1. Improving Access to Psychological Therapies in England
Dr Alan Cohen FRCGP
Director of Primary Care
West London Mental Health Trust

2. What I am going to cover Why IAPT evolved
What it is
Implementation issues
Engaging primary care
NICE guidelines, and its relation to IAPT
Treatment guidelines
This slide could be combined with the previous slide.

3. What I am not going to cover
Why the NHS is better (or worse) than the U.S. system
Whether socialism is better than capitalism for health care
Whether the health care reforms in the U.S. (or UK) are a good thing
Anything else even vaguely political!

4. How the NHS works Health care free at the point of delivery
Funded by central taxation
Primary Care
30,000 GPs (and teams) working from 10,000 practices
There are 350 hospitals providing about 160,000 beds

5. Performance management
Organisationally
Performance management
Policy DH
SHA
PCTs
GPs and Hospitals

6. Translating the Special Relationship
The NHS works on the principle of a purchaser:provider split
Purchaser of health care = commissioner
Provider of health care = GP or Trust
The local purchaser commissions for the local population
There is considerable variation in provision of services throughout England – there is no single immutable care pathway for anything

7. What is IAPT? I - Improving A - Access to P - Psychological
T – Therapies
A commissioner led, outcome focused programme to deliver improved access to psychological therapies, through the implementation of NICE guidelines
What is a commissioner?

8. This is the man responsible…

9. The IAPT Programme 2004: 10 Downing Street seminar on worklessness
2005: Manifesto commitment to improving access
2005: 2 Demonstration sites in Doncaster and Newham
2007: 10 Pathfinder sites

10. The IAPT Programme 10th Oct 2007 – World Mental Health Day
New Funding over 3 years
$53m in 2008
$166m in 2009
$279m in 2010
To deliver
Treatment for 900,000 people
3,500 new therapists
New Government committed to continue support
In total $1,200m programme

11. System TransformationDH
SHA
PCTs
GPs and Hospitals
Policy Imperative
Key Performance Indicators
Engage professional bodies
Voluntary sector campaign
Regional and local management structure
Clinical
Networks
Clinical
Leadership

12. What is NICE?

13. NICE
2004: Produced guidelines on the management of depression and the management of anxiety
2009: reviewed and updated guidelines

14. NICE Guidelines
IAPT implements NICE guidelines for depression and anxiety disorders
Only evidence based approaches included in NICE guidelines are intended to be implemented through IAPT teams
Stepped care essential

15. We will have this in the participant’s packet
We will have this in the participant’s packet. This slide is probably enough at this point with a little explanation from you and an indication that you are going to review the guidelines in depth later.

16. The way it used to be… Some GP practices had counsellors
No referral guidelines
No treatment guidelines
No way of monitoring use of evidence based interventions
No way of measuring success of treatment
About what %% of GPs used to have counsellors in their practices?
The methods for “monitoring and measuring” would be useful to explore in more depth later in the presentation.

17. The Vision Everybody has access to high quality therapists
Use evidence based referral and treatment guidelines
Monitor outcomes
What we came up with …

18. Characteristics of the IAPT service
Commissioner led
Commissioned against outcomes
A team approach to management of people with common mental health problems
Low intensity therapists
High intensity therapists
GP champions
Others as needed
A team per 250,000 population
40 therapists per team
60:40 split between high and low intensity therapists

19. Implementation New Staff Engage professional bodies
New ways of working
Engage professional bodies
Clinical leaders locally, and local networks
Dissemination of information
Develop evidence based outcomes

20. “New Ways of Working”
Focus on care pathway, and what is required by the patient, not what professionals choose to offer
Requires the review of traditional professional roles, and creation of new roles if neccessary

21. A Care Pathway

22. Training New Staff A need to recruit and train new staff
Not re-allocate current staff
Competency based (new ways of working)
Develop a curriculum
Identify educational establishments to deliver the training
Quality Assure the training
Deliver the training
What did you do to get the 3,600 therapists/counselors trained and placed. Explain the competency based training including who was trained (credentials type of training and supervision, placement ….more about the structure and content of the national training effort.

