Colour Breathing Relaxation Technique (CBRT ) 1 Providing Patients with structured relaxation support sessions

Colour Breathing Relaxation Technique (CBRT ) 1 Providing Patients with structured relaxation support sessions CBRT NHS Training Initiative 2013 - Putting Patients First. An Invest to Save Programme assisting Compassion in Practice (6C s) and Innovationn Health &Wealth. This QIPP 2 focused programme is about CBRT Colour Breathing Relaxation n Technique - a British Innovation, 3 providing a practical, safe, simple and effective way to help patients relax naturally. The two day CBRT Training Programme provides your staff with all the necessary skills and tools to be able to provide patients with structured and guided CBRT Relaxation Support Sessions. CBRT is a natural partnership with research and innovation to improve healthh outcomes. (Liberating the NHS: Developing the Healthcare Workforce 4 ) 10.01.2010 Initiative Name: CBRT NHS Training Initiative 5 Cost per participating CCG / Trust: 43,761 + VAT payable in three stagess -see page 11 for payment schedule. Implementation: from 1 st April 2013 Initiative Director: Alison Bourne 6, Managing Director, CBRT International Ltd. To read example illustrations of potential projected savings see page 6, pages 13 17. KEY POINTS: An NHS IAPT Commissioner of Psychological Therapies has written the following about this Initiative: The principles of building confidence and socialisation are good, as commissioners we understand how important this is for a patient s recovery. The proposal is very good and well presented, with a good evidence base and clinical outcomes. On paper, the savings are good, a reduction in primary care presentations, and this is similar to IAPT where we also know theree are reductions in referrals to secondary care. CBRT train 25 staff members at your location in the CBRT Technique - CBRT Practitioner Training Programme* (2 days.) 7 Staff complete their Training Programme content with 40 question Assessment Paper and 10 Case Studies of provision of CBRT to individuals and groups.(4 6 weeks.) Above papers marked and certificates of training returned. (3 weeks/15 working days.) After this, 5 CBRT trained staff are selected by Trust / CCG to attend a further Train the Trainer Training Programme available from June 2013. Each Trust/CCG will becomee self sufficient in Phase 2, receiving 100 CBRT Training Kits for their Trainers own use. The CBRT Training Programme is in preparation for CPD Accreditation by The Royal College of Nursing 8 and The College of Occupational Therapists 9. Colour Breathing tool kit and system has a CE file in preparation for CE marking 10 and ISO: 13485 11 Class 1 medical device status. The NIHR NHS Research Design Team South West 12 (Bournemouth University) is involved the development of an NHS led clinical research programme into CBRT, Depression, Dementia and Delirium - to prepare the pathway for CBRT to become a NICE approved relaxation technique.

1. CBRT NHS Training Initiative Overview CBRT NHS CCGs & Trusts Training Initiative April 2013 CBRT (Colour Breathing Relaxation Technique) provides individuals from all backgrounds with a comprehensive, very effective and easy to learn Relaxation Support Technique (CBRT RSS) which can become part of an integrated care package. A patent holding, UK invention 13, CBRT has been in consistent and progressive development stages since 1997. What started out as a simple idea as a selfhelp relaxation book kit using Colour Breathing Disks as a focus tool, was soon discovered to aid individuals and peer groups experiencing low to moderate depression and anxiety disorders. A series of one day workshops in 2002 within two years became a Practitioner Training Programme recognised by the BCMA (British Complementary Medicine Association 14. Patients are provided with a Colour Breathing Disks Easel Chart 15 as a visual tool to focus on (also see image on top of front page) containing a set of seven coloured disks whilst a) becoming aware of their natural breathing pattern and b) relaxing their body in seven stages. The product is very safe to use, being of printed matter. The seven Colour Breathing Disks have been specially designed with subtle gradient effects for individuals to use with ease. They are a physical item to see and hold, yet visual point of focus, for individual and group led relaxation support sessions. Individuals enjoy using CBRT as a relaxation technique and using colour as a means of expressing how they feel. The Initial Colour Breathing Trials of 1999 2000 16 involved over 120 members of the public engaged in a controlled comparison trial in the use of the Colour Breathing Disks and visualisation. Research has since involved training a wide group of mental health, education and complementary professionals the majority from within the UK, who have provided valuable case studies and feedback. Their valuable data includes a wide range of presented conditions and social care case studies including insomnia, GAD, the full spectrum for depression including PTSD and suicide tendencies. CBRT is a practical, low cost, simple and versatile innovation. In March 2011, CBRT scored 92.53% with the NHS National Innovation Centre Technology Scorecard. 17 The CBRT NHS Training Initiative is Patientcentred, recovery focused and promotes self-care. NHS Staff will be trained to be able to deliver structured and effective CBRT Relaxation Support Sessions to either individuals - or groups of between 5-20 Patients at a time, within 30 45 minutes. This Training Initiative will provide training for 28 members of your staff, with 5 of these receiving an additional two day Train the Trainer programme to enable self training of all future CBRT Training Programmes. CBRT is a Mind-Body Relaxation Technique 18 which combines breathing techniques 19, Mindfulness approach 20, positive thinking 21,self-help and guided self-help 22, MBSR (Mindfulness based stress reduction) 23, Mind-body interventions 24, creative visualisation 25, meditation 26, group therapy 27, anxiety breathing techniques 28 (including controlled breathing) all supported by NHS Evidence 29 as being beneficial components to mental health, preventative health and wellbeing programmes. (The aim of controlled breathing is to slow down your breathing and heart rate, relax tension in the muscles, quieten the mind and empty it of worrying thoughts.) The many associated benefits to having structured CBRT Relaxation Support Sessions available to both Patients and NHS Staff are many. Feedback from existing CBRT Practitioners is very positive, with CBRT Page 2 of 21

