Consultation Paper

A proposed service specification for an integrated

Primary care Talking Therapy service in Lambeth

October 2011

Lambeth Talking Therapy Board

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1. EXECUTIVE SUMMARY

1.1 As a result of the various drivers (4.1 below) influencing the future of primary care talking therapy services in the London Borough of Lambeth, the Talking Therapy Board has reviewed current provision. The outcome of the review has concluded that the service should be developed and enhanced. It is proposed this could be realised by reconfiguring the services into one integrated service, with a single point of entry into talking therapy provision. Under the proposals, people referred into the service will be assessed and directed to the most appropriate service to meet their needs. The purpose of any talking therapy service intervention arranged and the outcomes that the service will aim to achieve will be explicit and agreed with the service user.

1.2 In future, one integrated talking therapy service will work more collaboratively with other mental health and social care services, as well as relevant community based services, to aid people’s recovery and the maintenance of their physical and psychological health; to help them to retain and to return to employment, and to remove dependency on welfare benefits; and to aid optimum social functioning.

1.3 The consultation paper describes the approach that the Talking Therapy Board is proposing to take in order to introduce the changes. The Board is seeking views and comments from stakeholders as widely as possible. Attached to this paper is a questionnaire, which people may wish to use to submit their comments. Alternatively the Board will be pleased to receive views in whatever format stakeholders prefer.

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2. STRUCTURE OF THE CONSULTATION PAPER

2.1 This paper is structured as follows:

1. Executive Summary;

2. Structure of the consultation paper;

3. The proposed changes, including: o What the changes aim to achieve;

4. The current position, including:o The drivers for change;o The current demand; and o Current financial resources.

5. The proposed future service;

6. Proposed outcomes;

7. Consultation plan; and

8. Summary and conclusion

9. Appendix: Consultation Questions.

3. THE PROPOSED CHANGES

3.1 The proposal to re-commission the various talking therapies services from August 2012 into one Lambeth-wide, integrated counselling and Improving Access to Psychological Therapies (IAPT) service was ratified by the Lambeth Clinical Collaborative Commissioning Board (LCCCB) in June 2011. The proposal will result in commissioners holding one contract with a provider or group of providers, rather than the multiple contracts managed now.

What the Changes Aim to Achieve

3.2 Users will be able to access services in a much easier way and have more choice about who, when and where they are seen. If a change of approach or intervention is needed, they will be able to access this in a faster more seamless way.

3.3: Users will be able to receive more seamless care - there will be a strong focus of talking therapists working alongside people with long term physical health conditions, and social issues such as worklessness.

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3.4: There will be a greater emphasis on mainstreaming therapy that was previously only received within specialist services, such as elements of HIV counselling and other long term physical health conditions, making access more open and closer to home.

3.5 Service users will be able to take advantage of new ways of working which have been established by the Lambeth Living Well Collaborative. There will be a stronger focus on user enablement, peer support and social inclusion.

4. CURRENT POSITION, including a demand and resource analysis

Drivers for Change

4.1 There are a number of drivers contributing to the proposed changes:

Experience of service users and referrers: Although local information shows that service users and referrers are largely satisfied with services in Lambeth, there is inconsistency in practice. Some of the reasons for this are thought to include:o a variation in the ways GPs refer to services;o delays in services referring clients elsewhere, when needed; o tertiary psychotherapy services accepting referrals of service

users who could be seen by counselling or IAPT services;o service users being referred between or to more than one

service, without one service taking responsibility for ensuring continuity; and

o a lack of clarity about which service to refer service users to in given circumstances.

Provision of evidence based services: practice is inconsistent and does not always conform to National Institute of Clinical Excellence (NICE) guidance.

Service configuration: Consideration has to be given to whether current services should continue in their current form. IAPT services, nationally, are being asked, formally, by the Department of Health to broaden their remit. They are being asked to encompass modalities traditionally delivered by counselling services: such as counselling for depression, interpersonal therapy etc. In addition, IAPT will be required to meet specific Department of Health targets which will be dependent upon a sufficient number of service users being seen by IAPT services. The potential for IAPT and counselling services to see the same user group could risk achieving these targets, which could have financial implications.

