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IAPT

Programme

Progress

Report

Els Drewek

Head of Intensive Support IAPT Mental Health Unit

NHS England (els.drewek@nhs.net)

April 2015

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Adult IAPT Programme

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NHS Mandate – 2015/16

3.9 ………..extending and ensuring more open access to the Improving Access to Psychological Therapies (IAPT) programme, in particular for children and young people, and for those out of work, and to continue planning for country wide service transformation of children and young people’s IAPT. NHS England will work with stakeholders to ensure implementation is at all times in line with the best available evidence. NHS England will maintain the commitments that at least 15% of adults with relevant disorders will have timely access to IAPT services, with a recovery rate of 50%. In addition, NHS England will ensure that by March 2016, 75% of people referred to the IAPT programme begin treatment within 6 weeks of referral, and 95% begin treatment within 18 weeks of referral.

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July August September October November December January

Referrals 93,175 85,563 103,171 113,287 103,277 89,218 112,683

Referral Rate 18.29% 16.79% 20.25% 22.23% 20.27% 17.51% 22.12%

Entering treatment 68,808 56,150 66,571 72,278 68,515 61,285 76,749

Annualised Access

Rate 13.50% 11.02% 13.07% 14.19% 13.45% 12.03% 15.06%

Completers 39,351 35,274 40,567 42,444 38,738 37,031 39,790

Ave Waiting (Days) 34.2 33.8 32.3 28.5 28.1 31.5

Less than 6wks Wait to

Treatment 74.8 74.2 75.4 75.9 76.9 77.5

Less than 18wks Wait

to Treatment 94.2 93.8 94.3 94.5 94.5 95.3

Recovery Rate 44.4 45.0 44.2 44.7 43.9 45.1

No of working days 23 20 22 23 20 21 21

Access Daily Average 2,991.65 2,807.50 3,025.95 314,252.00 3,425.75 2,918.33 3,654.71

HSCIC – new monthly reports – Up to January 2015

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Adult IAPT What Next?

• Address Variation (Equity) – Access & Recovery

• Improve Choice – Provider & Treatment

• Introduce Waiting Time Standard

• Integrate provision with physical health care

pathways

• Improve access within mental health care

pathways

• Introduce an outcomes based currency and tariff

• Improve employment support

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IAPT Currency

Implementation

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IAPT PILOTS – TIMELINE

IAPT for Long Term Conditions (LTC) / Medically Unexplained Symptoms (MUS)

Piloting IAPT for people with long term conditions and/or medically unexplained symptoms including diabetes, COPD, stroke and other illnesses/disorders.

NHSE April 2015 Economic and clinical evaluation will be completed

IAPT for Severe Mental Illness (SMI) / Personality Disorder (PD)

A pilot to improve access to psychological therapies for people with severe mental illness (inc bipolar disorder, PD and psychosis).

NHSE Summer 2015

Financial and economic analysis to be completed

IAPT and Employment Pilot

To test the impact of referring ESA claimants participating in the Work Programme to IAPT for talking therapy.

DH/DWP/NHSE

Nov 2015 Assessment of Initiative undertaken by DWP and Cross Government Internal report published

IAPT Currency Development

A pilot to develop an outcomes-based payment approach for IAPT services.

NHSE 2016/17 Currency available for use with local prices

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Monitor / NHS England’s Framework

for Mental Health Payment Systems

Ensures Parity of Esteem

Financially transparen

t

Promotes Best

practice

Supports new

models of care

Outcomes focussed

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NHS England’s Priorities for Commissioners

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By April 2015 all contracts to be underpinned by an

understanding of need, evidence-based responses to need and

expected outcomes

By April 2016 all contracts to include clear incentives for the

delivery of outcomes, outcome and quality driven payment

models will have been introduced in a limited number of areas

AND have robust data on cost, activity, quality and outcomes

By April 2017 a wholesale shift to tariff based outcome-focused

contracting

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• 2015/16 - IAPT Currency Market Assessments

• Provider performance will be assessed against currency

model by central team;

• Develop local prices, business rules and guidance

• Commissioners to develop clear understanding of

local need informed by provider clustering.

• 2016/17 - IAPT Currency Road Test

• Shadow Implementation of Currency

• Contracts to underpin shadow implementation of

currency model; or, live implementation with risk-

share arrangements

• 2017/18 - IAPT Mandatory currency with local prices

• Contractual implementation of IAPT Currency Model

Implementation of IAPT Currency

aligned with these priorities

Referrals and Access

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Achieving and Sustaining Access Rates

Are referral rates sufficient to deliver 3.75% access rates each quarter taking into account known attrition rates?

• Nationally 35% of patients referred do not enter treatment.

• Only 7 out of 17 Lancashire and Greater Manchester CCGs had sufficient referrals (net of attrition rates) in Q3

• There is good evidence that long waiting lists suppress referrals.

