Preparing to implement the new access and waiting time standard for early intervention in psychosis Sarah Khan Deputy Head of Mental Health (Policy & Strategy)
1. Context for the introduction of access and waiting time standards for mental health services
MH 5YP: rebalancing the system Prevention Early intervention Effective care Recovery Right care Right time Right setting
The system is currently not in balance
There is a 15-20 year gap in the life expectancy of individuals with serious mental illness compared with the rest of the population Health promotion activity, physical health assessments and interventions need to be integrated at every level if the 15-20 year mortality gap is to be closed.
We are also missing opportunities to deliver better value care to individuals receiving treatment for a physical health condition If we are to improve outcomes and quality of life for individuals with physical health needs, then: a. Promotion of positive mental health as part of condition management b. Recognition of mental health needs c. Timely access to expert assessment and evidence based mental health care Will need to be integrated at every level of the physical healthcare system. a + b + c = reduced demand from repeat attendances in primary care, UEC and outpatient clinics = reduced acute length of stay = better outcomes at lower cost for individuals with long term conditions
2. The standards to be introduced from 2015/16
The first set of standards From 1 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. 75% of people referred to the Improving Access to Psychological Therapies programme will be treated within 6 weeks of referral, and 95% will be treated within 18 weeks of referral. 30m investment is to be targeted on effective models of liaison psychiatry in a greater number of acute hospitals.
The Financial Package The new standards for 15/16 are supported by an 80m funding package: 40m recurrent funding to support delivery of the early intervention in psychosis standard; 10m to support delivery of the IAPT; and 30m to support delivery of the liaison psychiatry standard. In addition: NICE (the National Collaborating Centre for Mental Health, NCCMH) has been commissioned to develop national resources to support implementation. Funding has been made available to support regional EIP preparedness programmes ( 200k per region). System resilience monies are being used in many areas to support preparedness efforts across EIP and liaison psychiatry services.
The Autumn Statement The Autumn Statement 2014 outlined the provision of additional funding of 30million recurrently for 5 years to be invested in a central NHS England programme to improve access for children and young people to specialist evidence-based community CAMHS eating disorder services. Part of this programme funding will be used to develop an access and waiting time standard.
The Spring Budget The Spring Budget 2015 included an announcement of 1.25bn new mental health funding over the next 5 years ( 250m per year) to improve access to mental health services for children and young people and for mothers experiencing perinatal mental illness.
3. The EIP standard: implementation preparation
EIP: why set a standard? In 2011, No Health Without Mental Health, highlighted the effectiveness of EIP services. When delivered in accordance with NICE standards they help people to recover from a first episode of psychosis and gain a good quality of life.
What is the standard The new access and waiting time standard requires that, by 1 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. The standard is two-pronged and both conditions must be met for the standard to be deemed to have been achieved, i.e. A maximum wait of two weeks from referral to treatment; and Treatment delivered in accordance with NICE guidelines for psychosis and schizophrenia - either in children and young people CG155 (2013) or in adults CG178 (2014). Most initial episodes of psychosis occur between early adolescence and age 25 but the standard applies to people of all ages in line with NICE guidance.
What data did we want from national datasets to support implementation? We wanted to be able to understand the baseline: Referral to treatment times in a way that makes sense for the FEP pathway; Whether people experiencing FEP are accessing the full range of interventions recommended by NICE; The outcomes people with FEP are achieving as a result of treatment; The nature, size and skills of the EIP workforce wte, profession, competency to deliver interventions recommended by NICE.
What are we doing about it? 1. We ve commissioned the National Collaborating Centre for Mental Health to support the programme and establish a reference group of EIP experts to: Design the RTT pathway; Specify the interventions that would need to be captured; Specify the outcomes dataset. 2. We worked with the HSCIC and provider information experts to agree the associated changes required to the MHLDDS and the timeframe for delivery. 3. We established 4 Regional EIP Preparedness Programmes and tasked them with undertaking workforce surveys that would provide granular data regarding skill-mix and competencies. 4. We are working with HQIP to commission a national clinical audit of EIP services to understand the current level of NICE concordance. 5. We are working with the RCPsych (CCQI) to establish an accreditation scheme for EIP services.
National support for implementation 1. Bringing together the required expertise 2. Developing the required dataset 3. Publication of commissioning guidance 4. Design of levers & incentives 5. Implementation support 6. Workforce development National expert reference group, NICE hosting, highly collaborative. Specifying the dataset, developing the MHSDS and commissioning national clinical audit. Service specifications, service model exemplars, staffing / skill mix calculators etc Planning guidance, payment system development, standard contract etc. Engagement with Monitor, TDA, CQC. Regional preparedness programmes, accreditation scheme national events etc. Joint work with HEE
How will we measure the standard? Both elements of the standard will be measured the wait from referral to treatment and whether the treatment accessed is NICE concordant. We have been 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 We are also working to specify what the EIP outcomes dataset should be. The changes to provider information systems and the MHLDDS will take effect from January 2016. We will be using national clinical audit and accreditation to assess the quality of service provision in 15/16.
