1. Hywel Dda Local Health Board Improving access to psychological therapies Catherine Hooper Facilitator IAPT Project (depression and anxiety) Cognitive Behavioural Therapist, Brynmair Clinic, Llanelli Chris Jones Cognitive Behavioural Psychotherapist Myddfai Psychotherapy Centre Carmarthen

2. Hywel Dda Local Health Board Why improve access? NICE guidelines Government policies and targets Locally- attention and concern within the Trust, establishment of the Psychological therapies group, Modernisation agenda

3. Hywel Dda Local Health Board Modernising the provision of Psychological Therapies Report compiled by Chris Jones, Psychotherapy Dept Aim: - to determine need for psychological therapy within the 3 counties - to determine the current capacity to provide psychological therapy - to develop options to address the gap

4. Hywel Dda Local Health Board a b c d e f CONTINUOUS OR STEPPED CARE PROGRAMME PRIMARY CARE SECONDARY CARE Before assessment and identification What Need and When? a – Prevalence of mental health problems in GP registered population. b – Attend GP (1st assessment) c – Referral to Primary Care Team d – Referral to Secondary Care Team e – Acceptance onto CPA f – Existing CPA pool

5. Hywel Dda Local Health Board DIAGNOSTIC CATEGORYI NCIDENCE pa/PREVALENCE ESTIMATES per 1000 in Ceredigion (popn 18-65yrs: 63,610) INCIDENCE pa/PREVALENCE ESTIMATES per 1000 in Pembrokeshire (popn 18- 65yrs: 69,187 INCIDENCE pa/PREVALENCE ESTIMATES per 1000 in Carmarthenshire (popn 18- 65yrs: 106,190 Anxiety – Panic Disorder89/50996/553148/850 Anxiety – Generalised Anxiety Disorder 279930444672 Anxiety –All phobias114512451911 Bipolar Disorder3/12093/13154/2018 Depression (incid. Of Major Depn) 191/1336208/1453319/2230 Eating Disorders – anorexia - bulimea No reliable estimate for adult popn (7/1000 girls; 1/1000 boys) 0.5-1% young women c. 477 No reliable estimate for adult popn (7/1000 girls; 1/1000 boys) 0.5-1% young women c.519 No reliable estimate for adult popn (7/1000 girls; 1/1000 boys) 0.5-1% young women c.796 Obsessive Compulsive Disorder38/67042/76164/1168 Body Dysmorphic Disorder318-445346-484531-743 Personality Disorder279930444672 Post-traumatic Stress Disorder159017302655 Schizophrenia7/3188/34612/531

6. Hywel Dda Local Health Board Estimated % prevalence of psychiatric diagnoses in Ceredigion, Carmarthenshire and Pembrokeshire

7. Hywel Dda Local Health Board DiagnosisCeredigion CMHTsPembrokeshire CMHTs Carmarthen CMHTs - projected Total Anxiety1931840 Depression423476 Anxiety & depression111290203 Bioplar306576171 Eating disorder44614 Anorexia6511 Psychosis119169230518 PTSD3249 OCD/BDD841022 PD not specified16613 Borderline PD2352250 Totals2563705011127 Judith Evan-Jones “Toolkit” assay of caseloads & skills in Trust CMHTs

8. Hywel Dda Local Health Board Toolkit: Caseload Composition Pembs. & Ceredigion CMHTs

9. Hywel Dda Local Health Board Casework Projections based on Corporate Data & CMHT Toolkit Responses Carm.Cered.Pembs.Total Anx’y & Dep’n 358119173650 OCD/BDD 2515646 BPAD 1925898348 Eating Disorders 2219647 Psychosis 5812292541064 PTSD 106319 PD (NOS) 152926 Borderline PD 56448108 Total 12594925572308

10. Hywel Dda Local Health Board Summary of Psychological Treatment per Case by Dominant Evidence ModalityHoursDuration Anxiety and depressionCBT8 - 204 months OCD/BDDCBT10+ BPADCBT166 - 9 months CBT – Family Work166 months Eating DisordersCBT20 – 406 – 12 months CAT25 +6+ months Psychodynamic25 +6 + months PsychosisCBT106 + months CBT – Family Work10+6 + months PTSDCBT8 – 123 months EMDR8 – 123 months PD inc BorderlineDBTc. 16012 months + SFTc. 27636 months CATLong Psychodynamic (TFP)c. 27636 months

11. Hywel Dda Local Health Board All P & D Adult CMHTs Formal Skills Skill level SkillAA-BBB-CCTotal CAT CBT5 319 Counselling183 12 DBT 9 9 EMDR 2 2 Personal Construct Psychotherapy Psychodynamic Therapy Psychosocial Interventions for Psychosis 310 13 Schema Focused Therapy Systemic Therapy Transactional Analysis 1 12 Total611253247

12. Hywel Dda Local Health Board Psychological Treatment Hours Estimated per annum by Modality (for all cases to have minimum treatment within one year) CMHT caseloads only Level B and Above DisorderCBTPsychod.CATEMDRDBTSFT Anx & dep5200- 13000 OCD/BDD460 BPAD1136 Eating dis. 940- 1880 1175 Psychosis21280 PTSD152-228 PD inc Bor Long 2144012328 (assume 1/3 take-up) Total29168- 37984 1175+ 152-2282144012328