being a popular and effective relaxation technique for men, women and children of all abilities who wish to lead healthier lives. CBRT is simple and safe to use (being non invasive or pharmacy lead) and encourages dialogue. Working with the Patients and getting them involved in the selection of their own affirmations for positive thinking is also both popular and beneficial. The proactive management of people with long-term conditions, including the promotion of self-care by patients, is a key priority for the NHS. CBRT provides active support for a positive approach to management of long term conditions 30 and primary prevention through focusing on a natural relaxation process for better self care. 2. Current mental health provision status within the NHS. Mental illness 'under-treated by NHS' 31 (18.06.12) is a report carried in the NHS Choices website 32. The report was written by the London School of Economics Centre for Economic Performance 33 Mental Health Policy Group Think Tank. The key report, How Mental Illness Loses Out in the NHS 34 was produced by a distinguished team of economists, psychologists, doctors and NHS managers convened by Professor Lord Layard 35 of the LSE Centre for Economic Performance. The report says that mental illness is widespread and is generally more debilitating than most chronic physical conditions. The researchers report that a third of all families in Britain have a family member with mental illness. Additionally, nearly half of all ill health in those younger than 65 years is due to mental illness and only a quarter of those needing treatment receive it. The report estimates that 6 million adults have depression or anxiety and 700,000 children have a mental health disorder. The report also found that mental health problems account for nearly half of absenteeism at work and a similar proportion of people on incapacity benefits. ii. Another report in Mental Health - Patchy Progress shown for Mental Health Treatment 36 states that according to the official IAPT statistics, of the six million people in England who have depression or anxiety problems, only 2% received talking therapies between April and June 2011. Of these: 210,540 were referred for psychological therapies 123,065 entered treatment 92,638 are waiting more than 28 days for treatment iii. The NICE Guideline on the Treatment and Management of Depression in Adults 37 (2010, page 293) states: Low-intensity interventions are clinically and cost effective for subthreshold depressive symptoms and mild depression, and therefore are to be preferred over individual and group CBT (and other high-intensity psychological interventions) as the initial treatment for subthreshold depressive symptoms and mild depression. Group CBT is an effective treatment for mild depression but, given the duration of the group and the staffing of such groups, it was viewed on cost-minimisation grounds as less cost effective than low-intensity interventions but more cost effective than individual CBT, and so was placed between them in the stepped-care model. With stress and anxiety affecting many millions of people in the current economic climate, mild to moderate mental health needs require support. The provision of CBRT Relaxation Support Sessions used as a health and social care interface is a practical and common sense approach to the above situation which can also support a diverse population, with individual and community support service needs. CBRT received an extremely positive and excellent response from NHS management attending the DH Healthcare Innovation Expo 2011 38 which has resulted in this CBRT NHS Initiative being written. Provider groups will benefit having an effective solution and providing an additional Patient Care based Page 3 of 21

service - to quickly increase capacity to care - for the growing numbers of individuals and groups requiring mental health and wellbeing support. Staff undertaking the Training Programme will benefit from feeling valued through having CPD training and enhanced skill sets. All NHS Staff will benefit from provision of CBRT RSS in their place of work, whether they work in the offices or A & E. 3. CBRT Brief History and Background - a culmination of 15+ years work 39 1997 1998 Colour Breathing Disks invented and prototypes created for UK Patent. 1999 2000 First Research Programme 2000 - UK Patent granted 2001 2004 Frankfurt, Australian, American, UK Book Publishing Fairs 2002 - First products production run and workshops including Denver, US. 2002 2004 Colour Breathing Practitioner Training Programme written 2003 2006 Colour Breathing part of EI Education Programme in Hampshire 2004 Colour Breathing first speech at ISMA (International Stress Management Association ) Annual Conference - London 2004 - Colour Breathing CBRT Training Programme was first acknowledged as a relaxation technique by the BCMA British Complementary Medicine Association 2004 First Colour Breathing Practitioner Training Programme 2005 2011 Over 250 individuals trained in Colour Breathing technique in UK and Australia. 2005 2008 Action Mental Health - Northern Ireland 40 2009 2012 SHSCT - Northern Ireland 41 2010 Colour Breathing becomes acronym CBRT in preparation for NHS entry. 2011 CBRT showcases at DH Healthcare Innovation Expo during which the CBRT products and evidence based case studies attracted great interest from the hundreds of healthcare professionals attending. 2011 Present. CBRT has completed the NHS NIC Technology Scorecard in March 2012 (92.53% score) and is preparing for NHS entry with support from the DH Innovation Procurement & Commercial Division with this Initiative. 2012 2013 CBRT work with the NHS South of England Innovations Promotion Manager to fine tune the new PowerPoint and Initiative content in preparation for the major NHS changes of 1 st April 2013. Improving outcomes CBRT provides a practical means of improving outcomes, including excluded groups in society, in contact with secondary mental health services. CBRT intends to work with the NHS NIHR Research Team to enable CBRT to become a NICE approved relaxation technique. This would enable CBRT in the future to be considered for future mental health funding for psychological services such as No health without mental health: A cross-government mental health outcomes strategy for people of all ages 42 ; and Talking therapies: A four-year plan of action 43. CBRT intends to support provider groups with an agenda for Positive Outcomes and is a QIPP focused 2 initiative providing Patients with better services, new self-care initiatives, innovation, and cost savings. Recent changes brought to the NHS procurement landscape as of January 2011 are provided in the websites www.innovateuk.org/health 44 and www.healthktn.org.uk 45 which states Each SHA holds a legal duty to promote innovation, raising the profile of innovation and encouraging a more rapid adoption of innovation throughout the health service. Innovation leads are employed in each Authority to deliver Page 4 of 21