23. Therapists Low Intensity – 2nd Step High Intensity – 3rd Step
Up to 4 – 5 sessions
Face to face, or telephone contacts
Skilled to deliver a variety of evidence based interventions
Delivers high volume contact
High Intensity – 3rd Step
Usually 12 – 20 sessions
Face to face therapy
Skilled to deliver CBT and other evidence based interventions 23

24. How many staff are needed?
An excel spreadsheet [check link] that calculated the number of new staff needed for a given population
Worked on assumptions
Population, morbidity, response to treatment etc
Number of sessions needed to treat a disorder
Add in cost of staff (national pay scales)
Used to estimate cost of a new service

25. How did the teams work?
Different teams discovered their own ways of working
Innovation
ownership
Team location
Supervision essential to high quality care
Links to other providers, primary care, and specialist mental health trusts
A requirement that the MDS was recorded on an approved database

26. Evidence Based Outcomes
Reviewed what questionnaires were available already
Identified those that were free to use
Agreed when the questionnaires were to be used
Agreed cut off scales
Recovery vs improvement
Plan to “Pay by Outcome” in 2012/2013

27. The MDS Clinical Choice and satisfaction Employment
PHQ-9, GAD-7, anxiety disorder specific measures
Choice and satisfaction
Employment
Quality of life (WHODAS)
I don’t understand this slide?

28. Benefits of an MDS Patient benefits Therapist benefits
Supervisor benefits
Commissioning benefits

29. Findings from Wave 1 sites
IAPT services appear to be beneficial to patients with clinical presentations that vary from mild to severe
Recovery vs improvement
Self referred patients were as severe as referred by GPs, but recovered in less sessions
Services that made good use of stepped care have higher recovery rates.
Patients were more likely to recover if they were seen in services that saw more patients
Can you get into more detail with this and next slide. The population prevalence, data collection, outcomes (data). Thanks

30. Findings from Wave 1 Sites
Compliance with NICE treatment recommendations associated with better outcomes
Provisional diagnoses are important to ensure patients receive NICE recommended treatments
Services that had a higher proportion of experienced therapists, had overall recovery rates
Certainly the first statement supports the reasons for using scientifically rigorous tx recommendations (NICE)

31. Challenges… Validity of NICE guidelines Tribal politics Money
Training new staff
Engaging primary care
What do you mean by the “validity of NICE guidelines”? I am concerned that based on the next slide you (or others) don’t support the evidence based guidelines. I understand that the implementation of guidelines must be tempered somewhat by clinical judgment but the consistent use of evidence based guidelines is one of the major reasons for our interest in the IAPT. Certainly there is always some resistance and that is a legitimate challenge. Please let me know. Also is the item “training new staff” necessary?

32. NICE guidelines Guideline structure is “rigid”
Dependence on a hierarchy of published research
Philosophical approach to “mental illness”
Why we had to use NICE guidelines
See previous slide

33. Tribal politics Psychologists/Therapists
Some interventions were not included in NICE guidelines
Enormous educational agenda
Mental health vs. physical health
GPs were skeptical (this was a mental health intervention)
FYI ..we call this professional “cultural differences”

34. Money Lots of new money How to allocate that resource
Equality vs innovation

35. Engage Primary Care
General practitioners were seen as crucial to success of programme
Mental health staff thought that primary care are “not interested” in mental health problems
Relationship with physical health, and medically unexplained symptoms
What has been done about this? Also how have patients been engaged?

36. Professional Engagement
A public statement from the leaders of ALL the primary care organisations that they supported this programme
Each team HAD to have a local GP leader
Provide training and support to the local leaders
Identify learning needs

37. Clinical Engagement
Help mental health staff realise that managing depression/anxiety had a significant impact on physical long term conditions
Develop work on savings accrued by providing psychological support to people with LTC/MUS
Educate mental health commissioners
Develop a national special interest group in psychological management of LTC/MUS

38. LTC/MUS Ground breaking research
linked databases
Improved clinical outcomes
significant savings possible
Engaged primary care clinicians not “interested” in mental health
Engaged acute hospital colleagues not “interested” in mental health
Introduction of collaborative care
Part of national policy

39. Next session What is the stepped care approach?
Savings and clinical pathways for people with LTC/MUS
Proposed changes to the NHS?

40. In memoriam Prof John C Nemiah
Emeritus Professor of Psychiatry, Dartmouth Medical School

41. Thank you More information Alan Cohen: doctoralancohen@mac.com
Thank you

42. NICE GUIDELINES
Breakout Session MeHAF Integrated Care Learning Community November 4, 2011 Bangor, Maine

43. Stepped Care

44. Step 1
Be alert to possible depression (particularly in those with previous depression or a chronic physical health problem).
Consider asking “During the last month have you often been bothered by:
Feeling down, depressed or hopeless?
Having little interest or pleasure in doing things?”
If the person also has a chronic physical health problem, consider asking three further questions
“During the last month have you often been bothered by:
Feelings of worthlessness?
Poor concentration?
Thoughts of death?”

