Sarah Khan Deputy Head of Mental Health Mental Health Clinical Policy & Strategy Team Preparing to implement the new access and waiting time standard for early intervention in psychosis

1. Context for the introduction of access and waiting time standards for mental health services

MH 5YP: rebalancing the system Right care Right time Right setting Prevention Early intervention Effective care Recovery

The system is currently not in balance

There is a year gap in the life expectancy of individuals with serious mental illness compared with the rest of the population Health promotion activity, physical health assessments and interventions need to be integrated at every level if the year mortality gap is to be closed.

We are also missing opportunities to deliver better value care to individuals receiving treatment for a physical health condition If we are to improve outcomes and quality of life for individuals with physical health needs, then: a.Promotion of positive mental health as part of condition management b.Recognition of mental health needs c.Timely access to expert assessment and evidence based mental health care Will need to be integrated at every level of the physical healthcare system. a + b + c = reduced demand from repeat attendances in primary care, UEC and outpatient clinics = reduced acute length of stay = better outcomes at lower cost for individuals with long term conditions

2. The standards to be introduced from 2015/16

From 1 April 2016: More than 50% of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral. 75% of people referred to the Improving Access to Psychological Therapies programme will be treated within 6 weeks of referral, and 95% will be treated within 18 weeks of referral. £30m investment is to be targeted on effective models of liaison psychiatry in a greater number of acute hospitals. The October announcement

The Financial Package The new standards for 15/16 are supported by an £80m funding package: £40m recurrent funding to support delivery of the early intervention in psychosis standard; £10m to support delivery of the IAPT; and £30m to support delivery of the liaison psychiatry standard. In addition: NICE (the National Collaborating Centre for Mental Health, NCCMH) has been commissioned to develop national resources to support implementation. Funding has been made available to support regional EIP preparedness programmes (£200k per region). System resilience monies are being used in many areas to support preparedness efforts across EIP and liaison psychiatry services.

The Autumn Statement The Autumn Statement 2014 outlined the provision of additional funding of £30million recurrently for 5 years to be invested in a central NHS England programme to improve access for children and young people to specialist evidence-based community CAMHS eating disorder services. Part of this programme funding will be used to develop an access and waiting time standard.

The Spring Budget The Spring Budget 2015 included an announcement of £1.25bn new mental health funding over the next 5 years (£250m per year) to improve access to mental health services for children and young people and for mothers experiencing perinatal mental illness.

Rt. Hon. Norman Lamb Minister of State for Care and Support “We need standards for access to mental health treatment for people of all ages that balance the equivalent standards for physical health. We need the same quality of data and transparency about performance for mental health services for people of all ages so that long waits for effective treatment are visible and have to be tackled.”

3. The EIP standard: implementation preparation

EIP: why set a standard? In 2011, No Health Without Mental Health, highlighted the effectiveness of EIP services. When delivered in accordance with NICE standards they help people to recover from a first episode of psychosis and gain a good quality of life.

The new access and waiting time standard requires that, by 1 April 2016, more than 50% of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral. The standard is ‘two-pronged’ and both conditions must be met for the standard to be deemed to have been achieved, i.e. A maximum wait of two weeks from referral to treatment; and Treatment delivered in accordance with NICE guidelines for psychosis and schizophrenia - either in children and young people CG155 (2013) or in adults CG178 (2014).CG155 (2013)CG178 (2014) Most initial episodes of psychosis occur between early adolescence and age 25 but the standard applies to people of all ages in line with NICE guidance. What is the standard

National support for implementation 1. Bringing together the required expertise National expert reference group, NICE ‘hosting’, highly collaborative. 2. Developing the required dataset Specifying the dataset, developing the MHSDS and commissioning national clinical audit. 3. Publication of commissioning guidance Service specifications, service model exemplars, staffing / skill mix calculators etc 4. Design of levers & incentives Planning guidance, payment system development, standard contract etc. Engagement with Monitor, TDA, CQC. 5. Implementation support Regional preparedness programmes, accreditation scheme national events etc. 6. Workforce development Joint work with HEE

We wanted to be able to understand: Referral to treatment times in a way that makes sense for the FEP pathway; Whether people experiencing FEP are accessing the full range of interventions recommended by NICE; The outcomes people with FEP are achieving as a result of treatment; The nature, size and skills of the EIP workforce – wte, profession, competency to deliver interventions recommended by NICE. What data did we want from national datasets to support implementation?

