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Improving Access To Psychological
Therapies for People in Early Intervention
in Psychosis Services
Alison Brabban
Sarah Khan
What Service Users Want
• To be listened to.
• To have experiences and feelings validated.
• To be seen as a person and not just as a set of
symptoms.
• To get help to make sense of their experiences.
• To be given hope.
3
NICE Guidelines for Schizophrenia & Psychosis
Update (2009)
We now have good evidence that CBT and FI for psychosis works.
CBT evidence:
31 RCTs reviewed, quality checks on methodology
(N=3052). (22 new trials)
Small but clear effect size on symptoms, including depression, but not
on relapse rates.
FI for psychosis evidence:
38 RCTs met quality checks (5 were follow ups) (N=3134).
32 studies (19 new trials) (N=2429) included in meta analysis.
FI reduce relapse consistently.
“These are substantial gains, considering the fact that the effects of
such psychological treatments add to medication.”
Pfammatter et al (2011) p.S1. (Schizophrenia Bulletin, 37 suppl 2, S1-S4)
4
Who Should be Offered CBTp and Family
Interventions? NICE (2014)
• Those “at-risk” of developing psychosis (should not be offered
antipsychotic medication).
• Those with a first episode of psychosis (if person wants to try therapy
alone, go ahead, but advise that more effective if combined with
medication – review after a month).
• Anyone with a diagnosis of schizophrenia or psychosis irrespective of
phase (i.e. acute, in remission).
5
How it should therapies be delivered?
CBTp:
• On a one to one basis (rather than group based).
• Offer at least 16 sessions.
Family Interventions:
• As single or multi family group (and include service user)
• 3 months to 1 year.
• At least 10 planned sessions
For Both…
• Therapists should have appropriate competence (see competence
framework).
• Therapists should have regular clinical supervision from competent
supervisors.
• Outcomes should be monitored regularly.
Availability of CBTp and FI
• According to National Audit of Schizophrenia:
• 39% of people have been offered CBT
• 12% of people said they had received a family
intervention.
• But….
• What type of CBT (was it CBTp?)
• What kind of family intervention?
• How competent were the therapists?
Availability of CBTp & FI
(from Specialist Psychological Therapy Audits)
• Approx 10% of service users had access to CBTp
• Less than 3% of Families were offered Family
Interventions
Barriers to Implementation
• Lack of staff with appropriate competences
• Lack of available training
• Lack of available clinical supervision
• Lack of ring-fenced time (specific therapy posts) –
competing demands.
• Priorities and team culture
Early Intervention in Psychosis
Services
The Ethos of EIP
• Target those with a first episode of psychosis (and those with ultra
high risk of developing psychosis)
• Aim to reduce Duration of Untreated Psychosis to less than 3
months.
• Provide the full range of evidence based psychological & social
interventions plus medication.
• Involve families/carers whenever possible.
• Recovery orientated: aim to improve wellbeing, purpose & meaning
to life not merely symptom reduction.
• Attempt to reduce stigma associated with psychosis and increase
therapeutic optimism.
The Success of EIP
• Improve outcomes: Reduce hospitalisation, improve engagement,
reduce suicide rates, increase employment, reduce likelihood of being
detained under MHA.
• Save Money (estimated net savings of £7972 per person after 3 years
mainly to NHS. Over a ten-year period, £15 in costs can be avoided for
every £1 invested. (Knapp et al (2014)).
• Are evidence based and therefore recommended by NICE.
• High level of satisfaction from Service Users and Carers (see
‘Schizophrenia Commission’ report)
*
Why does EIP work?
• Capped case loads?
• Recovery focused?
• Skilled & passionate staff?
• Team culture is psychosocially orientated?
• Access to full range of evidence based interventions including psychological
therapies?
Features of EIP delivery allow implementation
of psychological therapies
• 50% of EIP services reported
that their budgets had been
cut in the last year.
• 53% of EIP services reported
that the quality of their
services had reduced in the
last year
• 58% of EIP services have lost
staff over the last 12 months.
The New Access Standard
Why introduce access and
waiting time standards for
mental health services?
16 NHS | Presentation to [XXXX Company] | [Type Date]
MH 5YP: rebalancing the system
An effective ‘in balance’ mental health
system would:
• Ensure rapid detection of mental ill health
and access to evidence- based treatment
in community settings.
• Provide responsive and compassionate
care to individuals at risk of or in crisis.
