The new mental health access & waiting time standards · 28.11.14 Sarah Khan MH Senior Programme...

NHS | Presentation to [XXXX Company] | [Type Date] 1

The new mental health access &

waiting time standards

Dr Frank Burbach

Consultant Clinical Psychologist

Somerset Partnership NHS Foundation Trust

[email protected]

28.11.14 Sarah Khan MH Senior Programme Lead (Access & Waits) NHS England

Preparing to implement the new mental health access & waiting time standards

The Financial Package

2

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

The 15/16 Access & Waiting Time Standard for EIP

3

By April 2016:

• 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.


National Expert Reference

Group – Developing the new Access &

Waiting Times Target for Early

Intervention in Psychosis services

How will the standard be measured?

5

In order to monitor the new access & waiting time standard the national EIP ERG is working with the HSCIC to specify:

1. What the ‘clock starts’ and ‘clock stops’ should be to measure the two-week referral to treatment standard – the waiting time

2. What the NICE concordant “intervention codes” should be – the quality of care

The ERG is also working to specify what the EIP outcomes dataset should be.

One window to change the MHMDS in the next 2-3 years! Specify the changes required to the dataset by the end of November 2014 in order for the dataset (and the fields on RiO / Jade etc) to change from 1st April 2016.

In 15/16, RTT performance will be assessed using MHMDS proxies or a UNIFY collection.

We expect to use national clinical audit to assess the quality of service provision in 15/16

Draft EIP Referral to Treatment (RTT) pathway

6


South Region Expert

Reference Group –

Regional preparedness

Chair: Prof Belinda Lennox (Oxford AHSN)

Purpose of the South Region ERG


Improve the regions capacity and capability to deliver the

new standards;

Reduce unwarranted variation in workforce competency

across the region;

Regional preparedness work

9

1. Raising awareness

2. Bringing together the experts and establishing quality improvement networks

3. Understanding demand

4. Understanding baseline position + gap analysis – 2 week wait is the easy part…

5. Optimising RTT pathways – need to engage all of the potential referral sources

6. 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’? By far the biggest challenge! LETB engagement will be critical

7. Preparing for the new data collection requirements – training for service and information leads


Current staff provision and

training gap analysis

Data sources • Survey data

• Prediction data from http://www.psymaptic.org

• Population data ( source Survey, County websites)

• Staff predictor from IAPT SMI pilot services

EIP Readiness Data analysis 11

http://www.psymaptic.org/



Training needs survey to each of 25 EIP

teams/services


Demographics • Population 12.5 million

• 25 EIP services

• Employing 280 WTE staff

• Current caseload 3982 FEP

• Average caseload 19 FEP,

• Including 2 ARMS, 3 <18, 0.8 >35


Caseload ranging from 10-30

14 EIP Readiness Data analysis

0 5 10 15 20 25 30 35

Banes

Brighton

Bucks

Worthing

East Sussex

Mid Sussex

East Kent and Medway

Isle of Wight

Plymouth

Surrey

Portsmouth

Hampshire

West Surrey & NEHantpshire

Oxfordshire

Somerset

Cornwall

Torbay, Paignton and Brixham

Western West Sussex

Milton Keynes EIP

West Dorset EIP

Wiltshire

East Dorset

Bristol

North Somerset

Berkshire

Gloucs

Total Caseload Vs. Predicted cases

15 EIP Readiness Data analysis 0 100 200 300 400 500 600 700

Bucks

East Kent And Medway

Banes

Worthing

Isle Of Wight

Plymouth

Surrey

Portsmouth

Hampshire

West Surrey Ne Hampshire

Oxfordshire

Somerset

Cornwall

Torbay, Paignton And Brixham

Milton Keynes

West Dorset

Wiltshire

Sussex

Bristol

North Somerset

Berkshire

Gloucestershire

Predicted cases for 3 years

Caseload

Who works in EIP teams?

16 EIP Readiness Data analysis

21.0

10.3

4.3

17.5

2.0

2.2

133.4

25.7

34.2

38.6

2.0

10.6

23.1

4.2

4.0

0.1

0.2

0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0

Team Manager

Consultant Psychiatrist

Non Training Grade Psychiatrist

Psychologist Band 7-8

Psychology Assistants

Cbt Therapist

Community Psychiatric Nurse

Social Worker

Support Time And Recovery Worker

Occupational Therapist

Counsellors

Not Specified/Other

Admin

Vocational Advisor

Carer Liaison

Pharmacist

Research Assistant

WTE Total

suggested staff needed to

respond to AWT target Assessment, diagnosis, prescribing, physical health

monitoring 0.5 Consultant Psychiatrist

CBT for Psychosis (CBTp)

&

Family Intervention

1 Band 8a/b practitioner (supervisor)

2 Band 7 practitioners

[all working across both interventions]

Training level: Basic CBT + psychosis module, and train the trainer to

bring skills to wider team.

