Mapping Psychological Therapy Services

1. Mapping Psychological Therapy Services Professor Glenys Parry Mental Health Service Mapping Conference University of Durham 4th July 2002

2. Summary • Why do we need the map and why the NSF? • ‘Safe and Effective’: how to ensure it • The context for the map • Psychological therapies map: issues & concerns • Psychological therapies map: what does it show? • What could it show? • Future developments in service improvement

3. Why we need the map • To help monitor the implementation of the mental health service framework • Monitor moves towards equity in provision • Trends in service capacity and staffing • Compare ways services are provided between different localities with similar levels of need • Psychological therapies are a major form of treatment, with substantial evidence base • Have developed piecemeal & unmonitored

4. Why we need an NSF • Problems getting access to good mental health care, including psychological help • Staff shortages and patchy services with long waiting lists • Access is inequitable: relates to age, socio-economic status & ethnic group • Major quality problems in some areas • Poorly co-ordinated services • Referrers and service users lack knowledge of psychological therapy • Many mental health staff work with insufficient support, training & supervision • Standards 2 & 3 involve access to ‘safe and effective’ psychological therapies

5. How best to ensure safe & effective therapies? • Would it be a good idea to adopt US approach of Empirically Supported Treatments (ESTs)? • Every therapy type is tested in RCTs • Judged either • efficacious: 2+ independent studies, meta-analysis • possibly efficacious, 1 study & absence of contrary evidence • efficacious and specific, 2+ studies over placebo or alternative bone fide treatment • Analogous to ‘licensed medicines’ • Resulting list of therapies is approved for training, commissioning

6. What’s wrong with ESTs as a way to improve quality? • Findings from RCTs don’t generalise well • ‘Brand names’ don’t predict outcome • Equivalence of outcomes is still the usual finding • Therapist factors & relationship factors more important • Impossible to fund RCT on every therapy method • Allegiance effects are major problem • ESTs do not improve practice & delivery • Danger of stifling innovation & new approaches • Divisive and adversarial

7. Research Innovative practice Everyday Practice Improved patient care Theory Generating knowledge

8. Professional consensus and competence Training, education and CPD Clinical consensus Research Innovative practice Improved patient care Everyday Practice Theory Generating knowledge

9. Professional consensus and competence Training, education and CPD Clinical consensus Research Innovative practice Guidelines and protocols Improved patient care Everyday Practice Judgement Evidence based practice Theory Generating knowledge

10. Professional consensus and competence Training, education and CPD Clinical consensus Research Innovative practice Guidelines and protocols Improved patient care Everyday Practice Clinical audit Judgement Evaluation Evidence based practice Outcome benchmarking Theory Generating knowledge

11. Evidence based guideline on Treatment Choice in Psychotherapy & Counselling • developed by professional group including service managers • based on ‘best available research evidence’ • plus clinical consensus and user consultation • explicit process, externally reviewed, time-limited, independent of funding • indicates quality of evidence for each element • general principles & recommendations for specific conditions • But NOT a list of ESTs

12. Role of guidelines • Not a commissioning guideline: provides clinical and referral decision support • But does list a range of bona fide therapies & summarises state of evidence base. • Recommends needs for psychological therapy be considered for people with common mental health problems • Current NHS policy suggests commissioners: • invest in services that specify their appropriate patient groups on basis of evidence • those that audit elements of standard practice, e.g. premature endings, delivery standards • & those that monitor outcomes routinely

13. The context for the map • Range of psychological therapies (A) provided in team as integral part of wider mental health service, often CMHT (integral) (B) a psychological therapy service without a single theoretical basis: e.g. clinical psychology, counselling, often secondary care (generic) (C) a formal service by those training or trained to a specialist level in a specific theoretical approach (e.g. psychodynamic, or cognitive therapy), often a tertiary service

14. The context for the map • Provided by a multi-disciplinary workforce (A) mental health nurses, doctors, social workers (B) clinical psychologists, some mental health nurses, counsellors, art therapists (C) psychiatrists, psychologists and mental health nurses with post qualification specialist training • In a range of models of service delivery • Clinical psychologists in CMHTs & separate psychotherapy dept • Counsellors employed in PCTs or via Trust • Integrated psychological therapies services • Consulting & support services

15. Psychological therapies mapping: concerns & issues • Potentially, hugely valuable dataset, really worthwhile • Current data are very inaccurate: extremely high rate of errors, many examples • services missing • services wrongly included • service type inconsistently reported • Definitional problems • primary, secondary & tertiary services unclear • CBT - specialist or not? • Role of clinical psychologists • Are unreliable or erroneous data better than no data?

16. Psychological therapies mapping: concerns & issues • ‘General hospital settings’ particularly inaccurate • ‘Orientation’ is much less meaningful for type A&B therapies (integral & generic) than type C (formal), but this isn’t given • Distinction between ‘Behavioural’ & ‘CBT’ is not useful • Capacity data are very incomplete • No category for other therapies (e.g. CAT, systemic) • Skill range is enormous, but no details given of staff numbers, professions, skill levels etc. • ‘properly trained and qualified’ is left undefined

17. Psychological therapies map: what does it show? • Patchy provision: some LITs seem to have none! • Annual referrals rates suggest only a small minority of people with mental health problems are in receipt of psychological service • Absence of services in psychiatric settings suggest under-provision for people with psychosis • CBT is probably under-provided • For LITs with no specialist provision particularly, issues of supervision and training

18. What could it show? • Referrals/year by geographical area would be useful handle on access and equity • Could be linked to socio-demography, e.g. at LIT level, of mental ill health, ethnic mix, age structure and social deprivation indices • Track development of psychological services for common mental health problems in PCTs: supplementing counselling with CBT, stepped care & other approaches (e.g. CAT, systemic) • Is it possible to tweak the definitions?

19. Future developments in service improvement • Improving accuracy of service maps • NHS R&D agenda • User views of services & user-led quality improvement initiatives • HAS good practice framework • Routine outcome monitoring e.g CORE • Feedback on clinically significant and statistically reliable change • and ‘Expected Treatment Response’

20. One proposed research programme • Northern collaboration under NHS R&D funding for ‘Priorities and Needs’ • 17 NHS Trusts, 5 Universities, NCMH • Research team includes: • Michael Barkham, Glenys Parry, Else Guthrie, Mark Freeston, Chris Leach, David Shapiro, Mike Lucock, Roger Paxton, Jake Lyne, Frank Margison, Dawn Bennett, Gillian Hardy, Ian Kerr, Tom Ricketts & Derek Milne. • Plus over 20 research aware psychological therapists • Pool existing investment in psychotherapies R&D & take strategic approach

21. Themes within the programme • Effective therapy in complex mental health problems, e.g. personality disorder • Establishing effectiveness of psychological therapies in routine practice • Measures development • Change processes in psychological treatments • Developing good practice, e.g guidelines, training • Extending availability of psychological therapies, e.g. stepped care, guided self-help

22. End of therapy Intake score

23. End of therapy Intake score = 20 End of therapy score = 10 Intake score

24. End of therapy Intake score

25. No change line End of therapy Intake score

26. End of therapy Intake score

27. Expected treatment response • Using standardised outcome measure on large datasets • For given client group, plot average response to therapy over time • And upper and lower quartiles • Able to define ‘gold standard’ outcomes pragmatically • And to sound alarm for likely deterioration • More utility than effect size benchmarking against RCTs

28. 75th percentile Mental health index score 25th percentile Number of sessions

29. 75th percentile Mental health index score 25th percentile Number of sessions