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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.
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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)
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).
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How it should therapies be delivered?
• 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 sessionsFor Both…• Therapists should have appropriate competence (see competence
framework).• Therapists should have regular clinical supervision from competent
supervisors.• Outcomes should be monitored regularly.
CBTp:
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
NHS | Presentation to [XXXX Company] | [Type Date]16
Why introduce access and waiting time standards for mental health services?
www.england.nhs.uk
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
The 15/16 Access & Waiting Time Standards
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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:
• £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
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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 14/15Plus: 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
NHS | Presentation to [XXXX Company] | [Type Date]23
Approach to supporting implementation of the new standards
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National resources to support implementation1. 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
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Draft EIP Referral to Treatment (RTT) pathway
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Referrer suspects
first episode psychosis
(FEP)
Referrer suspects
first episode psychosis
(FEP)
Urgent / emergency
referral made
flagged as suspected
FEP
Urgent / emergency
referral made
flagged as suspected
FEP
Central triage point?
Central triage point?
Clock starts when
central triage point
receives referral
Clock starts when
central triage point
receives referral
Clock starts when EIP
service receives referral
Clock starts when EIP
service receives referral
Onward referral to EIP service
Onward referral to EIP service
Patient invited for
EIP assessment
Patient invited for
EIP assessment
DNA?DNA?
Active monitoring / watch and
wait
Active monitoring / watch and
wait
EIP assessment commences
EIP assessment commences
DNADNA
Active monitoring / watch and
wait
Active monitoring / watch and
wait
EIP assessment completed
EIP assessment completed
FEP?FEP?
Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. NICE concordant package of care commenced.
Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. NICE concordant package of care commenced.
Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. Specialist ARMS assessment commenced.
Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. Specialist ARMS assessment commenced.
ARMS?ARMS?
Commence NICE
concordant package of
care
Commence NICE
concordant package of
care
Onward referral to
appropriate service or discharge
Onward referral to
appropriate service or discharge
Y
N
Y
N Y
N
Y
N
Y
N
Referral to clock start
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1. Referrer suspects
first episode psychosis
(FEP)
1. Referrer suspects
first episode psychosis
(FEP)
2. Urgent / emergency
referral made
flagged as suspected
FEP
2. Urgent / emergency
referral made
flagged as suspected
FEP
Central triage point?
Central triage point?
3a. Clock starts when
central triage point
receives referral
3a. Clock starts when
central triage point
receives referral
3b. Clock starts when EIP service
receives referral
3b. Clock starts when EIP service
receives referral
Onward referral to EIP service
Onward referral to EIP service
Patient invited for
EIP assessment
Patient invited for
EIP assessment
Y
N
Assessment
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1. Patient invited for EIP
assessment
1. Patient invited for EIP
assessment
2a.DNA or cancella
tion?
2a.DNA or cancella
tion?
3a. Active monitoring / watch and
wait
3a. Active monitoring / watch and
wait
EIP assessment commences
EIP assessment commences
2b. DNA or cancellation?
2b. DNA or cancellation?
3b. Active monitoring / watch and
wait
3b. Active monitoring / watch and
wait
EIP assessment completed
EIP assessment completed
Y
N
Y
N
Assessment to clock stop
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1. EIP
assessment completed
1. EIP assessment completed
FEP?FEP?
2a. Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. NICE concordant package of care commenced.
2a. Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. NICE concordant package of care commenced.
2b. Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. Specialist ARMS assessment commenced.
2b. Clock stops when:1. Accepted on to EIP caseload2. EIP care coordinator allocated3. Specialist ARMS assessment commenced.
3. ARMS?
3. ARMS?
Commence NICE
concordant package of
care
Commence NICE
concordant package of
care
Onward referral to
appropriate service or discharge
Onward referral to
appropriate service or discharge
Y
N
Y
N
EIP – Regional Leads
London South Midlands & East
North
Stefanie Radford [email protected]
David Monk [email protected]
Belinda [email protected]
Sarah [email protected]
Peter [email protected]
Finola [email protected]
Alison [email protected]
Colin [email protected]
NHS | Presentation to [XXXX Company] | [Type Date]30
Regional preparedness work
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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’?
Challenges
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• 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
Opportunities
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• 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
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.
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