All essential for required skill mix for psychologically informed team.

Employment and activity support 1 Band 5/6 Occupational Therapist

Recovery oriented care coordination (recovery values

through train the trainer psychology approach)

- Information provision

- Engagement with YP

- Substance misuse support

- Physical health support

- Motivation interviewing/ basic CBT skills

1 team manager, Band 7

3 care coordinators, Band 6

2 care coordinator, Band 5

Caseload maximum 20 per case manager.

Specialist practitioners do not coordinate care or deliver the listed

interventions.

2 support workers, Band 3 (one of whom should be a peer support

worker)

Admin support 0.5 admin Band 3


Which would give a staff gap for

South England:

Predicted

WTE

Actual WTE Gap WTE

Consultant

Psychiatrist

50 11.5 38.5

8a

psychologist

100 18.5 281.5

Band 7

psychologist

200

Band 5/6 care

coordinators

500 242 258

Support

workers

200 39.6 160.4

Admin 50 25.2 24.8

OT 100 38.8 61.2

Team

managers

100 23.8 76.2 EIP Readiness Data analysis 18

Gaps in care coordinators by area


10.8

37.3

5.1 3.0 4.5 7.0 2.8 19.1

4.0 23.5

1.6 11.1 7.6

16.0 0.6 3.8 5.5 9.7 6.7 11.8 5.8 12.3 18.0

8.5

20

70

15 10 5 5 10

45

10

50

15

30

15 15

5 15 15

25

10

30

5

45 35 50

WTE treatment staff (non medical)

Skills gap survey of existing EIP staff

• CBT skills

• Family therapy interventions

• Vocational skills

• Physical health

• Assessment tools

• Calculated as % trained in each team x no. of all staff band 5-7


Skills gap survey results

• Total 280 WTE band 5-7 ‘treatment’ staff working in EIP in South England

• Of these, the number without training to deliver:

• NICE concordant CBT: 214

• CBT Informed Care (e.g. Graded Exposure and Behavioural activation): 82



0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

WTE treatment staff (non medical)

skills gap in CBT informed care (numberstaff)skill gap in NICE concordant CBT

Skills gap 2: • No. without training in NICE concordant family

therapy: 228

• No. without training in family interventions: 155

• No. without training in vocational support: 214

• No. without training in physical health interventions: 180


Skills gaps 3: assessment tools: • No. without training in CAARMS: 196

• No. without training in PANSS: 136


12th Feb 2015

1.2 Supporting funding

• The new standards for 15/16 will be supported by an £80m funding package: £40m recurrent funding to support delivery of the early intervention in psychosis standard;

• Monitor and the NHS Trust Development Authority (TDA) have highlighted the importance of prioritising achievement of the new standards in their planning frameworks for providers for 15/16.

1.3 Expectations of commissioners and providers

“Commissioners should agree robust implementation plans with providers as part of their 15/16 contract development work.” “Commissioners are required to agree service development and improvement plans (SDIPs) as part of their 15/16 contract with mental health providers, setting out how providers will prepare for and implement the new standards during 2015/16 and achieve them on an ongoing basis from 1 April 2016.”

2.5 Expectations of commissioners

• NHS England’s expectation is that the additional £40m funding being made available recurrently should be invested recurrently in EIP services to support sustainable delivery of the new access and waiting time standard.

• EIP services are subject to local agreement on pricing, and so commissioners should ensure that increases in the level of local investment take into account baseline performance against both elements of the EIP standard: Referral to treatment waiting times; and current levels of NICE concordance

2.3 How will the standard be measured?

• Both elements of the standard will be measured – the wait from referral to treatment and whether the treatment accessed is NICE concordant.

2.3.2 Assessing NICE concordance

• The approach to measurement will be necessarily retrospective. For year 1, the approach currently being explored is the commissioning of a national clinical audit focusing on the care offered and delivered to individuals identified as experiencing first episode psychosis during 2015/16.

• By April 2016, the mental health and learning disability dataset (MHLDDS) is to be updated to include the relevant NICE concordant interventions so that it should be possible in the medium term to draw the relevant data directly from provider systems. A third option under development is the establishment of an accreditation or service ‘kitemarking’ scheme for early intervention in psychosis services.

2.7 Regional Preparedness work should comprise:

• 1. Raising awareness of the requirements of the new standard.

