1. IAPT-SMI Demonstration Site for Psychosis Professor Philippa Garety
South London and Maudsley (SLaM)
IAPT-SMI Demonstration Site for Psychosis
Professor Philippa Garety
Clinical Director, Psychosis Clinical Academic Group
Thursday 7 March 2013

2. Service users want equal access to psychological therapies
Rethink survey (2010)
Research suggests that only 1 in 10 access CBT, despite NICE guidance (Schizophrenia Commission, 2012)

4. The Abandoned Illness The Schizophrenia Commission
“Research has led to a range of evidence-based psychological treatments. We know much more about ‘what works’ than we used to. . . The committed individuals who went into the mental health profession to improve lives should be helped to do exactly that.” Prof Sir Robin Murray
This is where IAPT-SMI comes in

5. Obstacles to access

6. Dolly Sen, Service User Consultant
“I always asked for some kind of psychological therapy or talking therapy but was told, no, it was too dangerous. I had to wait 20 years for something that was the most beneficial thing. [Therapy] has changed my life basically.”
Talking to Norman Lamb on 19 December 2012

7. 69% of Trusts have funding challenges for providing access to psychological therapies for people with a diagnosis of schizophrenia
94% have encountered obstacles in making psychological therapies available, including insufficient skilled staff

8. Delays in accessing CBTp Peters et al 2009 (N=74)
Mean length of illness was 8 years (range 0-32)
Mean of 2.8 in-patient admissions (range 0-20)
96% were on antipsychotic medication

9. South London and Maudlsey NHS Foundation Trust: the context
Core population - 4 South London Boroughs 1.3million; inner city, very high indices of social deprivation
Substantially raised rates of psychosis
Psychosis Care Pathways

10. SLaM Psychosis Demonstration site: Increasing access in two care pathways
Early Intervention Pathway
(Southwark, Lambeth, Croydon & Lewisham)
STEP TEAM
IAPT-EI
The road to recovery
Promoting Recovery Pathway
(Southwark, Croydon & Lewisham)
IAPT-PICuP
IAPT-SHARP
Promoting Recovery Pathway
(Lambeth) 10

12. STEP TEAM

13. SHARP

14. What IAPT-SMI offers for service users
CBT for psychosis:
weekly or fortnightly individual 1 hour sessions
6-9 months therapy
Therapists receive weekly-fortnightly group supervision
FI for psychosis:
Fortnightly 1 hour sessions with client and carer(s)
Up to ten sessions, over a period of 3-9 months
Therapy delivered by two trained therapists

15. Overcoming obstacles to access

16. Work we have already done in SLaM
Ten point charter addressing barriers and facilitators:
Service user involvement
Quality criteria and staff training
Data gathering, data systems and outcomes
Care pathways, ensuring integrated effective care in Early Intervention & Recovery pathways

17. Psychological treatments are not a quasi - medication=

18. Quality
One key challenge has been a lack of clarity about quality – psychological therapy is different from a chemical compound
Lack of criteria have resulted in an ‘anything goes’ approach to psychological therapy in MH services, and inflated estimates of provision
We need nationally agreed criteria for training and competencies in CBTp and FI
IAPT-SMI is doing this
Locally we have already developed criteria and standards and established a portfolio of training opportunities

19. Training and Supervision

20. Training and Supervision
Portfolio of training opportunities in psychological therapies for psychosis, in partnership with KCL
Span the workforce from non-clinical to managerial/supervisory
Academically accredited training and in-service courses
Short courses and modules build to an award
Supervised practice strongly emphasised
Supervision and support for supervisors

21. Training structure in the SLaM site

22. Service user and caregiver involvement & co-production
Involvement in development, design and evaluation of psychological therapy services
Training design and delivery
Co-produced workshops at SHARP and in the SLaM Recovery college
Co-working in group interventions: Hearing Voices; Mindfulness; Acceptance & Commitment Therapy
Training, supervision and support (practical, financial and emotional)
Personal development – CPD, co-authorship, conference attendance

23. SLaM demonstration site strategic approach to improving access to therapy
A 50% increase in access with the funding provided
Reduced waiting times
Implementation of our 10 Point Charter, with highly trained staff, and care pathways
Clear referral pathways, including self referral
Regular assessment of progress in therapy
Close and frequent supervision
Assessing improvement in a range of outcomes and in health economics

24. Effectiveness

25. Clinical outcomes: Service-user reported symptoms

26. Evidence of clinical outcomes with medium-large effect sizes
– voices and delusions
89% (voices) & 90% (delusions) have paired data at end of therapy
Effect size = mean 2 – mean 1 / sd of mean 1
This graph shows a reduction in psychotic symptoms
[voices (effect size: .73) and delusions (effect size: .59)]
following therapy (PICuP)