• Provide safe, high quality inpatient care
where community alternatives are not
appropriate
• Enable discharge from inpatient care
through provision of personalised
packages of home-based support
www.england.nhs.uk
The system is currently not in balance
www.england.nhs.uk
There is a 15-20 year gap in the life expectancy of individuals with
serious mental illness compared with the rest of the population
Health promotion
activity, physical health
assessments and
interventions need to
be integrated at every
level if the 15-20 year
mortality gap is to be
closed.
www.england.nhs.uk
We are also missing opportunities to deliver better value
care to individuals receiving treatment for a physical
health condition
If we are to improve outcomes and quality of
life for individuals with physical health needs,
then:
a. Promotion of positive mental health as
part of condition management
b. Recognition of mental health needs
c. Timely access to expert assessment and
evidence based mental health care
Will need to be integrated at every level of
the physical healthcare system.
a+b+c
= reduced demand from repeat
attendances in primary care, UEC
and outpatient clinics
= reduced acute length of stay
= better outcomes at lower cost
for individuals with long term
conditions
www.england.nhs.uk
The 15/16 Access & Waiting Time Standards
By April 2016:
•
75% of people referred to the Improved Access to Psychological Therapies
programme will be treated within 6 weeks of referral, and 95% will be
treated within 18 weeks of referral.
•
More than 50% of people experiencing a first episode of psychosis will be
treated with a NICE approved care package within two weeks of referral.
And there will be:
•
21
£30m targeted investment on effective models of liaison psychiatry in a
greater number of acute hospitals. Availability of liaison psychiatry will
inform CQC inspection and therefore contribute to ratings.
The Financial Package
Using a new £40 million funding boost for mental health services, secured to
kick-start delivery of the 2020 vision, we will be building capacity in some
priority areas in order to prepare for the introduction of new access standards in
the following year.
 £7m to CAMHS T4, £33m to EIP and crisis care in 14/15
 Plus: 4 x 200k EIP regional preparedness money
In 2015/16 a further £80m will be freed from existing budgets, enabling
introduction of the first access and waiting times standards of their kind – lines
in the sand – to be set on parity of esteem for mental health services.
 £40m to be targeted recurrently on EIP, £30m on liaison psychiatry and
£10m on IAPT
22
Approach to supporting
implementation of the new
standards
23 NHS | Presentation to [XXXX Company] | [Type Date]
National resources to support implementation
1. Bringing together the
required expertise
National expert reference group, NCCMH ‘hosting’, highly
collaborative. Regional implementation steering groups.
2. Developing the required
dataset – waiting times,
quality of care, outcomes
Different approaches for 15/16 and 16/17 and beyond.
Potential use of national clinical audit and accreditation
scheme.
Laying the groundwork for other A&W standards
3. Publication of
commissioning guidance
Service specifications, service model exemplars, staffing /
skill mix calculators etc
4. Design of levers &
incentives
Planning guidance, payment system development, standard
contract etc. Engagement with Monitor, TDA, CQC.
5. Implementation support
Sponsoring development of learning networks, regional and
national events etc.
6. Workforce development
Joint work with HEE
24
25
Draft EIP Referral to Treatment (RTT) pathway
Referrer
Referrer
suspects
suspects
first
first episode
episode
psychosis
psychosis
(FEP)
(FEP)
Urgent
Urgent //
emergency
emergency
referral
referral
made
made
flagged
flagged as
as
suspected
suspected
FEP
FEP
Central
Central
triage
triage
point?
point?
Y
Clock
Clock starts
starts
when
when
central
central
triage
triage point
point
receives
receives
referral
referral
Onward
Onward
referral
referral to
to
EIP
EIP service
service
N
Clock
Clock starts
starts
when
when EIP
EIP
service
service
receives
receives
referral
referral
Patient
Patient
invited
invited for
for
EIP
EIP
assessment
assessment
N
DNA?
DNA?
EIP
EIP
assessment
assessment
commences
commences
Y
Active
Active
monitoring
monitoring //
watch
watch and
and
wait
wait
DNA
DNA
Y
Active
Active
monitoring
monitoring //
watch
watch and
and
wait
wait
N
EIP
EIP
assessment
assessment
completed
completed
FEP?
FEP?
N
Y
Clock
Clock stops
stops when:
when:
1.
1. Accepted
Accepted on
on to
to
EIP
EIP caseload
caseload
2.
EIP
care
2. EIP care
coordinator
coordinator
allocated
allocated
3.
3. NICE
NICE
concordant
concordant
package
package of
of care
care
commenced.
commenced.
Clock
Clock stops
stops when:
when:
1.
1. Accepted
Accepted on
on to
to
EIP
caseload
EIP caseload
2.
2. EIP
EIP care
care
coordinator
coordinator
allocated
allocated
3.
3. Specialist
Specialist ARMS
ARMS
assessment
assessment
commenced.
commenced.
ARMS?
ARMS?
Y
N
Onward
Onward
referral
referral to
to
appropriate
appropriate
service
service or
or
discharge
discharge
26
Commence
Commence
NICE
NICE
concordant
concordant
package
package of
of
care
care
Referral to clock start
1.
1. Referrer
Referrer
suspects
suspects
first
first episode
episode
psychosis
psychosis
(FEP)
(FEP)
2.
2. Urgent
Urgent //
emergency
emergency
referral
referral
made
made
flagged
flagged as
as
suspected
suspected
FEP
FEP
Central
Central
triage
triage
point?
point?