New developments: The 2011 publication of ‘Talking Therapies: A four year plan of action’, a supporting document to ‘No Health without Mental

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Health (Feb 2011) outlines the Government’s intention of ensuring IAPT provides services, for example, to people with long term conditions, children and young people, older people and those with severe and enduring mental health needs.

Worklessness: The Department of Health has placed an emphasis on IAPT clinical interventions working alongside employment support to assist people to gain entry or maintain employment. Initially the Department of Health and the Department of Work and Pensions made funds available to each PCT to commission a employment support component. Funding has now ceased and decisions need to be made as to whether to include this element in a re-tendering exercise.

Lambeth Living Well Collaborative: New ways of working have been introduced by the Lambeth Living Well Collaborative, a group of users, carers, providers and commissioners who have come together to enable people with severe mental illness to recover and stay well through reorganising the transfer from secondary to primary health care and offering different types of support to people including action planning for recovery using a ‘personal guide, peer support, improved primary care mental health services and rapid, brief access to secondary care should this be needed (‘easy in and easy out’). For all users there will be improved access to relevant information, and, for those who require it, support in resolving stressful social problems through the Community Options Team. The absence of such facilities in the past has added to the difficulties of delivering talking therapies. Primary care talking therapists will now be able to focus on the core task of delivering brief treatments, but will be required to understand the overall management choices available and help users access them appropriately. The expectation is that there should be a strong focus on user enablement in the delivery of talking therapies

Reviewing existing service provision: The South East London Cluster is currently reviewing the CASCAID service, and commissioners are suggesting that services meeting low level, less complex needs should be mainstreamed.

Quality, innovation, productivity and prevention (QIPP) savings: Savings are required by NHS London, although these have yet to be specified.

Existing contracts coming to an end: The neighbourhood counselling service contracts end in October 2011and there is a requirement from the original IAPT submission to the Department of Health to re-tender the IAPT service from October 2012.

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Current Demand

4.2 National estimates suggest that at any one time 15.1% adults (over 15 years old) have symptoms of common mental disorder (CMD), such as: anxiety; depression; obsessive compulsive disorder; or post traumatic stress. About half of these (7.5%) are severe enough to warrant treatment (such as talking therapy or medication). In Lambeth, this results in estimates of between 30,000 and 53,000 people aged 16 – 74 years experiencing some symptoms of one or more of the listed disorders. An additional 1,000 people over the age of 74 are estimated to experience similar symptoms.

4.3 It is further estimated that between 15,500 and 27,000 people from this potential user group might benefit from some treatment. Prevalence of CMD in women is substantially higher (19.7%) than in men (12.5%).

4.4 The estimates are based on national surveys1 of mental illness, which is one reason for the large range in the expected numbers. The size of the range makes it difficult to plan services precisely.

4.5 In Lambeth there is a high degree of poverty and inequality, and a relatively young population. These factors are likely to lead to higher levels of CMD.

4.7 Lambeth’s population has a strong overrepresentation of younger working age adults, with high mobility, many of whom are born abroad, further reducing their access to services. These facts reduce the capacity to identify mental health problems, and require caution in projecting from national data.’

4.8 Nationally 90% of people with mental health problems are seen in primary care including people with both CMD and severe mental illness (SMI). Although only half of people with CMD consult their GP, nearly a third of people who consult (for whatever reason) have a mental health problem. For 20 - 25% of patients, a mental health problem will be the sole reason for attending the surgery.

4.9 These estimates have remained relatively stable between 2000 and 2007. Since the onset of the recession, spending cuts and substantial redundancies which may affect the incidence of mental illness (thought to affect Lambeth people disproportionately because of the numbers working in the public sector and low waged economy), no further national survey has been conducted.

