1. De praktijk in Engeland afgezet tegen de Nederlandse situatie Mike Firn - Healthcare Consultant

2. www.factcongres.nl Overview Why we are adopting FACT in England Number of teams using FACT approach Contextual differences in UK healthcare and how they impact on FACT adoption and adaption /fidelity English FACT Research and evaluation key findings The future and affordability- preparing people for self-management in primary care

3. www.factcongres.nl

4. Why in England? – Evidence lacking for ACT compared to standard community team care ACT was mandated across England in 2001 but not been a success. English CMHTs have performed well in studies as the control arm and always offered many elements that are considered internationally part of the ACT repertoire e.g. Multi-disciplinary team approach, home based outreach care as normal. Evidence that ACT has not impacted on bed use in English RCT studies. Increased recognition that orthodox ACT population is not static; time unlimited offer of ACT no longer valid or affordable Low caseloads (expensive) do not correlate with reduced bed use in meta regression analysis

5. www.factcongres.nl Why in England? – Anticipated benefits of the FACT model The whole SMI population (the other 90% not served by ACT) gains access to a higher level of care flexibly according to need. Access to intensive episodes of home based care below threshold for Crisis Team Desirability of titrating care easily and flexibly according to current need offers efficiency and continuity of care (avoids delay and transaction costs of transfer and referral between teams) Emerging Evidence that FACT can offer an alternative to ACT that may reduce bed use, with fewer contacts and not increase crisis episodes FACT provides a manualised model of care lacking in CMHTs FACT is a compensatory model for small CMHTs and cuts in ACT or poor fidelity ACT. Allows for merging teams for critical mass of staff and elements of ACT best practice

6. www.factcongres.nl Why in England? – summary Affordability: We have to deliver better care with less money £15-20bn productivity challenge

7. www.factcongres.nl (Re)Integrating specialised services

8. www.factcongres.nl Services in the adult care pathway example Merton & Sutton pop n 390,000

9. www.factcongres.nl ACT lack of effectiveness in the English system ACTs in England have not been able to impact on admission rates for “difficult to engage” clients beyond the effect of crisis teams plus standard CMHT care  CMHTs able to prevent admissions as effectively as ACT using fewer face to face contacts and higher case loads  No advantage of ACT over standard CMHTs care on any measure of clinical outcome except satisfaction  ACT not been shown to be cost-effective  ACT style is more acceptable to “difficult to engage” clients and less coercive than standard approaches

10. www.factcongres.nl Configurations in decreasing fidelity to the orthodox ACT model that are now found. Originally 250± ACT teams

12. www.factcongres.nl Evaluation-Aims and hypotheses We wanted to evaluate whether patients would be disadvantaged by dismantling two specialised AO teams and offering an alternative integrated model. We anticipated that contact rates would fall as caseloads increased (12-25/30) and no weekend service. However based on lack of UK evidence for ACT we aimed to demonstrate non-inferiority in clinical effectiveness and thereby show cost efficiencies for CMHT with FACT

13. www.factcongres.nl mirror image study FACT 1 (1 yr) Start psychiatric history t i m e 12 months -> Close ACT teams and replace with integrated CMHT+FACT mirror <- t i m e 12 months n= 112 eligible patients

14. www.factcongres.nl mirror image study FACT 1 (3 yr) Start psychiatric history t i m e 3 years-> Close ACT teams and replace with integrated CMHT+FACT mirror <- t i m e 3 years n= 72 eligible patients

15. www.factcongres.nl 1 year 112 patients followed up 3 year 72 patients followed up

16. www.factcongres.nl 1 year 112 patients followed up 3 year 72 patients followed up

17. www.factcongres.nl 1 year 112 patients followed up 3 year 72 patients followed up

18. www.factcongres.nl 1 year 112 patients followed up 3 year 72 patients followed up

19. www.factcongres.nl 1 year 112 patients followed up 3 year 72 patients followed up

20. www.factcongres.nl Results - contacts per week 1 YEAR. Mean contacts per week fell from 1.75 per week with ACT to 1.23 per week for CMHT with FACT. 3 YEAR. Mean contacts per week fell from 1.35 per week with ACT to 0.86 per week for CMHT with FACT. No significant change in the percentage of these contacts being delivered face-to-face,

21. www.factcongres.nl Conclusion Enhancing multi-disciplinary CMHTs with FACT provides a clinically and cost effective alternative to specialist ACT teams. In the year 1 study we calculated productivity savings of £747,864 in bed days and £277,920 in contacts. £72,000 released as cash resulting from the staff savings from the closure of the AO teams

22. www.factcongres.nl Replication study FACT 2 Learn from limitations of previous study by also interviewing patients pre and post for: –patient experience CSQ-8 –team attachment questionnaire (22 items) –social isolation (3 questions) –Free comments hopes, fears, what’s better what’s worse? Repeat previous study in a different locality

23. www.factcongres.nl Patient experience (n=37/65 pre-post) Compared to ACT team care is anything worse about the new service? “Yes, they only see you once in three months and the doctor once a year. They rely on housing support services too much” Compared to ACT team care is anything worse about the new service? “Yes, they only see you once in three months and the doctor once a year. They rely on housing support services too much” Is there anything else you would like to tell us? “Medication was better distributed by the ACT team instead of going through the GP” Is there anything else you would like to tell us? “Medication was better distributed by the ACT team instead of going through the GP” Hypothesis, marginally less satisfied, similar team attachment, concerns re shift to more self management and recovery versus ACT team taking responsibility

24. www.factcongres.nl Controlling costs and activity in primary and secondary care

25. www.factcongres.nl ‘DBC’ care clusters allocated by need (HoNOS PbR) Existing in primary care (IAPT ) Shift to primary care

26. www.factcongres.nl Cluster profile Adult CMHT Cluster profile Older Persons CMHT Shift to primary care

27. www.factcongres.nl Self management support- Recovery college Curriculum of Self- management courses co-run by peer trainers ‘Educational’ and ’coaching’ approach inc. goal setting & shared decision making

28. www.factcongres.nl Health service usage 2011/12 Pre coursePost courseP value Completed >70% or more Occupied bed days (n=44)80.9378.00P = 0.705 Community contacts (n=430)23.5820.34P = 0.001 6 months Pre coursePost courseP value Completed >70% or more Occupied bed days (n=21)107.7185.90P = 0.02 Community contacts (n=155)42.0733.62P = 0.001 12 months

29. Thank you Mike Firn - Healthcare Consultant