45. Step 1b
Conduct a comprehensive assessment that does NOT rely simply on a symptom count.
Consider
The degree of functional impairment
The duration of the episode
Explore the following:
History of depression or co-morbid mental/physical health problems
Past history of mood elevation
Response to previous treatments
Quality of interpersonal relationships
Social history including employment
If the person has a learning disability or cognitive impairment consider seeking advice from a specialist when developing a treatment plan.
Always ask a person with depression about suicidal ideation and intent.
If there is a risk of self harm or suicide:
Assess whether they have adequate social support
Arrange help appropriate to the risk
Advise them to seek help if the situation deteriorates
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46. Step 1c
If the person presents with considerable immediate risk to themselves or others, refer them urgently to specialist mental health services
Advise the person and their carers, of the following:
The potential for increased agitation and suicidal ideation early in treatment
The need to be aware of mood changes particularly when changing treatments
If the person is assessed to be at risk of suicide, consider:
Providing increased support
Referral to mental health specialists
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47. Step 2
Treatment options for people with sub-threshold or mild/moderate depression include:
General measures
Sleep hygiene
Active monitoring
Drug Treatment
For people without physical health problems
For people with physical health problems
Psychological interventions
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48. Step 2 General Measures: Sleep Hygiene: offer advice including:
Establishing regular sleep and wake times
Avoiding excessive alcohol, eating or smoking before bedtime
Creating a proper environment for sleep
Taking regular physical exercise
General Measures:
Active monitoring: for those people who do not want an intervention, who may recover spontaneously, or those with sub-threshold symptoms who request an intervention
Discuss the presenting problem
Arrange a further assessment in two weeks
Provide information about depression
Make contact if the person does not attend appointments
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49. Step 2
Drug Treatment
Do NOT use anti-depressants routinely to treat sub-threshold symptoms or mild depression but consider them for people with:
A past history of moderate/severe depression
Initial presentation of sub-threshold depression for two years
Symptoms that persist after other interventions
Drug Treatment for people with a chronic physical health problem
Do NOT use anti-depressants routinely to treat sub-threshold symptoms or mild depression but consider them for people with:
A past history of moderate/severe depression
Initial presentation of sub-threshold depression for two years
Symptoms that persist after other interventions
Mild depression that complicates the care of the physical health problem
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50. Step 2 Psychological and psychosocial interventions.
For people WITHOUT a chronic physical health problem
Offer one or more of the following interventions:
Individual guided self help
Computerised CBT
Structured group physical health activity
For those who decline any of the above, offer group based CBT
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51. Step 2 Psychological and psychosocial interventions.
For people WITH a chronic physical health problem
Offer one or more of the following:
A structured physical activity programme
A group based peer support programme
Individual guided self help based on CBT principles
Computerised CBT
The above interventions are modified to reflect the physical health needs of the person, and the inter-relationship between depression and the physical disorder
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52. Step 3
Treatment Options for people WITHOUT a chronic physical health problem:
For people who have not benefitted from a low intensity intervention (see Step 2) offer
An SSRI OR
A high intensity intervention i.e.
Cognitive behaviour therapy (CBT)
Interpersonal therapy (IPT)
Behavioural activation
Behavioural couples therapy
For people who decline the above consider counselling or short term psychodynamic psychotherapy
For people with moderate or severe symptoms combine CBT/IPT with drug treatment
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53. Step 3
Treatment Options for people WITH a chronic physical health problem:
For people who have not benefitted from a low intensity intervention (see Step 2) offer
An SSRI OR
A high intensity intervention i.e.
Cognitive behaviour therapy (CBT)
Group based CBT
Behavioural couples therapy
For people with severe symptoms combine CBT with drug treatment
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54. Step 3 Take into account risk of overdose:
Compared with other equally effective antidepressants Venlfaxine is associated with greater risk of death in overdose
Greatest risk of death in overdose associated with Tricyclics (except Lofepramine)
When prescribing other than SSRIs consider:
Increased likelihood of side effects
MAOIs, and Lithium should only be prescribed by specialists
Dosulepin should not be prescribed
Prescribing for older adults:
Prescribe age-appropriate doses
Monitor carefully for side effects
Dosulepin is NOT recommended
Choosing an antidepressant:
Discuss choice covering:
Anticipated side effects
Potential interactions
Persons perception of likely efficacy
Normally choose an SSRI; consider that:
SSRIs are associated with increased bleeding – consider gastro-protection measures
Fluoxetine, Fluoxetine, and Paroxetine have a higher propensity for drug interactions
Consider Citalopram or Sertraline as they have a lower propensity for interactions
Paroxetine is associated with higher incidence of discontinuation symptoms
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