Improving Access to Psychological Therapies in England

1. Improving Access to Psychological Therapies in England Dr Alan Cohen FRCGP Director of Primary Care West London Mental Health Trust

2. What I am going to cover • Why IAPT evolved • What it is • Implementation issues • Engaging primary care • NICE guidelines, and its relation to IAPT • Treatment guidelines

3. What I am not going to cover • Why the NHS is better (or worse) than the U.S. system • Whether socialism is better than capitalism for health care • Whether the health care reforms in the U.S. (or UK) are a good thing • Anything else even vaguely political!

4. How the NHS works • Health care free at the point of delivery • Funded by central taxation • Primary Care • 30,000 GPs (and teams) working from 10,000 practices • There are 350 hospitals providing about 160,000 beds

5. Organisationally Performance management Policy

6. Translating the Special Relationship • The NHS works on the principle of a purchaser:provider split • Purchaser of health care = commissioner • Provider of health care = GP or Trust • The local purchaser commissions for the local population • There is considerable variation in provision of services throughout England – there is no single immutable care pathway for anything

7. What is IAPT? I - Improving A - Access to P - Psychological T – Therapies A commissioner led, outcome focused programme to deliver improved access to psychological therapies, through the implementation of NICE guidelines

8. This is the man responsible…

9. The IAPT Programme • 2004: 10 Downing Street seminar on worklessness • 2005: Manifesto commitment to improving access • 2005: 2 Demonstration sites in Doncaster and Newham • 2007: 10 Pathfinder sites

10. The IAPT Programme • 10th Oct 2007 – World Mental Health Day • New Funding over 3 years • $53m in 2008 • $166m in 2009 • $279m in 2010 • To deliver • Treatment for 900,000 people • 3,500 new therapists • New Government committed to continue support • In total $1,200m programme

11. System Transformation Policy Imperative Key Performance Indicators Engage professional bodies Voluntary sector campaign Regional and local management structure Clinical Networks Clinical Leadership

12. What is NICE?

13. NICE • 2004: Produced guidelines on the management of depression and the management of anxiety • 2009: reviewed and updated guidelines

14. NICE Guidelines • IAPT implements NICE guidelines for depression and anxiety disorders • Only evidence based approaches included in NICE guidelines are intended to be implemented through IAPT teams • Stepped care essential

16. The way it used to be… • Some GP practices had counsellors • No referral guidelines • No treatment guidelines • No way of monitoring use of evidence based interventions • No way of measuring success of treatment

17. The Vision • Everybody has access to high quality therapists • Use evidence based referral and treatment guidelines • Monitor outcomes What we came up with …

18. Characteristics of the IAPT service • Commissioner led • Commissioned against outcomes • A team approach to management of people with common mental health problems • Low intensity therapists • High intensity therapists • GP champions • Others as needed • A team per 250,000 population • 40 therapists per team • 60:40 split between high and low intensity therapists

19. Implementation • New Staff • New ways of working • Engage professional bodies • Clinical leaders locally, and local networks • Dissemination of information • Develop evidence based outcomes

20. “New Ways of Working” • Focus on care pathway, and what is required by the patient, not what professionals choose to offer • Requires the review of traditional professional roles, and creation of new roles if neccessary

21. A Care Pathway

22. Training New Staff • A need to recruit and train new staff • Not re-allocate current staff • Competency based (new ways of working) • Develop a curriculum • Identify educational establishments to deliver the training • Quality Assure the training • Deliver the training

23. Therapists • Low Intensity – 2nd Step • Up to 4 – 5 sessions • Face to face, or telephone contacts • Skilled to deliver a variety of evidence based interventions • Delivers high volume contact • High Intensity – 3rd Step • Usually 12 – 20 sessions • Face to face therapy • Skilled to deliver CBT and other evidence based interventions

24. How many staff are needed? • An excel spreadsheet [check link] that calculated the number of new staff needed for a given population • Worked on assumptions • Population, morbidity, response to treatment etc • Number of sessions needed to treat a disorder • Add in cost of staff (national pay scales) • Used to estimate cost of a new service

25. How did the teams work? • Different teams discovered their own ways of working • Innovation • ownership • Team location • Supervision essential to high quality care • Links to other providers, primary care, and specialist mental health trusts • A requirement that the MDS was recorded on an approved database

26. Evidence Based Outcomes • Reviewed what questionnaires were available already • Identified those that were free to use • Agreed when the questionnaires were to be used • Agreed cut off scales • Recovery vs improvement • Plan to “Pay by Outcome” in 2012/2013

27. The MDS • Clinical • PHQ-9, GAD-7, anxiety disorder specific measures • Choice and satisfaction • Employment • Quality of life (WHODAS)

28. Benefits of an MDS • Patient benefits • Therapist benefits • Supervisor benefits • Commissioning benefits

29. Findings from Wave 1 sites • IAPT services appear to be beneficial to patients with clinical presentations that vary from mild to severe • Recovery vs improvement • Self referred patients were as severe as referred by GPs, but recovered in less sessions • Services that made good use of stepped care have higher recovery rates. • Patients were more likely to recover if they were seen in services that saw more patients