27. Evidence of clinical outcomes with medium-large effect sizes – anxiety and depression
85% have paired data at end of therapy
Effect size = mean 2 – mean 1 / sd of mean 1
This graph shows a reduction in emotional problems
[anxiety (effect size: .47) and depression (effect size: .55)]
following therapy PICuP

28. 85% (QoL) & 67% (CHOICE) have paired data at end of therapy
Evidence of clinical outcomes with medium-large effect sizes – quality of life (QoL) and recovery
85% (QoL) & 67% (CHOICE) have paired data at end of therapy
Effect size = mean 2 – mean 1 / sd of mean 1
This graph shows an increase in people’s quality of life (measured on the Manchester Short Assessment of Quality of Life; effect size: .51) and recovery ratings (measured on the CHOICE; effect size .79)
following therapy

29. Cost-effectiveness

30. Randomised Controlled Trial (Peters et al, 2010) – therapy costs are off-set by fewer inpatient costs at 3 months follow-up
(N = 74)

31. Reduction in service-use costs (admissions & home treatment team days) in the year following therapy, compared to the year prior to therapy (Wilcoxon test: p <.05*)
Data obtained from ePJS, Jan 2012
N = 70

32. Progress and preliminary outcomes

34. New clients - demographics New clients in the service
Variable
New clients in the service
Age distribution
Mean 38 years (18-70)
Gender
43% male, 57% female
Ethnicity
36% white, 64% BME

35. Demonstration site CBTp & FIp referral targets are being achieved
Existing
Projection
Monthly Referral Target (over 12m)
Progress at
4 months
CBT FI
106 15 50 10 14
2-3 95 11

36. 35 7 23 57 60% Waiting times are reduced (in days)
Referral received to opted-in
Opted-in to assessed
Assessed to receiving therapy
Total %
reduction in waiting times 35 7 23 57
60%

37. Health Utilisation data Mean number of days in 12m before therapy
Service
Mean number of days in 12m before therapy
Mental health admission
10.5 (0-126)
Crisis team / home treatment
0.7 (0-23)
Psychiatric liaison (A&E)
0.1 (0-2)

38. IAPT-SMI: CBT assessments
 Pre
PSYRATS – Voices & Beliefs 
WEMWBS
WSAS
EQ-5D
Short CHOICE
CORE-10
Brief IPQ
Measures Feedback
3-monthly
PSYRATS – Voices & Beliefs
Satisfaction with therapy 
Post
Satisfaction with therapy
Short CHOICE weekly

39. IAPT-SMI: Carer assessments
 Pre
Experience of caregiving inventory
WEMWBS
DASS-21
CORE-10
IPQ carer version
Confidant question
Measures Feedback
3-monthly
Satisfaction with therapy 
Post
Satisfaction with therapy

40. Patient Reported Outcome Measures
Completion rate
Session by session short CHOICE
81% of attended sessions
Pre-therapy:
PSYRATS
Questionnaires
98%
100%

41. London Tonight report from 19 December 2012 – visit to SLaM by Norman Lamb, Care and Support Minister and the official launch of the IAPT-SMI demonstration sites:

42. Dr Miriam Fornells-Ambrojo,
Operational Group
Dr Louise Johns,
Project Lead
Dr Miriam Fornells-Ambrojo,
IAPT-EI Lead
Rosanna Michalczuk Bina Sharma
Psychology Assistants
Dr Suzanne Jolley,
Lambeth Recovery
Psychology Lead
Dr Craig Milosh, Clinical Psychologist, SHARP
Devon Elliott, Business Intelligence Analyst
Dr Juliana Onwumere, FI Lead

43. Steering Group Lucy Canning, Psychosis CAG Service Director
Prof Philippa Garety, Psychosis CAG Clinical Director
Jonathan Beder, Psychosis CAG Deputy Director, Business and Performance
Dolly Sen and Garry Ellison, Service User consultants
Roger Oliver and Lorna Wilkinson, Carer consultants
Prof Tom Craig, Consultant Psychiatrist, SHARP
Marieke Wrigley, Team Leader, SHARP
Prof Elizabeth Kuipers, NICE Schizophrenia guideline lead
Dr Emmanuelle Peters, PICuP Director
Adrian Webster, CAG Psychological Therapies Lead
Jo Lawrence, Clinical Service Lead, EI
Dr Sarah Dilks, Lead Psychologist, Promoting Recovery pathway
Dr Eric Morris, Lead Psychologist, Early Intervention pathway
Penelope Fell, Head of Business Development
Dorothy Abrahams, Administrator

44. Thank you for listening!
You are welcome to our SLaM Demonstration Site Visit
Monday 1 July pm