1. Newham Improving Access to Psychological Therapies a partnership between Newham Primary Care Trust East London NHS Foundation Trust

2. Evidence Based Choices & ‘Complexity at the coalface’ Dr Ben Wright Lead Clinician Newham IAPT

3. Three dimensions of complexity Complexity of context –(Choice & Access) Complexity of systems –(Treatment Choice) Clinical complexity –(Choice outcome)

4. London Borough of Newham Very Diverse 61% BME 130+ Languages Deprived 44% live in poverty 20% intense poverty 40% greater demand for mental health services

5. Access - Pathways into Service Self Referral Formal referral by professional Telephone Assessment Flexible Engagement, Full Assessment & Treatment GP Occupational Health Resident in Newham Community Groups Pathways to work referral Routine screening of new IB claimants Secondary MH

6. Source of Referral (n=5,064)

7. Overall BME Access 64% of referrals from BME groups in 2008 66% of Newham residents come from BME groups

8. Impact of source of referral on access

9. Impact of source of referral on access for Men

10. Impact of source of referral on access for Women

11. Key points GP referral remain central to access process Must be supplemented by multiple points of access Different sub-groups respond differently to access points

12. Three dimensions of complexity Complexity of context –(Choice & Access) Complexity of systems –(Treatment Choice) Clinical complexity –(Choice outcome)

13. NICE Clinical Guideline 90 - Oct 2009 (partial update for depression guide, Research recommendation) 4.8 “In people with mild, moderate or severe depression, what system of care (stepped care versus matched care) is more clinically effective and cost effective in improving outcomes?” (Page 51)

14. Matched Care Pathway Used in Phase One of National IAPT Pilot, May 2006-07 Flexible engagement by assistant Referral – Mainly GP Formal High Intensity CBT Assessment by Qualified Therapist Other Services Low Intensity CBT

15. Semi-Stratified Stepped Care Pathway Brief Telephone Assessment (Qualified therapist) Low Intensity (CBT Based) Assessment & Intervention All Referrals Formal High Intensity CBT Assessment & Intervention Other Services Employment Support Service Administrator calls & offers appointments  

16. System – care pathway flow – impact on recovery rates

18. System – care pathway flow- impact on productivity

20. Three dimensions of complexity Complexity of context –(Choice & Access) Complexity of systems –(Treatment Choice) Clinical complexity –(Choice outcome)

21. Outcome of Low Intensity Care

22. Outcome of High Intensity Care

23. Equity of outcome Care pathways did have slightly different treatment of some BME groups (e.g. greater proportion Asian & Asian British people going direct to high intensity) however there were similar recovery rates for different BME groups for both Low and High Intensity care Having Low intensity care first did not alter drop out rate for High Intensity care.

24. Conclusion – what is needed? Clinicians need regular, good quality supervision Clinicians need easy access to a hierarchy of in-house experts –Includes medical psychotherapy & general psychiatry Integrated care pathways –Disaggregation reduces access, flow & quality Good IT system for managing monitoring and directing patients flow through care pathways