1 The most recent of these is the ONS Adult Psychiatric Morbidity In England 2007. This is a household survey published in 2009. http://www.ic.nhs.uk/statistics-and-data-collections/mental-health/mental-health-surveys/adult-psychiatric-morbidity-in-england-2007-results-of-a-household-survey

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Current Resources

4.10 The financial envelopes of: IAPT; the neighbourhood counselling teams; Waterloo Community Counselling (WCC provides multi-ethnic and Portuguese counselling services), funding for the Psychological Wellbeing Practitioners provided by Guys and St Thomas’ NHS Foundaiton Trust, and potentially, some aspects of the CASCAID service (HIV Counselling Service) will be used to fund this new integrated service.

4.11: Currenlty, Status Employment provides employment intervention to the IAPT service. This funding will cease at the end of July 212.

5. THE FUTURE SERVICE

5.1 The proposed future talking therapy service in Lambeth will aim to optimise the health and wellbeing of Lambeth’s population by:

providing high quality, easy to access, equitable (fair) services to people according to need, offering a range of interventions in line with evidence, especially NICE Guidance, with well communicated and easy to follow referral arrangements;

promoting recovery and social inclusion of all service users who use talking therapy services, focussing on: wellbeing, people being able to fulfil their role in family, work and society; and by addressing the wider influences on mental health as well as illness.

emphasising choice. Providers will be asked how their services will promote choice and personalisation across the whole care pathway, from: choice of therapist; location; service option; time of treatment etc

integrating physical and mental health treatment and care in a user-focused way, reducing duplication and gaps in communication, this includes o working collaboratively with other organisations (e.g. health,

social care and community and voluntary sector organisations) providing other services to service users receiving a talking therapy service; and

o encouraging and supporting skill development in other mental health services e.g. primary care, community health services, and for staff involved in lifestyle interventions for physical ill health problems e.g. weight management, smoking cessation, health trainers.

challenging the stigma surrounding mental health and the discrimination experienced by people with a mental health history in Lambeth, by promoting inclusion and a positive approach to diversity;

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being outwardly focused as a service that understands and fulfils its wider role in building community resilience and wellbeing in partnership with others across the health economy (e.g. council, police, schools etc).

5.2 The Provider shall be required to meet the following requirements:

the provision of language and culturally specific/translation services, as necessary, across the whole stepped care pathway;

an ‘easy in/easy out’ approach, enabling people to get the help they need when they need it with timely and appropriate access into, and exit out of, treatment, including: o a greater emphasis on self-referral;o offering locations across the borough in both primary and

community settings, both in the statutory and voluntary sectoro every user who has been triaged to receive a follow up

assessment/ treatment appointment on the day of their triage; and

o 100% of users who receive therapy to have a discharge plan which will be sent to their GP;

a co-production approach, with providers engaging with users, referrers and other stakeholders on a regular basis, ensuring the effective marketing of the service and that the service responds to need;

reciprocity, making the best use of resources and providing good

access to information: pooling of expertise, buildings, recognising that everyone has assets to offer. Services will be designed to harness the best of everyone’s contributions; and

an emphasis on prevention and building on existing resources in the community and primary care.

be creative in managing demand for the service, for example, by the provision of groups, self supporting groups, the use of peer support, budding.

5.3 The service will be available to:

all adults of 18 years and over willing to engage in the service;

adults living in Lambeth or registered with a Lambeth GP;

people experiencing mental distress due to anxiety and/or depression, whether related to a physical health condition, including HIV, or life

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circumstances e.g. unemployment, family breakdown, or for any other reason; and

people with a drug or alcohol problem, who are sober at the time of their treatment and willing to change.

5.4 The current IAPT service currently provides services within HMP Brixton and it is expected that this component will continue and will be developed.

5.5 All referrals will be made via a single point of entry. Service Users referred will receive an initial assessment at triage. Self referral will be strongly encouraged. Services will encourage active liaison with, and signposting to: primary care; liaison psychiatry services (e.g. from A&E); long term condition services, including HIV; the health improvement service of Guys and St Thomas’ Foundation Trust; and from mental health services, including those within the Lambeth Living Well Collaborative.