this requirement. The focus on encouraging the entry of innovation into the NHS is also underpinned in Innovation Health & Wealth* 3 (June 2012 version) Accelerating Adoption & diffusion in the NHS - mentioned at the beginning of this Initiative. 4. CBRT Research CBRT is working with the NHIR NHS Research Design Service Team South West 12 on research grant programmes and applications with Dr. Sarah Thomas, Dr. Zoe Shephard with additional support from Dr. Paul Ewings. One proposed area for research is Depression, Dementia and Delirium. CBRT have also met Professor Anthea Innes Head of BUDI Bournemouth University Institute of Dementia. 46 The CBRT Research Team 47 comprises Professor Stephen Westland, Dr. Vien Cheung, (Leeds University) Dr.Ute Leonards (Bristol University), Dr. Sophie Weurger (Liverpool University.) Since 1997, Alison Bourne has been supported by many leading medical, academic, healthcare, mental health and education specialists from across the UK and USA. During the R & D stages, over 250 professionals from the UK, Germany, Australia, Canada and Brazil have undertaken the CBRT Training Programme, using CBRT in their work, providing feedback and case studies. Since 2001 support has been received from leading academics from: Universities of Leeds, Bristol, Essex, Southampton, Oxford University, Faculty of the Mind, Royal Holloway, University of London. The CBRT Apparatus is a UK invention and healthcare technology with a current UK Patent, International Trademarks and Copyright. The international interest in CBRT underlines the importance of this CBRT NHS Training Initiative; CBRT International Ltd has taken advice and worked closely with many government bodies including SEHTA (South East Health Technologies Alliance) 48 South East Business Innovation Growth Team 49 UKTI (UK Trade & Investment) 50 over 20 meetings with Healthcare Sector Specialists from Europe and major countries e.g. USA, India, China, The Middle East. Examples of 100 individuals and groups CBRT Case Studies 51 can be viewed on dedicated webpagee. The CBRT Practitioners Code of Conduct 52 is based on the Midwifery Code. You can read the Colour Breathing Book Foreword 53 online by Consultant Gynaecologist Mr. M. Dooley MMs FFSRH FRCOG. 54 5. CBRT NHS Training Initiative - Goals and Benefits To provide additional benefits to Patients and a toolkit and system for self-care. 55,,56 A simple and effective relaxation technique which anyone can learn. CBRT provides a caring interface for Staff and Patients. 57 CBRT Initial Response Sheets used by professional are said to provide Patients with a form of talking therapy provision -Talking therapies: A four-year plan of action. 58,59 Reducing referrals for medically unexplained symptoms 60 Patient Choice. Satisfaction from knowing that they have played a part in helping themselves relax - Personal Health Budgets Report 60 Reducing referrals for medically unexplained symptoms 61 Staff trained in CBRT will learn a new skill to help their colleagues and Patients relax. Health and Social Care Provider Units in Healthcare 62 Help children and young people - read The Discovery Initiative (CBRT in Education and Preschool sectors) 63 Relaxation Support Sessions could provide a visible and tangible positive wellbeing effect for Page 5 of 21

Patients (including those with Personal Health Budgets.) A service to help Patients with measurable improvement towards individual recovery goals. Support for those with Dementia and their carers Living well with dementia: A national Dementia Strategy 66 Less chance of Patient relapses through having additional support. Patient Choice for those who do not wish (nor require) to start medication. 67 More appropriate use of healthcare resources and time. Potential savings for fewer GP appointments could lead to shorter waiting times. An all-inclusive and anti-discriminatory new service provision. The Initiative estimates that each Trust with 125 staff trained, it is possible to provide additional support to c.12, 000 Patients per annum. 5b. Potential cost savings - are anticipated through reducing GP appointments, a reduction in the requirement for medication, self care support and health prevention support. The following document NICE Quality Standards Programme Cost impact and commissioning assessment 67 : quality standard for depression in adults (March 2011) has recently been provided to CBRT by NHS Innovation SoE: http://www.nice.org.uk/media/01d/c3/depressionqscostassessment.pdf states on pages 8 and 9 that the total expected saving per IAPT patient rounded as being 340.00 in a two year period. 125 staff trained in CBRT would therefore only need to support a minimum of 264 Patients in Year One (less than one per day) to recoup the initial investment in the whole CBRT Training Initiative. (2.11 Patients per trained staff member.) Supporting more patients would, the NICE paper suggests, result in a saving to the organisation as well as enhanced quality of care and experience for the patient. 64, 65, 6. Target datelines for the initial CBRT NHS Training Initiative: 1. The CBRT National Training Team will train 28 of your staff members during late spring/ early summer of 2013. Please advise us of your preferred dates as soon as possible. 2. It is the responsibility of the provider group to ensure that all assessment papers and case studies by staff members are completed by the agreed date. 3. The CBRT National Training Team will train 5 members per group provider to become CBRT Trainers starting in the early summer of 2013. These will be permitted to train further CBRT Practitioners in their own group provider region/boundaries only. 4. We suggest each CBRT Trainer aim to train an additional 20 people each in 2013. The CBRT National Training Team may monitor and observe these initial training programmes. In the future, each NHS CBRT Trainer may train as many individuals as they wish, from within the boundaries of their group provider region, with supplies and stock available for purchase with NHS discount through CBRT International Ltd. It is hoped that future CBRT Training Programmes will be offered to individuals from within 3 rd sector support groups who could benefit from being able to provide the CBRT service e.g.: public health, local government, voluntary and community organisations, Social Services, Education sector, Prisons/Institutions. The Training provider is permitted to charge appropriate fees for this service. CBRT Relaxation Support Sessions can provide support for wider social care in the community; Job Centres, Prisons, Youth Offenders Units, etc 5. If a CCG or Trust wishes, all CBRT products may be customised to contain local logos, NHS addresses, local message to Patients, contact details and images, in full colour. CBRT products may be produced in different languages, font sizes, Braille, at additional cost. 7. Initiative Interdependencies and Inputs Having your staff trained in CBRT will provide a Primary care intervention to help people with mental health problems, through structured relaxation support sessions (care) which optimises engagement, Page 6 of 21

