South London and Maudsley (SLaM)IAPT-SMI Demonstration Site for Psychosis

Professor Philippa Garety Clinical Director, Psychosis Clinical Academic Group

Thursday 7 March 2013

Research suggests that only 1 in 10 access CBT, despite NICE guidance (Schizophrenia Commission, 2012)

Service users want equal access to psychological therapies Rethink survey (2010)

The Abandoned IllnessThe Schizophrenia Commission

“Research has led to a range of evidence-based psychological treatments. We know much more about ‘what works’ than we used to. . . The committed individuals who went into the mental health profession to improve lives should be helped to do exactly that.”

Prof Sir Robin Murray

This is where IAPT-SMI comes in

Obstacles to accessObstacles to access

Dolly Sen, Service User Consultant

“I always asked for some kind of psychological therapy or talking therapy but was told, no, it was too dangerous. I had to wait 20 years for something that was the most beneficial thing. [Therapy] has changed my life basically.”

Talking to Norman Lamb on 19 December 2012

94% have encountered obstacles in making psychological therapies available, including insufficient skilled staff

69% of Trusts have funding challenges for providing access to psychological therapies for people with a diagnosis of schizophrenia

Delays in accessing CBTpPeters et al 2009

(N=74)

• Mean length of illness was 8 years (range 0-32)• Mean of 2.8 in-patient admissions (range 0-20)• 96% were on antipsychotic medication

South London and Maudlsey NHS Foundation Trust: the context

• Core population - 4 South London Boroughs 1.3million; inner city, very high indices of social deprivation

• Substantially raised rates of psychosis

• Psychosis Care Pathways

SLaM Psychosis Demonstration site: Increasing access in two care pathways

Promoting Recovery Pathway (Southwark, Croydon & Lewisham)

Promoting Recovery Pathway (Lambeth)

Early Intervention Pathway (Southwark, Lambeth, Croydon & Lewisham)

IAPT-EIIAPT-EI

IAPT-IAPT-SHARPSHARP

IAPT-IAPT-PICuPPICuP

SHARPSHARP

What IAPT-SMI offers for service users

CBT for psychosis:

• weekly or fortnightly individual 1 hour sessions• 6-9 months therapy• Therapists receive weekly-fortnightly group

supervision

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

Overcoming obstacles to accessOvercoming obstacles to access

Work we have already done in SLaM• Ten point charter addressing

barriers and facilitators:– Service user involvement– Quality criteria and staff

training– Data gathering, data

systems and outcomes– Care pathways, ensuring

integrated effective care in Early Intervention & Recovery pathways

Psychological treatments are Psychological treatments are not a quasi - medicationnot a quasi - medication

=

Quality• One key challenge has been a lack of clarity about quality –

psychological therapy is different from a chemical compound• Lack of criteria have resulted in an ‘anything goes’ approach to

psychological therapy in MH services, and inflated estimates of provision

• We need nationally agreed criteria for training and competencies in CBTp and FI

• IAPT-SMI is doing this• Locally we have already developed criteria and standards and

established a portfolio of training opportunities

Training and SupervisionTraining and Supervision

Training and Supervision

• Portfolio of training opportunities in psychological therapies for psychosis, in partnership with KCL

• Span the workforce from non-clinical to managerial/supervisory

• Academically accredited training and in-service courses• Short courses and modules build to an award• Supervised practice strongly emphasised• Supervision and support for supervisors

Training structure in the SLaM site

Service user and caregiver involvement & co-production

• Involvement in development, design and evaluation of psychological therapy services

• Training design and delivery

• Co-produced workshops at SHARP and in the SLaM Recovery college

• Co-working in group interventions: Hearing Voices; Mindfulness; Acceptance & Commitment Therapy

• Training, supervision and support (practical, financial and emotional)

• Personal development – CPD, co-authorship, conference attendance

SLaM demonstration site strategic approach to improving access to therapy

• A 50% increase in access with the funding provided • Reduced waiting times • Implementation of our 10 Point Charter, with highly

trained staff, and care pathways• Clear referral pathways, including self referral• Regular assessment of progress in therapy• Close and frequent supervision• Assessing improvement in a range of outcomes and

in health economics

EffectivenessEffectiveness

Clinical outcomes: Service-user reported symptoms

Clinical outcomes: Service-user reported symptoms

15

20

25

30

Assessment (N=96,125)

Before therapy (N=70,80)

End of therapy (N=85,113)

Vo

ice

s

6

8

10

12

14

16

De

lus

ion

s

VoicesDelusions

This graph shows a reduction in psychotic symptoms [voices (effect size: .73) and delusions (effect size: .59)]

following therapy (PICuP)PICuP)

89% (voices) & 90% (delusions) have paired data at end of therapy

Evidence of clinical outcomes with Evidence of clinical outcomes with medium-large effect sizes medium-large effect sizes

– – voices and delusionsvoices and delusions

14

16

18

20

22

24

26

Assessment (N=176) Before therapy (118) End of therapy (148,152)