5.6: The current service also provides family and couple therapy where appropriate, and this is also expected to continue.

6. PROPOSED OUTCOMES

6.1 The table below provides details of the specific aims and proposed desired outcomes, encompassing both an individual and a Borough-wide focus.

Table 1. Aims and Outcomes of the Primary Care Talking Therapy Service

Specific Aims:

Desired outcomes: changes that match aims

People achieve their recovery goals

People achieve what they seek from the service.

People have a positive experience of the care process

Recovery goals are achieved equitably across all population groups.

To meet the needs of the population

The service works in partnership with others optimising the health and well being of the population, including the retention of, and return to, employment, improved physical health, and effective social functioning.

The service is easy to access by all who need it including people: who are non-English speaking; who need other communication support (such as BSL); who may have low levels of literacy or learning disability; who may have other difficulties because of physical ill health or

disability;

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who may be at risk of discrimination because of sexual orientation, gender identity, diagnosis (such as HIV), ethnic background or religious belief, nationality & residency status (such as asylum seeker);

who may find it difficult to access the service due to their socioeconomic situation;

The needs of people are met fairly including being offered a wide range of choices in relation to: the type and/or place of treatment, therapist etc;

The service is safe;

The service is provided to a consistent high quality;

The service is provided according to best available evidence;

The service engages well with stakeholders to support the achievement of the outcomes;.

The service reports transparently on its progress in meeting the outcomes

Staff are enabled to work to the highest standards

The strong focus on learning and development for staff and the service contributes actively to the ‘next generation’ of excellent talking therapists;

The service is recognised by stakeholders as providing a high quality service that integrates well with other services in Lambeth

The service provides maximum value for money

The service can demonstrate efficiency and effectiveness;

The service collaborates to ensure an integrated client centred approach to service provision;

6.2 The service will meet national specified standards, as outlined by NICE and the Department of Health.

6.3 The IAPT standards will also apply to the service and these are as follows:

the provision of NICE approved, evidenced-based, psychological therapies for people with depression and anxiety disorders. This includes low intensity provision such as guided self help, bibliotherapy, computer assisted psychological support, signposting.

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services and treatments accessible by people experiencing depression and anxiety disorders from all communities in the local population, irrespective of age; gender, ethnicity, diagnosis, socioeconomic status, sexuality, faith or disability;

timely access, with people waiting no longer than locally agreed waiting times standards;

increased health and wellbeing, with at least 50% of those completing treatment moving to recovery, and 90% experiencing a meaningful improvement in their condition;

high levels of patient choice and satisfaction expressed by people using the services and their carers; and

improved employment, benefit, and social inclusion status, including help for people to retain employment, return to work, improve their vocational situation, and participate in the activities of daily living.

7. CONSULTATION PLANS

7.1 The purpose of this consultation document is to help interested parties including, people who have used or may use the service, to contribute to the planning process for a new service. The timetable for consultation and implementation is detailed in the table below.

Table 2: Timetable of Consultation

Activity TimeframePeriod of consultation begins 10th October 2011Period of consultation ends 11th November 2011Workshop dates 1st November 12.30-

3.00pm 2011Feedback of consultation comments 12th November 2011Finalised document released in an Invitation to Tender Pack

21st November 2011.

New integrated service in place 1st August 2011

7.2 Stakeholders comments on all aspects of the proposals are sought, especially on;

the vision and scope of a talking therapy service for Lambeth, and whether the proposals meet need;

access: how people will enter the service; equity of access and intervention: making sure the service is fair in

terms of accessibility and the opportunities for people to benefit from it;

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the proposed outcomes, and what the service should aim to achieve; and

opportunities for working collaboratively and transparently with other organisations, especially primary care/GPs, community health services (e.g. health promotion, district nursing), the voluntary sector, social care and mental health services.

