IAPT-SMI Demonstration Site for Psychosis Professor Philippa Garety South London and Maudsley (SLaM) IAPT-SMI Demonstration Site for Psychosis Professor Philippa Garety Clinical Director, Psychosis Clinical Academic Group Thursday 7 March 2013

Service users want equal access to psychological therapies Rethink survey (2010) Research suggests that only 1 in 10 access CBT, despite NICE guidance (Schizophrenia Commission, 2012)

The Abandoned Illness The 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 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

69% of Trusts have funding challenges for providing access to psychological therapies for people with a diagnosis of schizophrenia 94% have encountered obstacles in making psychological therapies available, including insufficient skilled staff

Delays in accessing CBTp Peters 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 Early Intervention Pathway (Southwark, Lambeth, Croydon & Lewisham) STEP TEAM IAPT-EI The road to recovery Promoting Recovery Pathway (Southwark, Croydon & Lewisham) IAPT-PICuP IAPT-SHARP Promoting Recovery Pathway (Lambeth) 10

STEP TEAM

SHARP

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

Overcoming 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 not 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 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

Effectiveness

Clinical outcomes: Service-user reported symptoms

Evidence of clinical outcomes with medium-large effect sizes – voices and delusions 89% (voices) & 90% (delusions) have paired data at end of therapy Effect size = mean 2 – mean 1 / sd of mean 1 This graph shows a reduction in psychotic symptoms [voices (effect size: .73) and delusions (effect size: .59)] following therapy (PICuP)

Evidence of clinical outcomes with medium-large effect sizes – anxiety and depression 85% have paired data at end of therapy Effect size = mean 2 – mean 1 / sd of mean 1 This graph shows a reduction in emotional problems [anxiety (effect size: .47) and depression (effect size: .55)] following therapy PICuP

85% (QoL) & 67% (CHOICE) have paired data at end of therapy Evidence of clinical outcomes with medium-large effect sizes – quality of life (QoL) and recovery 85% (QoL) & 67% (CHOICE) have paired data at end of therapy Effect size = mean 2 – mean 1 / sd of mean 1 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-effectiveness

Randomised Controlled Trial (Peters et al, 2010) – therapy costs are off-set by fewer inpatient costs at 3 months follow-up (N = 74)

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*) Data obtained from ePJS, Jan 2012 N = 70

Progress and preliminary outcomes

New clients - demographics New clients in the service Variable New clients in the service Age distribution Mean 38 years (18-70) Gender 43% male, 57% female Ethnicity 36% white, 64% BME

Demonstration site CBTp & FIp referral targets are being achieved Existing Projection Monthly Referral Target (over 12m) Progress at 4 months CBT FI 106 15 50 10 14 2-3 95 11

35 7 23 57 60% 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 Mean number of days in 12m before therapy 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  Pre PSYRATS – Voices & Beliefs  WEMWBS WSAS EQ-5D Short CHOICE CORE-10 Brief IPQ Measures Feedback 3-monthly PSYRATS – Voices & Beliefs Satisfaction with therapy  Post Satisfaction with therapy Short CHOICE weekly

IAPT-SMI: Carer assessments  Pre Experience of caregiving inventory WEMWBS DASS-21 CORE-10 IPQ carer version Confidant question Measures Feedback 3-monthly Satisfaction with therapy  Post Satisfaction with therapy

Patient Reported Outcome Measures Completion rate Session by session short CHOICE 81% of attended sessions Pre-therapy: PSYRATS Questionnaires 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/

Dr Miriam Fornells-Ambrojo, Operational Group Dr Louise Johns, Project Lead Dr Miriam Fornells-Ambrojo, IAPT-EI Lead Rosanna Michalczuk Bina Sharma Psychology Assistants Dr Suzanne Jolley, Lambeth Recovery Psychology Lead Dr Craig Milosh, Clinical Psychologist, SHARP Devon Elliott, Business Intelligence Analyst Dr Juliana Onwumere, FI Lead

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 Monday 1 July 2013 1.00-5.00 pm Louise.johns@slam.nhs.uk