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
[email protected]@slam.nhs.uk
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