants
Pathways
to work
referral
Community Groups
GP
Occupational Health
Secondary MH
Formal referral
by professional
Telephone Assessment
Flexible Engagement, Full Assessment & Treatment
Source of Referral (n=5,064)
PW2W
5%
Self
22%
Professional
9%
GP
64%
Overall BME Access
66% of Newham
residents come from
BME groups
64% of referrals from
BME groups in 2008
Impact of source of referral on access
60%
Percentage
50%
40%
30%
20%
10%
0%
White
GP
Self
Mixed
PW2W
Asian
Other
Black
Other
Newham 2001 census
Impact of source of referral on access
for Men
45%
40%
Percentage
35%
30%
25%
20%
15%
10%
5%
0%
White
British
GP
White
Other
Self
Mixed
PW2W
Asian
Other
Black
Newham
0ther
Impact of source of referral on access
for Women
45%
40%
Percentage
35%
30%
25%
20%
15%
10%
5%
0%
White
British
GP
White
Other
Self
Mixed
PW2W
Asian
Other
Black
Newham
0ther
Key points
• GP referral remain central to
access process
• Must be supplemented by
multiple points of access
• Different sub-groups respond
differently to access points
Three dimensions of complexity
• Complexity of context
– (Choice & Access)
• Complexity of systems
– (Treatment Choice)
• Clinical complexity
– (Choice outcome)
NICE Clinical Guideline 90 - Oct 2009
(partial update for depression guide,
Research recommendation)
• 4.8 “In people with mild, moderate or
severe depression, what system of care
(stepped care versus matched care) is
more clinically effective and cost
effective in improving outcomes?”
(Page 51)
Matched Care Pathway
Used in Phase One of National
IAPT Pilot, May 2006-07
Other
Services
Referral –
Mainly GP
Flexible
engagement
by assistant
Assessment
by Qualified
Therapist
Formal
High
Intensity
CBT
Low
Intensity
CBT
Semi-Stratified Stepped Care
Pathway
All Referrals
Other Services
Administrator
calls & offers
appointments
Formal High Intensity CBT
Assessment & Intervention

Brief
Telephone
Assessment
(Qualified
therapist)

Low Intensity (CBT Based)
Assessment & Intervention
Employment Support Service
System – care pathway flow –
impact on recovery rates
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2006
2007
percent to low intensity
2008
Column 2
2009
System – care pathway flow –
impact on recovery rates
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2006
2007
percent to low intensity
2008
2009
Percentage recovery
System – care pathway flowimpact on productivity
100
90
80
70
60
50
40
30
20
10
0
2006
2007
percent to low intensity
2008
Column 2
2009
System – care pathway flowimpact on productivity
100
90
80
70
60
50
40
30
20
10
0
2006
2007
percent to low intensity
2008
2009
Number completed treatment per month
Three dimensions of complexity
• Complexity of context
– (Choice & Access)
• Complexity of systems
– (Treatment Choice)
• Clinical complexity
– (Choice outcome)
Outcome of Low Intensity Care
6%
25%
36%
Completed low
intensity care and
discharged
Dropped out
Stepped up High
Intensity CBT
Stepped up to
another service
33%
Outcome of High Intensity Care
31%
Completed High
intensity care
Referred onwards
Dropped out
4%
65%
Equity of outcome
• Care pathways did have slightly different
treatment of some BME groups (e.g. greater
proportion Asian & Asian British people going
direct to high intensity) however there were
similar recovery rates for different BME
groups for both Low and High Intensity care
• Having Low intensity care first did not alter
drop out rate for High Intensity care.
Conclusion – what is needed?
• Clinicians need regular, good quality
supervision
• Clinicians need easy access to a hierarchy of
in-house experts
– Includes medical psychotherapy & general psychiatry
• Integrated care pathways
– Disaggregation reduces access, flow & quality
• Good IT system for managing monitoring and
directing patients flow through care pathways