prevents or anticipates crisis, and reduces risk. The Coalition Our Programme for Government (May 2010) 68 included the government s commitment to talking therapies to reduce long-term NHS costs. The White Paper Equity and Excellence: Liberating the NHS (July 2010) 69 aims to: Enable long term savings to the NHS Meet local and individual needs while enabling equitable access for all Collect good quality data to inform future service delivery 1. The Spending Review (October 2010) 70 specifically stated that the health settlement will enable Department of Health to 'expand access to psychological therapies. 2. Equality Act 2010 71 requires all services to promote equality across their communities and to publish information in a way that the public can judge how it has been used to eliminate discrimination, advance equality of opportunity and foster good relations between different groups. (A socio-economic duty for public bodies and a public sector equality duty determined over the winter of 2010, which came into force in April 2011.) 3. Equality Focused Services: CBRT is a non denominational, non tactile and all inclusive relaxation technique. Demand for evidence-based psychological therapies services remains high across all communities. Some groups may have higher prevalence of anxiety disorders and depression than others (e.g. the homeless, military veterans). Other groups may have proportionately lower levels of identification despite high levels of need (e.g. people who are gay, lesbian or bisexual). The needs of all these groups should be taken into account alongside those with the legally protected characteristics of age, disability, ethnicity, faith, gender, sexual orientation, pregnancy and maternity. 8. As well as Compassion in Practice, Putting Patients first, QiPP and Innovation Health and Wealth, the CBRT NHS Training Initiative also supports these policies: 1. QIPP : Liberating the NHS, 2. Self Care: An Ethical Imperative 72, 3. Health and Social Care Provider Units in Healthcare 73, 4. Living well with dementia: A national Dementia Strategy 74, 5. National Mental Health Workforce Strategy (sections 1 6) 75, 6. Commissioning Talking Therapies for 2011/12 76 from which, 1.3; There is strong evidence that appropriate and inclusive services and care pathways for people with common mental health conditions reduce an individual s usage of NHS services leading to efficiencies and cost savings, as well as contributing to overall mental wellbeing. This approach promotes inclusive, equitable services that meet the needs of the whole community. Quote 1.4 Increasingly; there will be room for innovative approaches in the services commissioned, along with flexibility tailored to local need and to the personal needs of individuals seeking treatment. 7. The Kings Fund > Transforming our health care system Ten priorities for commissioners 77 of which relevant references include: a) Primary Prevention: Taking action to reduce the incidence of disease and health problems within the population, either through universal measures that reduce lifestyle risks or by targeting high-risk groups: The financial sustainability of the NHS in the future will depend on more systematic primary prevention in order to reduce the overall burden of disease in the population. Page 7 of 21

b) Secondary Prevention: Systematically detecting the early stages of disease and intervening before full symptoms develop for example... taking measures to reduce high blood pressure. The How to do it section here includes: Working systematically with local authorities and other partners to ensure primary care prevention forms part of a broader strategy on public health Working with community and voluntary sector groups to offer interventions to patients who do not engage well with mainstream health services. 8. Also relevant is The Royal College of Nursing (Q.30) response to the White Paper 78 - How can we ensure funding streams do not act as a discentive to innovation and are able to support changes in skill mix? with their answer being:- Funding streams for education and training need to be linked to service commissioning strategies and QIPP initiatives. The RCN believes that openness, fairness, equity and publishing regular audit updates is the absolute minimum. 10. CBRT NHS Training Initiative - Overview 1. The CBRT Training Programme is deemed suitable for NHS Staff of all levels. (Staff will need basic skills in computer competency to be able to complete their assessment paper and case studies online.) 2. CBRT is preparing for IS0: 13485 and CPD accreditation with The Royal College of Nursing and College of Occupational Therapists and will adhere to strict standards and guidelines. 3. The CBRT Training Programme and Handbook has been carefully developed through listening to learners feedback following every training programme. This will continue as CBRT will continue to ask Learners for this information; both Trainers and Materials will receive regular updates / be under constant review for ongoing quality assurance and improvements. 4. The Training facilities provision for up to 28 staff and the CBRT Trainer requires a lecture area with enough space to enable individuals to work in pairs (with table and 2 chairs each for individual work) and group work. 5. To keep the Training Programme at a low cost, CBRT do not include the provision of light refreshments or food for participants in their costings. Therefore a packed lunch or use of a staff canteen facility close to the training rooms, is the usual practice. 11. CBRT NHS Training Initiative 25 places + 3 free CBRT International Ltd are providing 3 free Training places (25 training places are costed) to ensure all places are filled to allow for sickness or non-attendance of your staff for whatever reason. Selection of the 25 + 3 NHS Staff to attend the Training Programme and 5 NHS CBRT Trainers is the responsibility of each group provider. 12. Initiative 12a. Resources, Training Facilities, Timing 1. CBRT stock will be available from completion of Phase 2; product allocations will be delivered directly to each provider group for internal distribution to trained staff. 2. The CBRT NHS Training Initiative will use some current product range as exhibited at the DH Healthcare Innovation Expo March 2011 with new 2013. Page 8 of 21

3. NHS staff will initially be able to deliver CBRT Relaxation Support sessions to groups of 6 patients using products provided at the Training Programme. The Case Study examples reflect this. Trained NHS staff will be able to deliver CBRT Relaxation Support Sessions for groups of up to 20 Patients if they wish. 4. The Training Programme will be delivered in Training Room facilities provided by each Trust / participating provider group at no additional cost to CBRT. 5. Timing once a Two Day Training Programme date has been agreed, dates are fixed to the agreed schedule. 6. CBRT believe the CBRT Training Programme to be deemed suitable for NHS Staff of all levels. 12b. Initiative Critical Success Factors (Key Performance Indicators) 1. All NHS staff to complete the Training Programme, 10 Case Studies and 40 question CBRT Assessment paper. 2. Certificates of Training will be sent to the Trust upon completion of all case studies and assessment papers. 2. The first 500 CBRT NHS staff to be trained will create the initial 5,000 Case Studies for NHS Evidence. 3. Trained CBRT Staff are required to provide an agreed number of 30-45 minutes CBRT Relaxation Support Sessions - for a target number of 5 Patients - into their schedule as soon as possible. 4. Encourage feedback from Patient groups and online. CBRT will work with the NHS to create a new database for Patients feedback. 5. Encourage Patients to use CBRT at home and keep a CBRT Observations Diary. 6. NHS staff to provide regular feedback of patient s response. Data collection rates will be monitored on a regular basis to help ensure that Staff is achieving at least 90% complete outcomes for the number of people who have had two or more therapeutic sessions, to include a Patient Health Questionnaire such as PHQ-9 79 and Generalised Anxiety Disorder GAD7 scale 80. 7. To keep the Training Programme at a low cost, CBRT do not include provision of light refreshments or food for participants. The group provider is required to provide light refreshments for all staff attending on both days of the Training Programme and/or provide use of a staff canteen facility close to the training rooms, as is the usual practice. Page 9 of 21

