Kevin Mullins National IAPT Director Improving Access to Psychological Therapies The First Million Patients 10th April 2014

Conflicts of Interest None to Declare

http://www.iapt.nhs.uk/silo/files/iapt-3-year-report.pdf

The IAPT Argument (Depression Report 2006) Much current service provision focuses on psychosis which deserves attention but affects 1% of population at any one time. Many more people suffer from anxiety and depression (approx.15% at any one time. 6 million people). Economic cost is huge (lost output £17 billion pa, of which £9 billion is a direct cost to the Exchequer). Effective psychological treatments exist. NICE Guidance recommends CBT for depression and ALL anxiety disorders plus some other treatments for individual conditions (EMDR for PTSD, Interpersonal Psychotherapy, Couples therapy, Counselling & Brief Dynamic Therapy for some levels of depression). Less than 5% of people with anxiety disorders or depression receive an evidence based psychological treatment. Patients show a 2:1 preference for psychological therapies versus medication Increased provision would largely pay for itself 4

The Original Economic Case Layard, Clark, Knapp & Mayraz (2007) National Institute Economic Review, 202, 1-9. Cost (per patient) 750 Benefits to Society Extra output 1,100 Medical costs saved 300 Extra QALYs 3,300 Total 4,700 Benefits to Exchequer Benefits & taxes 900 Healthcare utilisation reductions 300 Total 1,200

Which Psychological Treatments are recommended by NICE? Problem NICE Recommended Treatments Anxiety Disorders (all six) CBT only Depression (moderate-severe) CBT or IPT (with meds) Depression (mild-moderate) Low intensity CBT based interventions CBT (including group) Behavioural Activation IPT Behavioural Couples Therapy If patient declines above, consider: Counselling Short-term psychodynamic treatment

Demonstration Sites:Newham & Doncaster. Awarded £1.5- £2 million per annum to increase access to psychological treatments (includes special set-up) Stepped care * Least burden principle * Psychological Well-Being Practitioners, HI intensity therapists & employment advisers Session by session outcome monitoring Experiment with self-referral 7

Demonstration Sites: First Year Results (see Clark, Layard,Smithies, Richards et al. (2009) Behav. Res & Ther) Excellent data completeness (99% in Doncaster, 88% Newham). Large numbers treated (approx 3,500 in first year). Use of Low intensity important. Outcomes broadly in line with NICE Guidance for those who engaged with treatment (52% recover). Employment benefits. Maintenance of gains. When compared with GP referrals, self- referrals were as severe, tended to have had their anxiety disorder or depression for longer, and had BME rates that were more representative of the community. Ditto social phobia & PTSD. Outcome does not differ by ethnic status or referral route White 50% Black 54% Asian 67% 8

The National Programme First 3 years (2008-2011) funded in 2007 CSR (£300 million above baseline). Train at least 6,000 new therapists and employ them in new clinical services for depression & anxiety disorders. Initial focus on CBT. Now being expanded to other NICE approved therapies Services follow NICE Guidelines (including stepped care). National Training Curricula (high and low intensity practitioners: PWPs) Published set of competencies for all therapies (Roth, Pilling et al) Success to be judged by clinical outcomes (50% recovery target, with many others showing some benefit) Self-referral & Session by session outcomes measurement 9

Talking Therapies: four – year plan of action (2011-15) funded in 2011 (£400m) Complete roll-out of services for adults Improve access to psychological therapies for people with Psychosis, Bipolar Disorder, Personality Disorder Talking Therapies 2011 - 2015 Initiate stand – alone programme for children and young people Improve access for older people and BME communities Develop models of care for: Long Term Conditions Medically Unexplained Symptoms

Resources Available Policy 2011/12 2012/13 2013/14 2014/15 Completing roll out 43 88 133 Children & Young People Pilots 8 20 14 MUS/LTC Pilots 2 Total 51 110 149 147

Start Point & Planning Assumptions

At End of Q2 2013/14 IAPT services established in 100% of health areas Approx 5,000 new High & low intensity therapists trained At December 2014 programme is on target Over 2.2 million people seen in services Over 75,000 moved off sick pay & benefits 46% recovery rate Current access rate pa c700,000 Initiation of a major CAMHS transformation using IAPT quality markers 14

IAPT for Adults – Quality Standards

Public Transparency: A Revolution for English Mental Health Services Originally IAPT services submit to government quarterly data on number of people seen and average recovery rates for the service. Public access (www.ic.nhs.uk) Now IAPT services required to submit 50 data items per patient covering demographics, diagnosis, type of treatment and pre & post treatment scores.

Key Performance Indicators Pathway data ie referrals, waits, access, completers Patient demographics (age, gender, sexual orientation, ethnicity, disabilities, etc) ICD-10 provisional diagnoses, problem duration, medication, benefits, Outcome measures at pre and post (PHQ, GAD, Anxiety Disorder Specific Measures, WSAS) Post July 1st 2014 Measure of need, mental health cluster Patient experience questionnaire (pre and post). Type of treatment, number of sessions, step-up/down

Performance Management NHS Operating Framework for 12/13 Access – full roll out by 2014/15 (BME & Older People) Recovery – 50% in fully established services Scope – SMI (inc PD) & LTCs NHS Mandate 2013/15 & 2014/15 Access 15 % by 2015 Recovery Rate 50% Prepare for full roll out of Children & Young People IAPT

Map showing PCT with IAPT Services & Projects KEY No IAPT Service IAPT Service IAPT Service + PBR IAPT Service + LTC/MUS IAPT Service + CYP IAPT Service + SMI IAPT Service + PBR + CYP IAPT Service + PBR + SMI IAPT Service + CYP + SMI IAPT Service + CYP + LTC/MUS IAPT Service + PBR + LTC/MUS + CYP IAPT Service + LTC/MUS + CYP + SMI

National Training Summary Table Total Commissions Replacement Commissions Additional Cumulative Additional commissions 2012/13 226 4,995 2013/14 (filled) 973 206 767 5,762 2014/15 (Planned ) 756 200 556 6,318

Access Performance to Q4 12/13

Recovery Performance to Q4 12/13

Performance to Q4 12/13

Performance to Q2 13/14

Challenges & Opportunities Winning the economic argument for investment Winning & maintaining political support Programme design & consistent delivery of NICE compliant services Quality Standard development, alignment and compliance Training curricula – practitioners/supervisors Data set development, implementation & reporting

What Next? Extending scope & transforming services for: Children & Young People People with Severe Mental Illness People with Long Term Conditions Increasing scale to reach 25% of those in need Sustainability through development and system wide adoption of an outcomes based currency and tariff International adoption Norway - Demark Sweden - Canada Iceland

Kevin.mullins@nhs.net Tel +44207 972 5917 Mob +447789 876 546 Questions? Kevin.mullins@nhs.net Tel +44207 972 5917 Mob +447789 876 546