1.We’ve commissioned the National Collaborating Centre for Mental Health to support the programme and establish a reference group of EIP experts to: Design the RTT pathway; Specify the interventions that would need to be captured; Specify the outcomes dataset. 2.We worked with the HSCIC and provider information experts to agree the associated changes required to the MHLDDS and the timeframe for delivery. 3.We established 4 Regional EIP Preparedness Programmes and tasked them with undertaking workforce surveys that would provide granular data regarding skill-mix and competencies. 4.We are working with HQIP to commission a national clinical audit of EIP services to understand the current level of NICE concordance. 5.We are working with the RCPsych (CCQI) to establish an accreditation scheme for EIP services. What are we doing about it?

How will we measure the standard? Both elements of the standard will be measured – the wait from referral to treatment and whether the treatment accessed is NICE concordant. We have been working with the HSCIC to specify: 1.What the ‘clock starts’ and ‘clock stops’ should be to measure the two-week referral to treatment standard – the waiting time 2.What the NICE concordant “intervention codes” should be – the quality of care We are also working to specify what the EIP outcomes dataset should be. The changes to provider information systems and the MHLDDS will take effect from 1 st January We will be using national clinical audit and accreditation to assess the quality of service provision in 15/16.

The February guidance Clarifies the requirements of each of the new 15/16 mental health access and waiting time standards and associated expectations of CCG commissioners in line with the planning guidance. Includes in Appendix the draft approach to measuring the EIP RTT standard.

21 Referral to clock start Referrals from anywhere in the system will ‘count’ (not just external)

22 Assessment DNAs and cancellations will not stop the clock

23 Assessment to clock stop The clock does not stop until treatment begins (and the assessment of ‘NICE concordance’ does not stop there). NICE guidelines should be followed for people assessed as having an at risk mental state (ARMS)

1.Guidance for referrers - when should an urgent / emergency ‘suspected FEP’ referral be made? 2.Guidance for instances where people need to be taken out of the EIP RTT cohort (repeated DNAs +++, drug-induced psychosis, organic conditions, not experiencing FEP or needing ARMS assessment) 3.A very clear ‘clock stop’ definition 4.Clock-stop guidance for referrals made at the start of or during a CRHT / inpatient episode 5.A check that the list of intervention codes is correct 6.A check re the level of measurement for the indicator given varying incidence levels (CCG vs provider) 7.Complete vs incomplete pathways 8.Review of the DUP definition 9.Outcomes dataset Outstanding data issues where we are seeking ERG expertise

Clinical Leads North – Alison Brabban M&E – Peter Jones London – Philippa Garety South – Belinda Lennox Regional preparedness

Regional preparedness work 26 1.Raising awareness – What are the requirements of the new standard? What are the implications? What are the opportunities? 2.Bringing together the experts and establishing quality improvement networks 3.Understanding demand – incidence, incidence profiles etc 4.Understanding the baseline position + gap analysis – staffing, skill-mix, competency to deliver full range of NICE concordant interventions 5.Optimising RTT pathways – need to engage all of the potential referral sources, many of which will be internal within secondary care 6.Preparing for the new data collection requirements – training for service and information leads 7.Developing the workforce – capacity, skills & leadership – can the workforce deliver the full range of NICE concordant interventions as this will be the definition of ‘treatment’?

28 Initial findings from the South Region Population 12.5 million 15 Mental Health Trusts 25 EIP services Caseload of c4000 And c70 psychological therapists And c5 consultant psychiatrists Based on caseload, a gap of c75 care coordinators

We want to get the EIP standard right. This standard has the potential to help to improve the lives of thousands of people and their life opportunities. The way that we measure and implement the standard is critical – it can’t ‘just’ be a waiting time standard. It must also be about the quality of care that people access after the clock stops. We hope to take a very similar approach to the introduction of other access and waiting time standards:  A clinically informed maximum waiting time (RTT)  For access to NICE-concordant care. This approach has the potential to support transform care, improve outcomes and have a significant impact on ‘rebalancing’ the system. There is an awful lot to do and collaboration is essential! Reflections and hopes for the future