The new mental health access & waiting time standards

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1 1 NHS Presentation to [XXXX Company] [Type Date] The new mental health access & waiting time standards Dr Frank Burbach Consultant Clinical Psychologist Somerset Partnership NHS Foundation Trust

2 Sarah Khan MH Senior Programme Lead (Access & Waits) NHS England Preparing to implement the new mental health access & waiting time standards The Financial Package 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 2

3 The 15/16 Access & Waiting Time Standard for EIP 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. 3

4 4 NHS Presentation to [XXXX Company] [Type Date] National Expert Reference Group Developing the new Access & Waiting Times Target for Early Intervention in Psychosis services

5 How will the standard be measured? 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 1 st April 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 5

6 6 Draft EIP Referral to Treatment (RTT) pathway

7 7 NHS Presentation to [XXXX Company] [Type Date] South Region Expert Reference Group Regional preparedness Chair: Prof Belinda Lennox (Oxford AHSN)

8 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; 8 NHS Presentation to [XXXX Company] [Type Date]

9 Regional preparedness work 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 9

10 10 NHS Presentation to [XXXX Company] [Type Date] Current staff provision and training gap analysis

11 Data sources Survey data Prediction data from Population data ( source Survey, County websites) Staff predictor from IAPT SMI pilot services 11 EIP Readiness Data analysis

12 Training needs survey to each of 25 EIP teams/services 12 NHS Presentation to [XXXX Company] [Type Date]

13 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 13 EIP Readiness Data analysis

14 Caseload ranging from Gloucs Berkshire North Somerset Bristol East Dorset Wiltshire West Dorset EIP Milton Keynes EIP Western West Sussex Torbay, Paignton and Brixham Cornwall Somerset Oxfordshire West Surrey & NEHantpshire Hampshire Portsmouth Surrey Plymouth Isle of Wight East Kent and Medway Mid Sussex East Sussex Worthing Bucks 14 EIP Readiness Data analysis Brighton Banes

15 Total Caseload Vs. Predicted cases Gloucestershire Berkshire North Somerset Bristol Sussex Wiltshire West Dorset Milton Keynes Torbay, Paignton And Brixham Cornwall Somerset Oxfordshire West Surrey Ne Hampshire Hampshire Portsmouth Surrey Plymouth Isle Of Wight Worthing Banes East Kent And Medway Bucks 15 EIP Readiness Data analysis Predicted cases for 3 years Caseload

16 Who works in EIP teams? Research Assistant Pharmacist Carer Liaison Vocational Advisor Admin Not Specified/Other Counsellors Occupational Therapist Support Time And Recovery Worker Social Worker Community Psychiatric Nurse Cbt Therapist Psychology Assistants Psychologist Band 7-8 Non Training Grade Psychiatrist Consultant Psychiatrist Team Manager 16 EIP Readiness Data analysis

17 suggested staff needed to respond to AWT target Assessment, diagnosis, prescribing, physical health monitoring CBT for Psychosis (CBTp) & Family Intervention 0.5 Consultant Psychiatrist 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 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 Band 5/6 Occupational Therapist 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 17 EIP Readiness Data analysis

18 Which would give a staff gap for South England: 18 Consultant Psychiatrist 8a psychologist Band 7 psychologist Band 5/6 care coordinators Support workers Predicted WTE Actual WTE Gap WTE Admin OT Team managers EIP Readiness Data analysis

19 Gaps in care coordinators by area WTE treatment staff (non medical) EIP Readiness Data analysis

20 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 EIP Readiness Data analysis

21 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): EIP Readiness Data analysis

22 WTE treatment staff (non medical) skills gap in CBT informed care (number staff) skill gap in NICE concordant CBT EIP Readiness Data analysis

23 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: EIP Readiness Data analysis

24 Skills gaps 3: assessment tools: No. without training in CAARMS: 196 No. without training in PANSS: EIP Readiness Data analysis

25 12 th Feb 2015

26 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;

27 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.

28 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.

29 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

30 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.

31 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.

32 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.

33 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.

34 How will this be taken forward? National ERG Regional ERGs Linking with : -IRIS -NHS Benchmarking -SMI IAPT & Competence Frameworks -? You

45 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

46 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

47 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)

48 Overcoming obstacles to access through IAPT-SMI

49 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 PD, 2 psychosis, 1 bipolar disorder Data collection until Dec 2014, final report by April 2015

50 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

51 IAPT-SMI: CBT assessments Pre 3-month Post PSYRATS Voices & Beliefs PSYRATS Voices & Beliefs PSYRATS Voices & Beliefs WEMWBS WEMWBS WEMWBS WSAS WSAS WSAS EQ-5D EQ-5D EQ-5D Short CHOICE Short CHOICE Short CHOICE CORE-10 CORE-10 CORE-10 Brief IPQ Brief IPQ Brief IPQ Measures Feedback Measures Feedback Measures Feedback Satisfaction with therapy & PEQ Satisfaction with therapy & PEQ Short CHOICE weekly

52 IAPT-SMI: Carer assessments Pre Post Experience of caregiving inventory Experience of caregiving inventory WEMWBS WEMWBS DASS-21 DASS-21 CORE-10 CORE-10 IPQ carer version IPQ carer version Confidant question Confidant question Measures Feedback Measures Feedback Satisfaction with therapy Sessional satisfaction measure

53 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.

54 Competence Framework for Psychological Interventions for people with Psychosis / Bipolar Disorder (Roth & Pilling, 2013) Modular training outline From awareness supervision & service change RE

56 CBTp in SLaM Demonstration Site 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.

57 Levels of training for psychosis

58 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

59 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)

60 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

61 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

62 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.

63 Lancashire EIS: setting the scene Lancashire Early Intervention Service EIS Shared Learning Conference

64 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 EIS Shared Learning Conference

65 A Matched-Care / Tiered Approach to Psychological Care Psycho-social interventions Tier 1 Specific PSI Training Supervision/ Consultation Case managers/ ST&R Formal CBT or FI, Discrete Problems Tier 2 Staff with: Formal CBT training or COPE Msc (under supervision) Complex / multiple problems longer term CBT or FI Tier 3 Cognitive Therapists Clinical Psychologists

66 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.

67 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

The new mental health access & waiting time standards Dr Frank Burbach Consultant Clinical Psychologist Somerset Partnership NHS Foundation Trust frank.burbach@sompar.nhs.uk 1 NHS Presentation to [XXXX