Y
3a.
3a. Clock
Clock
starts
starts when
when
central
central
triage
triage point
point
receives
receives
referral
referral
Onward
Onward
referral
referral to
to
EIP
EIP service
service
N
3b.
3b. Clock
Clock
starts
starts when
when
EIP
service
EIP service
receives
receives
referral
referral
27
Patient
Patient
invited
invited for
for
EIP
EIP
assessment
assessment
Assessment
1.
Patient
1. Patient
invited
EIP
for EIP
invited for
assessment
assessment
2a.
2a.
N
DNA
or
DNA or
cancella
cancella
tion?
tion?
EIP
EIP
assessment
assessment
commences
commences
Y
Y
3a.
Active
3a. Active
monitoring
monitoring //
watch
and
watch and
wait
wait
28
2b.
2b.
DNA
or
DNA or
cancell
cancell
ation?
ation?
3b.
Active
3b. Active
monitoring
monitoring //
watch
and
watch and
wait
wait
N
EIP
EIP
assessment
assessment
completed
completed
Assessment to clock stop
1.
1. EIP
EIP
assessment
assessment
completed
completed
FEP?
FEP?
N
Y
2a.
2a. Clock
Clock stops
stops
when:
when:
1.
1. Accepted
Accepted on
on to
to
EIP
EIP caseload
caseload
2.
2. EIP
EIP care
care
coordinator
coordinator
allocated
allocated
3.
3. NICE
NICE
concordant
concordant
package
package of
of care
care
commenced.
commenced.
2b.
2b. Clock
Clock stops
stops
when:
when:
1.
1. Accepted
Accepted on
on to
to
EIP
EIP caseload
caseload
2.
2. EIP
EIP care
care
coordinator
coordinator
allocated
allocated
3.
3. Specialist
Specialist ARMS
ARMS
assessment
assessment
commenced.
commenced.
3.
3.
ARMS?
ARMS?
Y
N
Onward
Onward
referral
referral to
to
appropriate
appropriate
service
service or
or
discharge
discharge
29
Commence
Commence
NICE
NICE
concordant
concordant
package
package of
of
care
care
EIP – Regional Leads
London
South
Midlands &
East
North
Stefanie Radford
stefanie.radford@
nhs.net
Belinda Lennox
belinda.lennox@p
sych.ox.ac.uk
Peter Jones
pbj21@cam.ac.uk
Alison Brabban
abrabban@btopen
world.com
David Monk
david.monk@sym
metricpartnership.
co.uk
Sarah Amani
sarah.amani@earl
yintervention.oxfor
dahsn.org
Finola Munir
finola.munir@nhs.
net
Colin McIlwain
colin.mcilwain@nh
s.net
30 NHS | Presentation to [XXXX Company] | [Type Date]
Regional preparedness work
1. Raising awareness – What are the requirements of the new standard? What are the
implications? What are the opportunities?
2. Bringing together the experts and establishing quality improvement networks
3. Understanding demand – incidence, incidence profiles etc
4. Understanding the baseline position + gap analysis – staffing, skill-mix, competency to
deliver full range of NICE concordant interventions (the 2 week wait is the easy part…)
5. Optimising RTT pathways – need to engage all of the potential referral sources, many of
which will be internal within secondary care
6. Preparing for the new data collection requirements – training for service and information
leads
7. Developing the workforce – capacity, skills & leadership – can the workforce deliver the
full range of NICE concordant interventions as this will be the definition of ‘treatment’?
31
Challenges
•
We need to prepare this implementation support package quickly but we
also want to do it well
•
Needs to be shared understanding regarding not only on the benefits of EIP
services but also ‘what good looks like’ and the complete package of
interventions / staffing / skillmix required to deliver these benefits.
•
Investing ‘upstream’ always more challenging against a background of
significant financial pressures
•
Delivery of the EIP standard will require significant workforce development
– capacity and access to accredited training programmes
•
A paucity of granular baseline data
32
Opportunities
•
We have a real opportunity to improve the quality of care that people
receive and improve outcomes
•
Can set a precedent for future access & waiting time standards – clinically
informed waiting time standards for evidence based care
•
Doing this quickly and doing this well will demand collaboration and joint
working – great energy and enthusiasm to be harnessed
•
Opportunities to review levers and incentives to try to ensure that they
better ‘line up’ to incentivise timely access to effective care
•
Could deliver a ‘step change’ in the quality of the data that we have
available to evaluate the value of care delivered
33
What Next?
• Additional ring fenced therapy posts (How Many?) (New recurrent
funding announced by NHSE)
• Additional Staff with competences to deliver psychological therapies
• National syllabus
• Accredited Training Available (inc supervision)
• Funding required to deliver this (HEE and MH provider commitment
required).
• Demonstrate impact: collect relevant intervention and outcomes data.
alison.brabban@nhs.net
sarah.khan@nhs.net
35 ]
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discussion on twitter
#newsavoy2015