13. Hywel Dda Local Health Board Therapy Capacity Deficit Hours per annum; Level B and Above CBTPsychodCATEMDRDBTSFT Therapy needed (h) 29168- 37984 1175+ 152-2282144012328 CMHT #400290 CMHT Cap. (h) 4600002300103500 Deficit range 24568- 33384 1175+ 2148- 2372 1109012328 Addnl WTE range (25h/wk 46wk/yr) 21.4- 29.0 1.0 -1.9 to- 1.8 9.610.7

14. Hywel Dda Local Health Board Mind the Gap Evidence base largely supports and recommends CBT for many common disorders Effective, accessible, speedy, economic, variety of methods Not for all, however Clinical experience and a less prolific evidence base also suggest the utility of other therapies (dynamic work, CAT, SFT, art) Provides choice of approach – highly meaningful to clients Indicated for specific disorders – for some may need to be intense and lengthy Practice evidence indicates use for long-term and sometimes ill-defined (and profound) distress Applications for team and organisational development Basic, psychologically informed engagement skills also necessary for majority of work force e.g. basic listening and other counselling skills

15. Hywel Dda Local Health Board Results Huge gap between need and provision On CMHT caseloads: estimated deficits- 29,168 – 37,984 of treatment hours per annum for CBT alone, 5,200-13,000 deficit of treatment hours for people with anxiety\ depression, 21,280 deficit of treatment hours for people with psychosis

16. Hywel Dda Local Health Board How can we address the gap? Improving access to Psychological Therapies Project launched in 2009 Stage one will be concerned with improving access for people with anxiety and depression

17. Hywel Dda Local Health Board Aim of the IAPT (depression and anxiety) Project For patients entering our service to receive evidence based psychological therapies delivered by mental health professionals who are competent in their use For our service to be NICE compliant NICE guidelines (2004) Depression and Anxiety( panic disorder with or without agoraphobia and generalised anxiety disorder) To train a sustainable psychologically skilled workforce to provide interventions now and in the future

18. Hywel Dda Local Health Board Progress so far 8-day CBT training programme designed Curriculum based on the DOH(2007) Report ‘ The competencies required to deliver CBT to people with depression and anxiety’ Aim to train mental health professionals up to Level B status

19. Hywel Dda Local Health Board Level B definition A practitioner who is able to deliver formulation based or manualised evidence based interventions for specific problems, through regular structured sessions for an agreed time. Requires training in the particular interventions appropriate to the particular diagnosed problem, but will only work under close consultative supervision

20. Hywel Dda Local Health Board Why CBT? Evidence base largely supports and recommends CBT for most mental health problems Therefore in most cases CBT should be the first psychological intervention that is offered However recognised that it certainly does not work for everyone and other psychological models should continue to be provided and developed

21. Hywel Dda Local Health Board Who are we training? We are providing the training course in all 3 counties and in all CMHT’S both adult and older adult In some areas ward staff and CRT members have been trained So far 18 mental health professionals have been trained in Llanelli and Pembrokeshire With a further 30 in training in Ceridigion Updates are also being offered to staff who have already done their basic training All professions have been represented amongst the trainees

22. Hywel Dda Local Health Board Training is not enough ! Past experience nationally and locally tells us that training without appropriate support and supervision is not enough to change practice To address this we have set up supervision groups across the counties. Supervision starts in training and continues thereafter The psychological therapies group has formed a subgroup which manages and monitors the project

23. Hywel Dda Local Health Board Measuring competencies For trainees we are using the Cognitive Therapy Scale- Revised, which is a validated scale used nationally by all respected Cognitive Therapy training courses Practically trainees submit tape recordings for scrutiny and have to reach a certain standard before being awarded Level B status After initial training continuous professional development is provided and trainees are expected to attend, this programme has started in Llanelli and Pembrokeshire

24. Hywel Dda Local Health Board Competencies for supervisors All IAPT supervisors have attended training in CBT supervision Supervision group for the supervisors set up About to introduce validated scale to assess competencies of the supervisors- Supervision:adherance& guidance evaluation (SAGE) instrument.

25. Hywel Dda Local Health Board Will it work? Audit to find out Have we increased access? Were the interventions effective? Were the patients satisfied with the service?

26. Hywel Dda Local Health Board The future Stage 2 is planned to begin in next few months and will be concerned with increasing access for people with established psychosis Discussions with Learning Disability services to include them in the project Discussion with Swansea University, School of Health Studies to accredit the training Training to become part of induction process for all mental health professionals?

27. Hywel Dda Local Health Board Now you can help us! What difficulties do you envisage introducing psychological interventions into TAU? Groups of 5 Brainstorm difficulties & solutions Feedback

28. Hywel Dda Local Health Board The challenge Integrating psychological interventions into ‘normal’ care Care coordination and CBT- can they mix ? Fitting it all in- giving psychological care equal status Changing the habits of a lifetime or several lifetimes….