1. Buckinghamshire Healthy Minds Dr John Pimm, Clinical Lead Madhur Virathajenman Deputy Clinical Lead Thanks to David M Clark, National Clinical Advisor for Adult IAPT, University of Oxford The Common Mental Health Disorders Fingertips Tool and using PDSA to improve Recovery in Buckinghamshire

2. IAPT So Far  Revolutionized treatment of anxiety & depression  Stepped care psychological therapy services established in every area of England.  Approx 13-14% of local prevalence seen in services  Around 60% have course of treatment (430,000 per year)  Outcomes recorded in 97% of cases (pre-IAPT 38%)  Very strict (depression & anxiety) recovery criteria  Nationally 46% recover and further 15% improve.  59 CCGs have recovery over 50%, some over 60%.  Variability must be the next focus.

3. What should a good IAPT look like?  Access 15% or more  Majority of patients have course of treatment  Adequate dose of therapy in line with NICE  Recovery rates 50% or more  Reliable improvement higher

4. How can commissioners and clinicians see how their service is doing?  IAPT has a very rich dataset.  Local reports can be generated by services  All services upload 50 data items on each patient to HSCIC for central processing each month  HSCIC issues reports monthly, quarterly, annually. BUT  Public Health England (PHE) Mental Health, Dementia and Neurology Information Network’s Common Mental Health Disorders Profiles (Fingertips) Tool is the most accessible source for benchmarking.

6. Thames Valley CCGs

7.  IAPT Pathfinder and 1 st wave site  One of two IAPT services provided by Oxford Health  LTC Pathfinder – COPD  Partnerships – Richmond Fellowship employment advice, - Relate couples therapy  Well established regional network IAPT services  AHSN IAPT network Buckinghamshire Healthy Minds

8.  Referrals Jan-Dec 2014 8,781  Entering tx Jan-Dec 2014 6,614  Bucks Estimated no. anxiety depression 43,357  Proportion entering tx 75.32%  Proportion of prevalence entering tx 15.25%  65 and over entering tx 15.06%  BME entering tx 14.46%  LTC entering tx 31.19% Buckinghamshire Healthy Minds continued…

9. Plan, Do, Study, Act (PDSA) Langley, et al (2009)

10.  Average recovery rates below 50%  Variation over time, location and step  Difference between recovery rate and reliable improvement (people discharged after making good progress but not getting to recovery)  Repeated attempts to understand and intervene small and short term effect The Problem - PLAN

11. Recovery Rate 2013 (by month)

12.  Review of clinical notes for all patients discharged not recovered  Identify themes/common patterns in the data What did we DO?

13.  Clients discharged with reliable improvement but not recovered  Clients stepped out to counselling above caseness  Clinicians unaware or not attending to cut offs  Clients stepped up without a trial at step 2  Failure to repeat ADSM Study - Themes and patterns

14.  Monthly performance report for all therapists includes Attendance, Recovery rate, DNA Rate, Completion Rate, Targets, etc.  Change procedures, training and supervision  Asked staff to aim for 65% recovery  Check recovery rate weekly, check practice changed, feedback to staff regularly  Adherence to the stepped care model  Adequate dose of treatment step 2/3  Offering CBT, IPT, EMDR, Mindfulness, couples therapy for depression at step 3  Simultaneous PDSA cycles ACT

15. Recovery Rate Sept 2013 – Dec 2014

17. Buckinghamshire – IAPT Waiting times

18. Change in Referrals, Entering Treatment & Treatment Completers

19.  Continued attention to service, team & individual recovery rates  Identifying & tackling new and old themes  Staff turnover & drift – need to train & re-train  CPD – developing expert practitioners (Tracey, et al. 2014)  Recovery rates – problem descriptors PTSD, social anxiety etc. Maintaining Change

20.  Examine your data  Improve your data quality  Study people discharged non-recovered – identify themes  Facilitate & monitor change with a structured improvement methodology e.g. PDSA Key Learning

21. How can this be achieved? (1)  Outcome data on everyone (> 95%)**  Wait to treatment low (> 75% start in 6 weeks)**  Problems being treated identified in everyone (ICD-10 codes).**  Type of Therapy in line with NICE guidance**  Adequate dose of therapy in line with NICE guidance** (service average 8-10 sessions per course of treatment)  Good use of stepped care**  Choice of therapies for depression (CBT, IPT, couples therapy, counselling, brief psychodynamic). Just CBT for anxiety.

22. How can this be achieved? (2)  Adequate size workforce (nationally we are too small)  Core of experienced staff (at least third)  Excellent clinical leadership  Recovery focused  Attention to service and therapist outcomes (feedback)  Create inquisitive, supportive, work environment  Weekly helpful supervision for all staff  Tailored CPD programme for staff

23. Proportion of Estimated Buckinghamshire Population Prevalence Entering Treatment

24. Access - % Entering Treatment Within 28 days

25. Number waiting for step 3 treatment

26. Step Up Rates

27. Treatment Dose

28. Clinical Activity: Number of Treatment sessions provided

29. Clinical Activity: Number of minutes of treatment provided

30. Number of Attended Sessions for Completed Cases

31. Total Minutes Attended for Completed Cases