12c. CBRT NHS Training Initiative Terms 1 2 3 4 5 As stated at the Healthcare Innovation Expo 2011 the cost of provision of this CBRT initiative is based on the provision of your training facilities. We train on your home site, saving you staff costs for travel and accommodation. The CBRT Training Programmes will commence from SPRING 2013. All participating staff are required to have completed an online applicant information form.(details will be provided.) NHS Staff attending the CBRT Training Programme will each receive the CBRT Practitioner Kit (see Page 12 for details) and members use of the www.colourbreathing.com website for members post training paperwork including assessment paper and case studies. CBRT Practitioners agree to abide by the CBRT Practitioners "Code of Conduct" which is based on the Midwifery Code of Conduct. Individual NHS CBRT Practitioners using CBRT in their place of work will not be required to pay the CBRT Practitioner Annual Licence fee - as they will not be earning private income from the use of CBRT products. All CBRT trained staff will be required to provide feedback and comments online to maintain quality assurance and improve ongoing Patient Care. 6 All NHS Staff becoming CBRT Trainers will be trained by a CBRT National Trainer. 7 8 9 10 11 12 *CBRT Train the Trainer Training for 5 members of staff per provider group will take place over 2 days available from April 2013 onwards following completion of their CBRT Practitioner Training Programme. All NHS staff are required to provide 10 Case Studies each. Each provider group is responsible for the return of all post training paperwork. Payment for the CBRT Training Programmes is payable in three stages by BACs (see schedule on page 21. ) The CBRT National Training Team is to have completed the training of 25-28 NHS Staff and 5 NHS Trainers as per an agreed schedule. The allocation of additional CBRT Easel Cards and products included in the contract price will be delivered to each group provider in Phase 2. Costs shown are correct at time of printing, but may change due to unforeseen transport, production and/or materials price increases. Page 10 of 21

12d. CBRT NHS Initiative Cost detail (at 08.04.2013) Phase 1 CBRT NHS Training Initiative Phase 1 CBRT provided Training Programmes: 10,033.50 Price includes : 25 CBRT Practitioner Training Kits CBRT Practitioner Training Kits Bonus places provided free of charge by CBRT International Ltd 3 2 One NHS National Trainers per training day 2 One NHS National Trainer Assistant Trainer per training day 5 CBRT NHS "Train the Trainer" programme kit. 2 One CBRT National Trainer -"Train the Trainer" 28 Marking of Assessment Papers National Trainers and Assistant Trainer - Travel allowance and overnight accommodation. *flights (only if necessary) will be invoiced in addition, at cost 4 To support NHS cost savings, the NHS client is responsible for the provision of training room facilities. Phase 2 CBRT Stock Phase 2 for NHS Trainers to provide CBRT Training Programmes 33,727.50 Price includes : 100 CBRT equipment* - 100 NHS Staff for breakdown see 12e. 25 New design CBRT Affirmation cards Sets - for staff trained in Phase 1 NHS CBRT additional stock for trained staff 375 CBRT Easel Charts Sets ( 14 x 5 sets per box.) Each member of staff trained in CBRT to receive 3 x CBRT Easel Charts Sets for group sessions. 500 500 Allocation of 4 x CBRT Book Kits per member of staff trained in CBRT for Patients Use. Allocation of 4 x CBRT Observation Diaries per member of staff trained in CBRT for Patients Use. TOTAL 43,761.00 Payment for the CBRT NHS Training Initiative is in three stages: Deposit Upon booking Initiative 5,000.00 Week 1 +VAT Upon booking Initiative Stage 1 Weeks 4-6 Prior to Training. Payment of 50% invoice 19,380.50 + VAT Upon contract signature Stage 2 Week 12 Upon receipt of CBRT NHS products the final 50% invoice is payable within 10 working days of good received. 19, 380.50 43,761.00 +VAT Upon receipt of products Page 11 of 21

12e - CBRT Training Resource Kit Cost detail (prices include NHS discount) CBRT NHS Training Resource Kit cost* ( at 08.04.2013) Basic CBRT NHS Training Kit comprises: 1 x CBRT Book, Easel Card and Audio CD Kit* 18.75 1 x CBRT Practitioner Training Handbook 45.00 1 x CBRT Affirmation Cards Set 8.96 1 x Set of five CBRT Easel Cards 23.96 1 x CBRT Observations Diary* 7.46 1 x Assessment paper - 1 x 10 Case Studies - 1 x Certificate (upon completion) 10.00 Total 114.14 12 f - Future product launches In 2013/4 CBRT intend to launch CBRT Affirmation Cards for use in clinics for specific conditions, such as PTSD, GAD, COPD, weight issues, smoking cessation, and bereavement. Other subjects such as bullying and self esteem are also planned. 12g - IPR and other information: Registered Office: CBRT International Ltd, Transport House, Uxbridge Road, Hillingdon Heath, Middlesex, UB10 0LY. Registered in England and Wales No 7393535. Vat Registration No GB 119 9391 81 Colour Breathing, The Colour Breathing Disks, products and CBRT Practitioner Training Programmes are subject to International IP, Patent, Copyright, Design and Trademark Laws. Colour Breathing Relaxation Technique, CBRT Relaxation Support Sessions, CBRT, CBRT, CBRT Practitioner Training Handbook, Colour Breathing at Home, Colour Breathing Foundation Fund and all future Color Breathing US and international generics all Alison m Bourne and CBRT International Limited 1997-2012. Costs* correct at time of printing, but may change due to unforeseen transport, production and/or materials price increases. For any further information, please contact Director Alison Bourne on: 01425 629602 or 07977 900716 Email: nationalhealth@colourbreathing.com Page 12 of 21

