IRIS Guidelines Update September Revision of the original 1998 IRIS Guidelines

NEW IRIS Guidelines Stephen McGowan

Then… IRIS NSF PIG NIMH(E) NEIP NMHDU WHO IRIS

Early Intervention in Psychosis Early Detection Reduced treatment delays Sustained, phase-specific intervention through the Critical Period Improved outcomes

Achievements Coverage: Over 60,000 Outcomes: - A better course of illness and fewer symptoms - Halving of suicide rates - Substantial reduction in admission rates % recovery rates (2011) Cost savings: ‘EIP can save in the order of £5,000 per case in year one, rising to £14,000 by year three compared to treatment as usual’. (McCrone et al 2009)

Now… Partial Reform World wide recession Cuts to public services S75 divorces Post NSF: - CCGs - Block grant payment system - Payment by Results £21bn!

Fourteen years on from the original IRIS guidelines, EIP has become established as the preferred model of service for young people with emerging psychosis and their families: Endorsed by NICE core Schizophrenia Guidelines (NICE CG ) Highlighted in current mental health policy (DH 2011 No Health without Mental Health; Section 7.13; p66) A commitment in the 2012/13 NHS operating framework (DH Nov 2011) Featuring in the emerging PbR toolkit cluster 10 One of the most researched areas in MH

2012 Research Headlines People treated by early intervention in psychosis had significantly fewer admissions, readmissions and total bed days and better engagement with services (The Psychiatrist, 2008) Specialised EI programmes are cost effective over the long term and can deliver a higher recovery rate at 33% of the cost of standard mental health services. (Schizophrenia Bulletin, 2009) For people with early psychosis, early intervention services appear to have clinically important benefits over standard care improving access to treatment and reducing hospital admission, relapse rates and symptom severity (BJPsych, 2010) Functional recovery at 14-month follow-up significantly predicted both full functional recovery and remission of negative symptoms at 7.5 years. Early recovery plays a pivotal role in preventing the development of chronic negative symptoms and disability (Schizophrenia Research, 2012)

IRIS Guidelines Update September Revision of the original 1998 IRIS Guidelines

[Cut to PDF of Guidelines]

‘EIP is one of the keys to improving mental health services and national mental wellbeing. The problem is that in these times of intense spending pressures the incentives to invest in these services risks being crowded out by much shorter term pressures. Any decision to redesign community MH services must draw on the evidence base and safeguard the important functions and outcomes of EIP teams that make them so effective’. Steve Shrubb, NHS Confederation, Director of the MH Network, 2011 Challenges

Better for Less? Cost savings are impacting on service provision Tough decisions delegated to directorates and teams Short term cost savings: - Clumsy efficiency drives - ‘Salami slicing’ - Loss of leadership - Dumbing down Can we afford EIP in the current climate?

Potential Savings from Expanding EI services in England over next 20 years Paying the Price: The cost of mental health care in England to 2026 McCrone P, Dhanasiri S, Patel A, Knapp M, Lawton-Smith S Kings Fund 2008 National Coverage by EI teams Assumes 50% coverage in % coverage 90% coverage 80% coverage 70% coverage 60% coverage £5000 saved per case/year with EI teams 5,500 new cases of Schizophrenia/ year (Fearon et al, 2006) Annual national savings (£ Million) Similar pattern with Bipolar Disorder

‘Early intervention is crucial to improving outcomes. The Commission’s view is that Early Intervention in Psychosis has been the most positive development in mental health services since the beginning of community care. These services are popular with service users and families and there is a clear evidence of their effectiveness’ Schizophrenia Commission, November 2012

Summary EIP has not only transformed the lives of thousands of young English people but has inspired and encouraged leaders and professionals in many other countries to move in the same direction. EIP has a clear and consistent evidence base, improving outcomes and saving money if delivered in accordance with the evidence. EIP does not describe an intervention but rather a model of service and a philosophy of care. A specialist team model is most able to deliver clinical and cost effectiveness. Success is closely related to fidelity. We have come a long way but there is still further to go

The Future? The future of the EIP reform may lie within a wider and more ambitious reengineering of the health system EIP into CMHT or CMHT into EIP? Providing early intervention and recovery within a broad spectrum youth mental health model? Psychosis pathways and PBR? Integration? Prevention? Competition?

IRIS From a questionable acronym with modest ambition To a new paradigm of genuine recovery for those with the most serious MH problems By linking research, policy, activists, service users and, vitally, service commissioners and providers

THE ABANDONED ILLNESS A report by the Schizophrenia Commission

This briefing presents the evidence base and some key considerations which may helpfully inform and provide a focus for discussions between commissioners and providers in the planning and delivery of community mental health and early intervention in psychosis services.

IRIS Guidelines Update September Revision of the original 1998 IRIS Guidelines