• 2. Bringing together local experts and establishing quality improvement networks, ensuring effective linkage with strategic clinical networks.

• 3. Understanding levels of demand in constituent CCGs and any inequities in access relative to the levels and patterns of psychosis incidence in the population.

• 4. Understanding baseline performance and undertaking a gap analysis.

• 5. Optimising referral to treatment pathways, engaging all of the likely referral sources.

• 6. Preparing for the new data collection requirements and providing training for EIP service and information leads.

• 7. Supporting local workforce development programmes.

Challenges

• £40M will become available to Trusts that have signed up for the enhanced tariff BEFORE we have completed the national and regional work – particularly defining the 2015 EIP spec for ‘clock stop’ (for commissioner guidelines) and the gap analysis to follow the baseline surveys.

• The waiting time target will be a MDS requirement next year not this.

How will this be taken forward?

• National ERG

• Regional ERGs

• Linking with :

-IRIS

-NHS Benchmarking

-SMI IAPT & Competence Frameworks

-? You

Improving Access to Psychological Therapies

for People with Psychosis:

Delivering High Quality Therapy

Dr Louise Johns Consultant Clinical Psychologist

South London and Maudsley NHS Foundation Trust

Oxford Early Intervention Team

February 2015

Implementation of CBTp

• Psychological therapies are not readily accessible for people with psychosis

• Delivery rates in routine NHS services in UK are 10% (The Schizophrenia Commission, 2012)

THE ABANDONED ILLNESS

A report by the Schizophrenia Commission

November 2012

Barriers to access

• Unclear referral pathways • Prioritisation of other interventions • Lack of suitably trained, competent and confident

staff • Restricted access to training, support and

supervision for therapists • Lack of organisational support

(Shafran et al., 2009; Prytys et al., 2011)

Overcoming obstacles to access through IAPT-SMI

IAPT for SMI Initiative • Part of the government’s four-year plan to increase access to talking

therapies • Transforming mental health services to be better able to provide NICE

approved psychological therapies to people with bipolar disorder, personality disorders and psychosis

• Equity of provision regardless of age, gender & BME status

• 6 SMI demonstration sites, started in Nov 2012 • 3 PD, 2 psychosis, 1 bipolar disorder • Data collection until Dec 2014, final report by April 2015

What IAPT-SMI offers CBT for psychosis:

• Weekly or fortnightly individual 1 hour sessions • 6-9 months therapy • Therapists receive weekly-fortnightly group supervision • See clients locally at the team base

FI for psychosis:

• Fortnightly 1 hour sessions with client and carer(s) • Up to ten sessions, over a period of 3-9 months • Therapy delivered by two trained therapists • Therapists receive weekly-fortnightly group supervision

IAPT-SMI: CBT assessments Pre

PSYRATS – Voices & Beliefs

WEMWBS

WSAS

EQ-5D

Short CHOICE

CORE-10

Brief IPQ

Measures Feedback

3-month


WEMWBS

WSAS

EQ-5D

Short CHOICE

CORE-10

Brief IPQ

Measures Feedback

Satisfaction with therapy & PEQ

Post


WEMWBS

WSAS

EQ-5D

Short CHOICE

CORE-10

Brief IPQ

Measures Feedback

Satisfaction with therapy & PEQ

Short CHOICE weekly

IAPT-SMI: Carer assessments Pre

Experience of caregiving inventory

WEMWBS

DASS-21

CORE-10

IPQ carer version

Confidant question

Measures Feedback

Post

Experience of caregiving inventory

WEMWBS

DASS-21

CORE-10

IPQ carer version

Confidant question

Measures Feedback

Satisfaction with therapy

Sessional satisfaction measure

Quality of CBTp • A key challenge has been lack of clarity about quality

• Lack of criteria have resulted in an ‘anything goes’ approach to psychological therapy in mental health services, and inflated estimates of provision

• RCTs: Generic CBT competencies are not associated with good clinical outcomes (Durham et al, 2003); specific CBTp competencies are (Wykes et al, 2008 ; Steel et al, 2011)

• IAPT-SMI: nationally agreed criteria for training and competencies in CBTp and FI

• Competency Frameworks for Psychosis, Bi-Polar Disorder and Personality Disorder. www.ucl.ac.uk/CORE/

http://www.ucl.ac.uk/CORE/

Competence Framework for Psychological

Interventions for people with Psychosis / Bipolar

Disorder (Roth & Pilling, 2013)

• Modular training outline

• From awareness supervision & service change

• www.ucl.ac.uk/CORE

• Individualised and formulation based, but adheres to published manuals and the CORE CBTp competence framework (Roth and Pilling, 2013).