ILLUSTRATIONS FOR NHS Initiative Projected QIPP Cost Savings An NHS IAPT Commissioner of Psychological Therapies has written the following about this Initiative: The principles of building confidence and socialisation are good, as commissioners we understand how important this is for a patient s recovery. The proposal is very good and well presented, with a good evidence base and clinical outcomes. On paper, the savings are good, a reduction in primary care presentations, and this is similar to IAPT where we also know there are reductions in referrals to secondary care. NICE QUALITY STANDARDS PROGRAMME The following document NICE Quality Standards Programme Cost impact and commissioning assessment: quality standard for depression in adults (March 2011): http://www.nice.org.uk/media/01d/c3/depressionqscostassessment.pdf states on pages 8 and 9 that the total expected saving per IAPT patient rounded as being 340.00 in a two year period. 125 staff trained in CBRT would therefore only need to support a minimum of 264 Patients in Year One (less than one per day) to recoup the initial investment in the whole CBRT Training Initiative. (2.11 Patients per trained staff member.) Supporting more patients would, the NICE paper suggests, result in a saving to the organisation as well as enhanced quality of care and experience for the patient. Also, in this document, In Table 7, it indicates example training costs for low-intensity psychosocial intervention therapies is 4000 4300 per staff member trained. The CBRT two day Training Programme Initiative includes 28 staff trained initially, 5 are trained as Trainers and 100 additional CBRT Training Kits are provided. A significant cost saving. 1. Phase 1 provides the necessary training and preparation of 25 NHS Staff to launch CBRT to Patients in 2013. 2. Phase 2 includes training of 5 staff as Trainers and additional 100 staff training kits. The Staff costs in the following illustrations are based on the NHS Agenda for Change 81 pay scales and Primary Care Costing Template which include 70% overheads for room provision and costs associated with GP practice rates. NOTE: The next four pages are for Illustration purposes only as examples of potential QIPP savings. Page 13 of 21

Example illustration only of Potential QiPP Savings - Phase 1 = 129,600 per annum Illustration is of potential cost saving of having 25 Staff completing CBRT Training in Spring 2013. Example with 25 Staff trained 25 Staff e.g. Practice Nurses or Band 5 equivalent Staff, complete two day CBRT Training Programme and case studies within 4-6 weeks of Training Programme. Upon successful completion and marking of all case studies and assessment paper, Stafff may provide CBRT Relaxation Support Sessions to Patients as individuals or in groups of up to 20 Patients in their clinics and surgeries. CBRT is a suitable intervention suitable to help integration between primary care and Wellbeing, Social Care and Community services e.g. Healthcare Assistants, Children s support services, Teachers, Learning Mentors. Five of the above Staff to be selected by the Trust to attend a further two day Train the Trainer CBRT Training Programme in early spring 2013. 100 additional CBRT Training Kits are included in the Initiative cost (e.g. each provider group will have the potential to have 125 staff trained in CBRT by the end of 2013.) *In this example, Patients use the CBRT Staff working kit and are not provided with their own kit "to keep." Example 1 - Grade 5 Practice Nurse, Occupational Therapist, or equivalent 1 25 GP Band 5 Patients Sessions Months Appointments 36 18 1 5 8 8 4 4 1,000 4,000 45 11 10 8 11 11,000 Cost of Grade 5 Practice Nurse or equivalent 25 x Nurses provide 8 x 45 mins CBRT sessions (@ 18 cost) each pcm = 25 x Nurses provide 8 x 45 mins CBRT sessions each month x 4 months = 25 x Nurses provide 8 x 45 mins CBRT sessions each month x 11 months = Number of Patients seen, based on 5 patients per session 25 x Nurses provide 8 x CBRT sessions for 5 Patients each pcm = 25 x Nurses provide 8 x CBRT sessions for 5 Patients each month x 4 months 25 x Nurses provide 8 x CBRT sessions for 5 Patients each month x 11 months 3,600 pcm 14,400 4 months 39,600 per annum 1,000 pcm 4,000 4 months 11,000 per annum Equivalent GP Appointment Costs 1000 x GP Appointments@ 36.00 each 4000 x GP Appointments @ 36.00 each 11000 x GP Appointments @ 36.00 each Total Potential Cost Savings 1000 x GP Appointments @ 36.00 each 4000 x GP Appointments @ 36.00 each 11000 x GP Appointments @ 36.00 each 36,000 pcm 144,000 4 months 396,000 per annum 32,400 pcm 129,600 4 months 356,400 per annum Summary: 25 x Band 5 Nurses, or equivalent (@ 24 per hour 82 ) provide 8 x 45 mins* (* 18) CBRT sessions each,*pcm (5 Patients* each session) x 4 months to end of early spring = 1,000 Patients pcm = 11,000 GP Patients appointments per annum total. 11 months per annum allows for Stafff holidays and/or sickness allowance. Patients benefit through having a full 45 minutes session with their Practice Nurse ratherr than a 12 minute appointment with their GP 83. E.g. each CBRT Nurse sees 240 Patients each in a 4 months period. 25 Nurses provide 48 CBRT sessions each = 1200 sessions for 6000 Patients. Phase 1 Illustration of Potential Savings of 129,600 within a 4 months period. Page 14 of 21