7.3 There are several ways to contribute to the consultation, either via the workshop or feedback via joiss.soumahoro@lambethpct.nhs.uk Tel: 0203 049 4381. There is also a list of questions attached to the end of this consultation document that stakeholders can complete and return. Please note that in order for comments to be taken into account, they are required by 11 th November 2011, at the latest.

8. SUMMARY AND CONCLUSIONS

8.1 This consultation document describes the proposals underpinning an integrated talking therapy service in Lambeth, which is proposed because:

the Talking Therapy Board believes that the experience of users and referrers, and provision of evidence-based services can be improved;

existing contracts are coming to an end; changes in Government Policy and local initiatives have created the

need for a more inclusive approach; and the current economic environment is asking for increased quality, but

within a reduced financial envelope.

8.2 The document describes the suggested vision for the service, its scope, routes into the service, outcomes, standards, and how success will be measured.

8.3 The following section outlines key questions which the Talking Therapy Board wishes stakeholders to consider. The Board wishes to receive comments from a wide range of stakeholders, including users, referrers, and those who host services, including employees from both statutory and voluntary sector provision.

8.4 Through the consultation exercise, the Board wishes to further refine the plans for the service so that a clear outcomes framework is agreed, which will better meet the needs of users in Lambeth.

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Lambeth Talking Therapies Services Consultation Feedback Form 2011Consultation Questions

Name (optional):

Contact details:

Note: If you give your details we may contact you with the findings of the consultation or invite you to participate further in this review. You will not be contacted for any other reason.

Your organisation/ employer (if relevant):

Please tick the appropriate box(es)

You are answering as an individual

You are answering on behalf of a provider organisation

You are answering in another capacity (please say which)

You are a health professional

Please tick

If you have been a user of an IAPT Service (Lambeth or elsewhere)

You have used neighbourhood counselling provided at your GP practice

You have used guided self help such as reading books on prescription,

exercise on prescription, computer based psychological support, or other

intervention to help with a mental health problem.

You currently deliver a talking therapy service. Please specify__________

Please answer the questions that are of most interest to you. You do not have to complete all questions to contribute. Please feel free to make any other comments or ask any questions about the proposals. Please return your comments by 11th November 2011 to: Joiss.soumahoro@lambethpct.nhs.uk or by post to Joiss Soumahoro,

Primary Care Implementation Manager, NHS Lambeth, 1 Lower Marsh, London, SE1 7NT1. What do you think of the vision as set out in section 5?

Does it leave anything out?

Does it include something that shouldn’t be in?

Do you have any comments about how we can ensure this vision

becomes a reality?

2. What do you think of the proposed outcomes of the new service as set

out in 6.1?

Should we include other things? If so what do you suggest?

3. IAPT currently provides an employment support alongside its clinical

services. Employment support helps people with issues pertaining to

retaining existing employment as well as finding a new job. Do you think this

function should be maintained in the integrated service? If so, what are your

ideas around how it should be offered?

4. What do you think are the most important things that have been learnt in

the last 3 years within current service provision?

What’s really worked well?

What has not worked well?

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What ideas do you have for making sure any mistakes are not

repeated?

5. All public organisations such as health and social care are required to

offer services that are fair so people with equal need get equal services and

equal chance to benefit from that service. This doesn’t always happen, for

instance older or younger people, men or women, people of different ethnic

background or disabled people can be left out.

We want to ensure the service is fair to and suits. What do you think we

should do to ensure the new talking therapy service is fair for everyone and

does not discriminate against people?

6. Have you any comments on proposed routes into the service (paragraph

5.5)?

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7. How could the concepts of the Living Well Collaborative be applied within the

service?

8. Do you think we need more information to help us in our decision about

future service arrangements?

If yes, what is this information and where might we obtain it from?

9. Do you have any other comments or questions?

Thank you for taking the time to contribute. Feedback from this consultation will be available by 12th November 2011 via the NHS Lambeth website which can be found at www.lambethpct.nhs.uk. . If you wish to see a copy of the report, please ensure your contact email is included.

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