De

pre

ss

ion

14

16

18

20

22

24

An

xie

ty

Depression

Anxiety

This graph shows a reduction in emotional problems [anxiety (effect size: .47) and depression (effect size: .55)]

following therapy PICuPPICuP

85% have paired data at end of therapy

Evidence of clinical outcomes with medium-Evidence of clinical outcomes with medium-large effect sizes – anxiety and depressionlarge effect sizes – anxiety and depression

44

46

48

50

52

54

Before therapy (174; 113) End of therapy (131, 76)

MA

NS

A

80

90

100

110

120

130

140

CH

OIC

E

QoL

Recovery

85% (QoL) & 67% (CHOICE) have paired data at end of therapy

Evidence of clinical outcomes with medium-Evidence of clinical outcomes with medium-large effect sizes – quality of life (QoL) and large effect sizes – quality of life (QoL) and

recoveryrecovery

This graph shows an increase in people’s quality of life (measured on the Manchester Short Assessment of Quality of Life; effect size: .51) and recovery ratings (measured on the

CHOICE; effect size .79) following therapy

Cost-effectivenessCost-effectiveness

£7236£6602

£9018

£12,558

0

2000

4000

6000

8000

10000

12000

14000

Therapy(baseline)

Control(baseline)

Therapy(follow-up)

Control(follow-up)

Mea

n 9-

mon

th c

ost

(200

5/6

£s)

TherapyInpatient careNon-inpatient care

Randomised Controlled Trial (Peters et al, 2010) – therapy costs are off-set by fewer inpatient costs at 3 months follow-up

(N = 74)

0

100

200

300

400

500

1 year prior to therapy 1 year following therapy

451.46

172.24

Cost

s per

mon

th (£

)Reduction in service-use costs (admissions & home treatment team days) in the year following therapy, compared to the year

prior to therapy (Wilcoxon test: p <.05*)

N = 70

Data obtained from ePJS, Jan 2012

Progress and preliminary outcomesProgress and preliminary outcomes

Variable New clients in the service

Age distribution Mean 38 years (18-70)

Gender 43% male, 57% female

Ethnicity 36% white, 64% BME

New clients - demographics

Demonstration site CBTp & FIp Demonstration site CBTp & FIp referral targets are being achievedreferral targets are being achieved

Existing Projection Monthly Referral Target

(over 12m)

Progress at 4 months

CBT FI CBT FI CBT FI CBT FI

106 15 50 10 14 2-3 95 11

Waiting times are reduced (in days)Waiting times are reduced (in days)

Referral received to

opted-in

Opted-in to

assessed

Assessed to

receiving therapy

Total%

reduction in waiting

times

35 7 23 57 60%

Health Utilisation data Health Utilisation data

Service Mean number of days in 12m before therapy

Mental health admission 10.5 (0-126)

Crisis team / home treatment 0.7 (0-23)

Psychiatric liaison (A&E) 0.1 (0-2)

IAPT-SMI: CBT assessments

Short CHOICE weekly

IAPT-SMI: Carer assessments

Patient Reported Outcome MeasuresPatient Reported Outcome Measures

Measure Completion rate

Session by session short CHOICE

81% of attended sessions

Pre-therapy:PSYRATSQuestionnaires

98%100%

London Tonight report from 19 December 2012 – visit to SLaM by Norman Lamb, Care and Support Minister and the official launch of the IAPT-SMI demonstration sites:

http://www.itv.com/news/london/update/2012-12-20/maudsley-hospital-pioneers-mental-health-therapy-scheme/

Operational Group

Dr Louise Johns,Project Lead

Dr Miriam Fornells-Ambrojo,IAPT-EI Lead

Rosanna Michalczuk Bina Sharma Psychology Assistants

Dr Suzanne Jolley,Lambeth RecoveryPsychology Lead

Dr Juliana Onwumere, FI Lead

Dr Craig Milosh, Clinical Psychologist, SHARP

Devon Elliott, Business Intelligence Analyst

Steering Group• Lucy Canning, Psychosis CAG Service Director• Prof Philippa Garety, Psychosis CAG Clinical Director• Jonathan Beder, Psychosis CAG Deputy Director, Business and Performance• Dolly Sen and Garry Ellison, Service User consultants • Roger Oliver and Lorna Wilkinson, Carer consultants• Prof Tom Craig, Consultant Psychiatrist, SHARP• Marieke Wrigley, Team Leader, SHARP• Prof Elizabeth Kuipers, NICE Schizophrenia guideline lead• Dr Emmanuelle Peters, PICuP Director• Adrian Webster, CAG Psychological Therapies Lead• Jo Lawrence, Clinical Service Lead, EI• Dr Sarah Dilks, Lead Psychologist, Promoting Recovery pathway• Dr Eric Morris, Lead Psychologist, Early Intervention pathway• Penelope Fell, Head of Business Development• Dorothy Abrahams, Administrator

Thank you for listening!You are welcome to our SLaM

Demonstration Site Visit

Thank you for listening!You are welcome to our SLaM

Demonstration Site Visit

Monday 1 July 2013 Monday 1 July 2013 1.00-5.00 pm1.00-5.00 pm

Louise.johns@slam.nhs.ukLouise.johns@slam.nhs.uk