30. Findings from Wave 1 Sites • Compliance with NICE treatment recommendations associated with better outcomes • Provisional diagnoses are important to ensure patients receive NICE recommended treatments • Services that had a higher proportion of experienced therapists, had overall recovery rates

31. Challenges… • Validity of NICE guidelines • Tribal politics • Money • Training new staff • Engaging primary care

32. NICE guidelines • Guideline structure is “rigid” • Dependence on a hierarchy of published research • Philosophical approach to “mental illness” • Why we had to use NICE guidelines

33. Tribal politics • Psychologists/Therapists • Some interventions were not included in NICE guidelines • Enormous educational agenda • Mental health vs. physical health • GPs were skeptical (this was a mental health intervention)

34. Money • Lots of new money • How to allocate that resource • Equality vs innovation

35. Engage Primary Care • General practitioners were seen as crucial to success of programme • Mental health staff thought that primary care are “not interested” in mental health problems • Relationship with physical health, and medically unexplained symptoms

36. Professional Engagement • A public statement from the leaders of ALL the primary care organisations that they supported this programme • Each team HAD to have a local GP leader • Provide training and support to the local leaders • Identify learning needs

37. Clinical Engagement • Help mental health staff realise that managing depression/anxiety had a significant impact on physical long term conditions • Develop work on savings accrued by providing psychological support to people with LTC/MUS • Educate mental health commissioners • Develop a national special interest group in psychological management of LTC/MUS

38. LTC/MUS • Ground breaking research • linked databases • Improved clinical outcomes • significant savings possible • Engaged primary care clinicians not “interested” in mental health • Engaged acute hospital colleagues not “interested” in mental health • Introduction of collaborative care • Part of national policy

39. Next session • What is the stepped care approach? • Savings and clinical pathways for people with LTC/MUS • Proposed changes to the NHS?

40. In memoriam Prof John C Nemiah Emeritus Professor of Psychiatry, Dartmouth Medical School 1919 - 2009

41. More information • Alan Cohen: doctoralancohen@mac.com • www.iapt.nhs.uk Thank you

42. NICE GUIDELINES Breakout Session MeHAF Integrated Care Learning Community November 4, 2011 Bangor, Maine

43. Stepped Care

44. Step 1 Be alert to possible depression (particularly in those with previous depression or a chronic physical health problem). Consider asking “During the last month have you often been bothered by: Feeling down, depressed or hopeless? Having little interest or pleasure in doing things?” If the person also has a chronic physical health problem, consider asking three further questions “During the last month have you often been bothered by: Feelings of worthlessness? Poor concentration? Thoughts of death?”

45. Step 1b If the person has a learning disability or cognitive impairment consider seeking advice from a specialist when developing a treatment plan. Always ask a person with depression about suicidal ideation and intent. If there is a risk of self harm or suicide: • Assess whether they have adequate social support • Arrange help appropriate to the risk • Advise them to seek help if the situation deteriorates Conduct a comprehensive assessment that does NOT rely simply on a symptom count. Consider The degree of functional impairment The duration of the episode Explore the following: History of depression or co-morbid mental/physical health problems Past history of mood elevation Response to previous treatments Quality of interpersonal relationships Social history including employment

46. Step 1c If the person presents with considerable immediate risk to themselves or others, refer them urgently to specialist mental health services Advise the person and their carers, of the following: The potential for increased agitation and suicidal ideation early in treatment The need to be aware of mood changes particularly when changing treatments If the person is assessed to be at risk of suicide, consider: Providing increased support Referral to mental health specialists

47. Step 2 Treatment options for people with sub-threshold or mild/moderate depression include: • General measures • Sleep hygiene • Active monitoring • Drug Treatment • For people without physical health problems • For people with physical health problems • Psychological interventions

48. Step 2 General Measures: Active monitoring: for those people who do not want an intervention, who may recover spontaneously, or those with sub-threshold symptoms who request an intervention • Discuss the presenting problem • Arrange a further assessment in two weeks • Provide information about depression • Make contact if the person does not attend appointments General Measures: Sleep Hygiene: offer advice including: Establishing regular sleep and wake times Avoiding excessive alcohol, eating or smoking before bedtime Creating a proper environment for sleep Taking regular physical exercise

49. Step 2 Drug Treatment for people with a chronic physical health problem Do NOT use anti-depressants routinely to treat sub-threshold symptoms or mild depression but consider them for people with: • A past history of moderate/severe depression • Initial presentation of sub-threshold depression for two years • Symptoms that persist after other interventions • Mild depression that complicates the care of the physical health problem Drug Treatment Do NOT use anti-depressants routinely to treat sub-threshold symptoms or mild depression but consider them for people with: A past history of moderate/severe depression Initial presentation of sub-threshold depression for two years Symptoms that persist after other interventions

50. Step 2 Psychological and psychosocial interventions. For people WITHOUT a chronic physical health problem Offer one or more of the following interventions: Individual guided self help Computerised CBT Structured group physical health activity For those who decline any of the above, offer group based CBT