Expectations of commissioners Planning guidance requirement that SDIPs are agreed setting out how commissioners and providers will prepare for and implement the new standard in 15/16 and achieve it on an ongoing basis from 1 April 2014. Clear expectation that the additional 40m funding being made available recurrently should be invested recurrently in EIP services. Local agreement on pricing so increases should take into account baseline performance against both elements of the EIP standard: Referral to treatment waiting times; and Current levels of NICE concordance access to the range of evidence-based biological, psychological and social interventions as recommended by NICE guidelines for psychosis and schizophrenia in children and young people CG155 (2013) and in adults CG178 (2014).
The February guidance Clarifies the requirements of each of the new 15/16 mental health access and waiting time standards and associated expectations of CCG commissioners in line with the planning guidance. Includes in Appendix the draft approach to measuring the EIP RTT standard. Referrer suspects first episode psychosis (FEP) Urgent / emergency referral made flagged as suspected FEP Central triage point? Clock starts when Y central triage point receives referral Onward referral to EIP service N Clock starts when EIP service receives referral Patient invited for EIP assessment DNA? Y N EIP assessment commences DNA Y N EIP assessment completed FEP? N Y Clock stops when: 1. Accepted on to EIP caseload 2. EIP care coordinator allocated 3. NICE concordant package of care commenced. Active monitoring / watch and wait Active monitoring / watch and wait Clock stops when: 1. Accepted on to EIP caseload 2. EIP care coordinator allocated 3. Specialist ARMS assessment commenced. ARMS? N Y Commence NICE concordant package of care Onward referral to appropriate service or discharge
Referral to clock start 1. Referrer suspects first episode psychosis (FEP) 2. Urgent / emergency referral made flagged as suspected FEP Central triage point? Y 3a. Clock starts when central triage point receives referral Onward referral to EIP service N Referrals from anywhere in the system will count (not just external) 3b. Clock starts when EIP service receives referral Patient invited for EIP assessment 21
Assessment 1. Patient invited for EIP assessment 2a. DNA or cancella tion? N EIP assessment commences 2b. DNA or cancell ation? N EIP assessment completed Y Y 3a. Active monitoring / watch and wait 3b. Active monitoring / watch and wait DNAs and cancellations will not stop the clock 22
Assessment to clock stop The clock does not stop until treatment begins (and the assessment of NICE concordance does not stop there). NICE guidelines should be followed for people assessed as having an at risk mental state (ARMS) 23
Issues raised where we sought further ERG expertise 1. Guidance for referrers - when should an urgent / emergency suspected FEP referral be made? 2. Guidance for instances where people need to be taken out of the EIP RTT cohort (repeated DNAs +++, drug-induced psychosis, organic conditions, not experiencing FEP or needing ARMS assessment) 3. A very clear clock stop definition 4. Clock-stop guidance for referrals made at the start of or during a CRHT / inpatient episode 5. A check that the list of intervention codes is correct 6. A check re the level of measurement for the indicator given varying incidence levels (CCG vs provider) 7. Complete vs incomplete pathways 8. Review of the DUP definition 9. Outcomes dataset
Regional preparedness Clinical Leads North Alison Brabban M&E Peter Jones London Philippa Garety South Belinda Lennox
Regional preparedness work 1. Raising awareness What are the requirements of the new standard? What are the implications? What are the opportunities? 2. Bringing together the experts and establishing quality improvement networks 3. Understanding demand incidence, incidence profiles etc 4. Understanding the baseline position + gap analysis staffing, skill-mix, competency to deliver full range of NICE concordant interventions 5. Optimising RTT pathways need to engage all of the potential referral sources, many of which will be internal within secondary care 6. Preparing for the new data collection requirements training for service and information leads 7. 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? 2 6
Reflections and hopes for the future We want to get the EIP standard right. This standard has the potential to help to improve the lives of thousands of people and their life opportunities. The way that we measure and implement the standard is critical it can t just be a waiting time standard. It must also be about the quality of care that people access after the clock stops. We hope to take a very similar approach to the introduction of other access and waiting time standards: A clinically informed maximum waiting time (RTT) For access to NICE-concordant care. This approach has the potential to support transform care, improve outcomes and have a significant impact on rebalancing the system. There is an awful lot to do and collaboration is essential!
sarah.khan@nhs.net