Example illustration only - Potential QiPP Savings Phase 2 = 601,800 per annum. This illustration of potential cost savings is based on having 25 Staff (Band 7) using CBRT for one year Example here is based on Band 7 Psychiatric Nurses caring for mild to moderate mental health issues. 1. Phase 2 is for the period of one year. 2. Example is 25 x Psychiatric Community Nurses CBRT to small groups of 5 Patients. GP estimated cost at 36 19 per 12 minute consultation taken from Quality and Outcomes Framework Programme NICE cost impact statement July 2011. 28 Phase 2, Example 1 - Grade 7 Psychiatric Nurse * 45 mins 25 PN Patients Sessions Months Weeks 59 1 2 4 1 44.25 5 8 16 10 48 250 4000 11 Cost of Psychiatric Nurse for 45 minutes session 1 x P Nurse provides 2 x 45 mins CBRT sessions (@ 44.25* cost) each week = 89 per week 25 x P Nurse provides 2 x 45 mins CBRT sessions (@ 44.25* cost) each week = 2,213 per week 25 x P Nurses provide 8 x 45 mins CBRT sessions each month x 4 months = 35,400 4 months 25 x P Nurses provide 8 x 45 mins CBRT sessions each month x 11 months = 97,350 per annum Number of Patients seen, based on 5 patients per session 1 x P Nurse provides 2 x CBRT sessions for 5 Patients each week = 10 per week 25 x P Nurses provide 2 x CBRT sessions for 5 Patients each week = 250 per week 25 x P Nurses provide 2 x CBRT sessions for 5 Patients each month x 4 months = 4,000 4 months 25 x P Nurses provide 2 x CBRT sessions for 5 Patients each month x 11 months = 11,000 per annum Cost of normal Psychiatric Nurse Service (for Individual) per hour 1 x Individual P Nurse x 10 Appointments@ 59.00 each = 590 per week 25 x P Nurses x 10 Individual Nurse Appointments @ 59.00 each = 14,750 per week 25 x P Nurses x 2 Individual Nurse Appointments @ 59.00 each = 47,200 4 months 25 x P Nurses x 25 Individual Nurse Appointments per month @ 59.00 each = 36,875 per month 25 x P Nurses x 25 Individual Nurse Appointments per month @ 59.00 each = 405,625 per annum Cost per Patient for 1 x CBRT sessions per week 5 patients provided with 2 x CBRT Relaxation Support Sessions per week 9 per week COST SAVING Direct comparison 1 25 x P Nurses provide 2 x CBRT sessions for 5 Patients each week = 2,213 per week 25 x P Nurses x 10 Individual Nurse Appointments @ 59.00 each 14,750 per week Total weekly Potential Saving based on 10 Patients each Nurse 12,538 per week Total annual Potential Saving based on 10 Patients each Nurse 601,800 per annum COST SAVING Direct comparison 2 25 x P Nurses x 10 Individual Nurse Appointments per month @ 59.00 each x 11 months = 162,250 per annum 25 x P Nurses provide 2 x CBRT sessions for 5 Patients each month x 11 months = 24,338 per annum Total Annual Potential Saving based on 10 Patients each per month 137,913 per annum Summary: 25 x Psychiatric Nurses 84 provide 2 x 45 mins CBRT sessions each per week, for groups of 5 Patients each session, (10 Patients in total) as an alternative to seeing the patients individually. These sessions are also beneficial to larger peer groups. Each CBRT Nurse is able to support 40 Patients per month. Phase 2, Example 1 - Annual Potential Saving 601,800 per group provider, per annum. Illustration of Potential Savings in Phase 2 = 601,800 per annum, per Trust. Page 15 of 21

Example illustration only - Potential QiPP Savings - Phase 2 = 641,520 per annum. Example here is based on Band 5 Practice Nurses caring for mild to moderate mental health conditions 1. 45 x Band 5 Practice Nurses or equivalent provide 2 x 30-45 minutes walk in CBRT Relaxation Support Sessions in GP surgeries and Clinics each week. 2. Any Patients may attend, especially those who being able to relax will help their condition e.g. hypertension, COPD, smoking cessation, obesity, bereavement, unemployment, insomnia, and stress related conditions. The intention here is to provide a care service to reduce the number of Patients feeling the need to visit their GP. Example 2 - Grade 5 Practice Nurse, Occupational Therapist, or equivalent 1 45 GP Band 5 Patients Sessions Months Appointments 36 18 1 8 1 1,800 5 8 11 3,600 10 8 19,8000 Cost of Grade 5 Practice Nurse or equivalent 45 Nurses provide 8 x 45 mins CBRT sessions (@ 18 cost) each pcm = 45 Nurses provide 8 x 45 mins CBRT sessions each month x 11 months = Number of Patients seen, based on 5 patients per session 45 Nurses provide 8 x CBRT sessions for 5 Patients each pcm = 45 Nurses provide 8 x CBRT sessions for 5 Patients each month x 11 months = Number of Patients seen, based on 10 patients per session 45 Nurses provide 8 x CBRT sessions for 10 Patients each pcm = 45 Nurses provide 8 x CBRT sessions for 10 Patients each month x 11 months Equivalent GP Appointment Costs 1,800 x GP Appointments @ 36.00 each 3,600 x GP Appointments @ 36.00 each 19,800 x GP Appointments @ 36.00 each Total Potential cost savings 19,800 x GP Appointments @ 36.00 each 45 Nurses provide 8 x 45 mins CBRT sessions each month x 11 months = 6,480 pcm 71,280 per annum 1,800 pcm 19,800 per annum 3,600 pcm 39,600 per annum 64,800 pcm 129,600 pcm 712,800 per annum 712,800 per annum 71,280 per annum 641,520 per annum Summary 45 x Nurses provide 2 x 30-45 minutes CBRT RSS sessions each per week. The examplee here is for 5 Patients the CBRT Nurse has enough equipment to be able to relax up to 20 Patients per session - if required. Patients use the CBRT kit which belongs to the CBRT staff; so there is therefore no additional cost. GP cost at 36 per 12 minute consultation 83 taken from Quality and Outcomes Framework Programme NICE cost impact statement July 2011. Illustration of Potential Savings in Phase 2, = 641,520 per annum, per group provider Page 16 of 21