• Therapists are trained to competence, using assessments of adherence and competence.

• Supervision provided weekly to fortnightly in groups of 3-6 therapists for 1.5 hours, with fortnightly to monthly individual supervision.

• Supervisors are senior clinicians with experience of training therapists and of providing therapy within RCTs.

CBTp in SLaM Demonstration Site

Levels of training for psychosis

http://sites.intranet.slam.nhs.uk/commteam/Picture Library2/1/SouthLond Maudsley FT Col B.jpg

Assessment of therapist adherence

•Cognitive Therapy Scale – Revised (CTS-R) (Young and Beck, 1980; Blackburn et al., 2001)

• 11 items measuring quality of key CBT skills e.g.

Agenda setting, guided discovery, homework

•Score of 3 or more indicates competence

•Revised-Cognitive Therapy for Psychosis

Adherence Scale (R-CTPAS) (Startup et al., 2002; Rollinson et

al., 2008)

•21 items rated for frequency during each therapy

session

• 4 sections : Insight orientated; assessment and

formulation; active cognitive strategies; relapse

prevention

Competence outcomes for clinicians

Comparison of ratings of 23 paired audio recordings from first

formative to summative in students successfully completing

course

Cognitive Therapy Scale (score of 3 indicates competence

in CBT)

• First formatives: majority of items scored <3

• Summatives: all items score >3

• Significant improvements on eliciting feedback,

collaboration, strategy for change, application of CBT

techniques, homework

CT Psychosis Adherence Scale

40% increase in psychosis-specific content in sessions (i.e.

24 minute increase)

Clinical outcomes for clients Jolley et al. (in press, Behavioural and Cognitive

Psychotherapy)

• 20 clients receiving CBTp therapy from 9 therapists undertaking PG diploma in CBTp •Pre-post effect sizes for change in psychotic symptoms was large (d=1.0) and medium (d=0.6) for affect •Possible to train therapists to RCT-therapist standard •Effect sizes suggest that training costs may be offset by clinical benefits to clients

CBTp Distance Learning

• Development of a distance learning version of

the PG Dip in CBTp to enable :

•Increased access to UK clinicians

•Increased access to international clinicians

•Increased flexibility for clinicians in training

Conclusions from SLaM Site • NICE-recommended individual psychological therapy can be

successfully delivered in routine services

• In our demonstration site, primary facilitators were: – ring-fenced investment in competent therapy provision – ring-fenced time for therapists to deliver therapies – adequate supervision, training and CPD – trained independent assessors – established service pathways & governance structures – strong clinical leadership & management

• Our framework is potentially replicable to inform wider implementation in other services.

EIS Shared Learning Conference

Lancashire

EIS: setting

the scene

Lancashire Early Intervention Service

EIS Shared Learning Conference

Why we were chosen: • Whole Service Ethos of Psychosocial Care :

– Matched care or tiered approached to delivering psychological care across whole workforce

• Education & Training :

– PSI Training: All of our staff are trained in CBT-informed interventions (manualised, effective and accredited)

– Behavioural Family Therapy: We have 20+ staff trained and have our own BFT trainers

– CBT & CBFI: Cohort of staff trained to Masters & Diploma level

– REaCh: Routine Enquiry about Childhood Adversity

• Research and Contribution to Evidence-Base -

– E.g., LEAD Clinic, IMPACT Trial & REACT Trial

A Matched-Care / Tiered Approach to Psychological Care

Psycho-social

interventions

Case

managers/

ST&R

Tier 2

Tier 3

Formal CBT or FI,

Discrete Problems

Staff with:

Formal CBT training

or COPE Msc

(under supervision)

Complex / multiple

problems longer term

CBT or FI

Tier 1 Specific PSI

Training

Supervision/ Consultation

Cognitive Therapists

Clinical Psychologists

3 days of PSI training for all EIS workers & a manual/

written resource

• To support EIS staff in the delivery of a CBT-informed

approach. • To evaluate impact on knowledge, confidence and

application of PSI in routine clinical practice. • To build on existing knowledge & skills. • To include on-going supervision and support. • Should be easily integrated into practice and

supports EI service model.

PSI Manual

• Engagement (MI skills)

• Normalising Approaches

• Maintenance Formulation

• Problem lists and Prioritisation

• SMART Goals & Agenda Setting

• Activity Scheduling

• Relapse Prevention (+ Manual)

• Recovery Approach

• Measuring Change

The new mental health access & waiting time standards · 28.11.14 Sarah Khan MH Senior Programme...

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