Example illustration only - Potential QiPP Savings - Phase 2 = 957,528 per annum. Example here is based on Band 5 Nurses using CBRT to help Patients wishing to lower their medication requirements. 1) Patients agree to attend a series of 6 x 30-45 min CBRT Sessions (over 3 weeks) and receive their own CBRT kit to a) help their condition e.g. they are borderline whether they need or wish to take prescribed medication or b) they wish to gradually stop taking medication. Example 3 - Band 5 Practice Nurse, Occupational Therapist, or equivalent 1 45 No of No of No of 3 week Total Medication Band 5 Patients Sessions Weeks Cycles Patients 170 18 5 10 6 3 16 450 7,200 CBRT Kit 26.21 Medication for depression @ 170 15 per annum Cost of Grade 5 Practice Nurse or equivalent for 45 minute session 18 each 45 Nurses provide 6 x 45 mins (1 cycle) of CBRT sessions (6 x 18) for 10 Patients, every 3 weeks 45 Nurses provide 16 cycles of 6 x CBRT sessions for 10 Patients per annum Cost of CBRT NHS Patient kits required, based on 10 patients per 3 week cycle 45 Nurses provide 1 x CBRT NHS Kit for 10 Patients per cycle = 45 Nurses provide 1 x CBRT Kit for 10 Patients for 16 cycles = Cost for CBRT service 45 Nurses and 450 kits 45 Nurses and 7,200 kits Number of Patients seen, based on 10 patients per 3 week cycle 45 Nurses provide 1 cycle (6 x CBRT sessions) for 10 Patients every 3 weeks = 45 Nurses provide 16 cycles of (6 x CBRT sessions) for 10 Patients every year = Equivalent Medication Costs 450 x Annual Medication @ 170.00 each 7,200 x Annual Medication @ 170.00 each Total Equivalent Medication Cost Savings using CBRT NHS Relaxation Support Sessions 4,860 3 weeks 77,760 per annum 11,795 3 weeks 188,712 per annum 16,655 3 weeks 266,472 per annum 450 3 weeks 7,200 per annum 76,500 3 weeks 1,224,000 per annum 59,846 3 weeks 957,528 per annum Summary Medication for depression @ 170 per patient, per annum taken from The Social Exclusion Unit s (SEU) report - Mental Health and Social Exclusion 85, published in June 2004 includes a useful summary of the costs of various forms of mental health services: www.socialexclusion.gov.uk/downloaddoc.asp?id=134 For this initiative example, each Patient receives their own CBRT Training Resource Kit & CBRT Observations Diary (total cost 26.21 + VAT) to use at home as part of their healthcare programme. This additional cost has been factored into this example. The CBRT Observations Diary allows the Patient and Nurse to monitor progress for a 3 month period. Many people find it helpful to keep a diary during therapeutic intervention. Illustration of Potential Savings Phase 2 = 957,528 per annum, per group provider Page 17 of 21

References CBRT NHS CCGs & Trusts Training Initiative April 2013 1. CBRT (Colour Breathing Relaxation Technique - CBRT RSS) www.colourbreathing.com 2. QIPP : Liberating the NHS http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf 3. Innovation Health & Wealth (June 2012 version) Accelerating Adoption & diffusion in the NHS http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_134597.pdf 4. (Liberating the NHS: Developing the Healthcare Workforce 3 ) 10.01.2010 http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_132076 5. CBRT Training Initiative http://www.colourbreathing.com/cbrt-training-2/cbrt-national-health-training-programme/ 6. Alison Bourne http://www.colourbreathing.com/about-cbrt/the-innovation-of-colourbreathing-and-cbrt/ 7. CBRT Technique - CBRT Practitioner Training Programme* (2 days.) 7 http://www.colourbreathing.com/cbrt-training- 2/become-a-cbrt-practitioner/ 8. CPD Accreditation The Royal College of Nursing http://www.rcn.org.uk/development/learning/accreditation 9. The College of Occupational Therapists http://www.cot.co.uk/accreditation-endorsement/accreditation-endorsement 10. CE Marking NHS National Innovation Centre http://navigator.nic.nhs.uk/documentdetails.aspx?backtext=az%20directory&docid=31 11. ISO : 13485 http://www.iso.org/iso/catalogue_detail?csnumber=36786 12. NIHR NHS Research Design Team South West (Bournemouth University) http://www.rds-sw.nihr.ac.uk/ 13. A patent holding UK invention http://www.colourbreathing.com/home-2/patents-copyright-ipr/ 14. BCMA (British Complementary Medicine Association. http://www.bcma.co.uk/ 15. Colour Breathing Disks Easel Chart http://www.colourbreathing.com/about-cbrt/how-cbrt-works/ 16. Initial research and development started in 1999/2000 http://www.colourbreathing.com/research/the-initial-colour-breathing-trials-of-1999-2000/ 17. CBRT scored 92.53% with the NHS National Innovation Centre Technology Scorecard http://www.colourbreathing.com/cbrt-nhs-national-innovation-centre-technology-scorecard/ 18. Mind-Body Relaxation technique NHS Evidence http://www.evidence.nhs.uk/search?q=mind- Body+and+Relaxation+Techniques 19. Breathing Techniques NHS Evidence http://www.evidence.nhs.uk/search?q=breathing++techniques 20. Mindfulness approach NHS Evidence http://www.evidence.nhs.uk/search?q=mindfulness 21. positive thinking NHS Evidence http://www.evidence.nhs.uk/search?q=positive%20thinking&ps=30 22. self-help and guided self-help http://www.evidence.nhs.uk/search?q=guided+self+help 23. MBSR (Mindfulness based stress reduction) http://www.evidence.nhs.uk/search?q=mindfulness+relaxation+ 24. Mind-body interventions http://www.evidence.nhs.uk/search?q=mind+body+interventions 25. creative visualisation http://www.evidence.nhs.uk/search?q=creative+visualisation 26. meditation 26 http://www.evidence.nhs.uk/search?q=meditation+ 27. group therapy 27 http://www.evidence.nhs.uk/search?q=group+therapy 28. anxiety breathing techniques http://www.evidence.nhs.uk/search?q=anxiety%20breathing%20techniques 29. NHS Evidence http://www.evidence.nhs.uk/ 30. Management of long term conditions http://www.kingsfund.org.uk/current_projects/gp_inquiry/dimensions_of_care/the_management_of_1.html 31. Mental illness 'under-treated by NHS ' http://www.nhs.uk/news/2012/06june/pages/mental-health-undertreatment-scandal-lse-report.aspx 32. NHS Choices website http://www.nhs.uk/pages/homepage.aspx 33. London School of Economics Centre for Economic Performance http://www2.lse.ac.uk/home.aspx 34. How Mental Illness Loses out in the NHS report http://cep.lse.ac.uk/pubs/download/special/cepsp26.pdf 35. Professor Lord Layard Mental Health Policy Group 2011 2012 http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp 36. Patchy Progress shown for Mental Health Treatment http://www.mentalhealthy.co.uk/news/935-patchy-progress-for-mental-health-treatment.html 37. NICE Guideline on the Treatment and Management of Depression in Adults http://www.nice.org.uk/nicemedia/live/12329/45896/45896.pdf 38. DH Healthcare Innovation Expo http://www.healthcareinnovationexpo.com/index.asp Page 18 of 21