Is there a clear longer term strategy (CCG / HWBB / PHE) with immediate priorities and a marketing plan including:

• Simplified access and self referral routes

• Truly primary care and not medically led

• Links with physical health

• Early intervention and valuing the benefit Step 2 therapy can make to wellbeing of the population including specialisation of PWPs

• Maximising older people access and BME Access

Recovery and Reliable

Improvement

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Diagnosis Analysis – Q2

Problem Descriptor Finished course of

treatment

Not at Caseness Recovered Recovery Rate

(%)

F10 - Mental and behavioural disorders due to use of alcohol 75 15 15 25.0

F50 - Eating disorders 215 30 70 38.6

F33 - Recurrent depressive disorder 4,350 230 1,635 39.7

F43 - Reaction to severe stress, and adjustment disorders 3,560 300 1,370 42.1

F99 - Mental disorder, not otherwise specified 4,855 800 1,730 42.6

F31 - Bipolar affective disorder 110 15 40 43.3

Other ICD10 code 1,745 170 700 44.3

Z63 - Oth probs related to prim sup grp, inc family circumstances 870 125 335 45.0

F32 - Depressive episode 18,780 1,350 7,865 45.1

F40 - Phobic anxiety disorders 3,590 605 1,375 46.1

F42 - Obsessive-compulsive disorder 2,000 185 870 48.0

F41 - Other anxiety disorders 36,025 3,170 16,060 48.9

F45 - Somatoform disorders 830 95 405 55.2

Invalid Code 220 45 100 58.7

No code provided 37,475 4,530 13,795 41.9

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Ordered by recovery rate, with the lowest recovery rate first.

Based on quarterly supplementary analysis and displayed at 3 digit ICD10 code

level in line with v1.5 reporting Data source: Improving Access to Psychological Therapies (Adult IAPT) Dataset

Data Quality and Provisional Diagnosis

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Few providers are giving a valid Anxiety disorder specific measure that is relevant to the diagnosis. In these

cases GAD7 will be used instead of an ADSM.

Provisional Diagnosis (now Problem Descriptor) recording has shown improvement and is now at 60%

Recording of therapy type is still lower than in version 1, but has increased from 59% to 70% validity. This

rise in validity is responsible for the variation between version 1 and version 1.5 entering treatment figures in

the October Final activity data.

New data quality measures have been introduced with version 1.5 of the dataset.

>= 80 70 - 79 60 - 69 50 - 59 40 - 49 < 40

Oct13 Nov13 Dec13 Jan14 Feb14 Mar14 Apr14 May14 Jun14 Jul14 Aug14 Sep14 Oct14

75 75 76 77 77 77 77 77 77 69 71 71 7210 9 9 9

75 77 80 82 81 79 83 80 84 98 98 98 98

91 94 95 96 96 97 97 97 97 96 95 96 96

93 93 92 93 93 93 92 92 93 94 94 93 93

93 93 93 92

97 96 98 99

93 93 92 93 93 93 92 92 93 93 94 93 93

51 52 52 52 53 53 53 53 53 50 52 58 60

80 79 79 87 87 86 86 85 85 59 66 68 70Therapy Types (1-4)

Provisional Diagnosis

Patient Health Questionnaire (PHQ9) Score

Organisation Code of Commissioner

NHS Number

Generalised Anxiety Disorder (GAD7) Score

General Medical Practice Code

Appointment Type

Anxiety Disorder Specific Measures

Validity by Data Item (Valid %): October 2013 to October 2014 Final

NATIONAL

Data source: Improving Access to Psychological Therapies (Adult IAPT) Dataset

Recovery and Reliable Improvement

Summary • For 2015-16 the KPI is the 50% Recovery. However, Recovery and Reliable

Improvement are equally important as they measure different things and services need to understand how their performance varies from the national average on both.

• Commissioners and the providers need to understand through sound audits or root cause analysis why the recovery rate is not being reached so that the cause can be addressed.

• On reliable improvement, if a service is below average it equally needs to be understood through audits why high numbers of patients do not show reliable change/improvement.

• Recommendations –

– Monitor both together at all times.

– Make the link between presenting condition/diagnosis during treatment, NICE guidance for that condition and therapy offered

– Understand outcomes by Step, by Team, by modality, by therapist

– Offer choice of therapy by commissioning the full range of NICE Recommended modalities so that it meets the needs of your population

Waiting Standards

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Measurement of the standard

• Guidance was published on 20 February to support

measurement of the new waiting time standard.

• The new national indicators will measure waiting times

from referral date to the start of a course of treatment –

i.e. for those people who have two or more treatment

sessions.

• Local areas will also be required to capture and monitor

waits from referral to first treatment appointment for all

people who enter the service and this should include

people who receive a single treatment session.

• Patient-initiated delays will not be taken into

consideration when calculating the IAPT indicator.

Tolerances have been built into the IAPT standard to

allow for such delays.

• A number of additional measures will be captured in

national reports to guard against the introduction of

perverse incentives into local commissioning

arrangements

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Improving Access to IAPT – Waiting Times

Improving Waiting times for Psychological Therapies (IAPT) Guidelines

and FAQs, http://www.england.nhs.uk/2015/02/13/mh-standards/

Access & Waits -operationalisation Focused on entry to a course of treatment in order to ensure the standard doesn’t

introduce a perverse incentive into local commissioning arrangements affecting current

case mix or encouraging providers to:

Increase the proportion of patients offered a single session of assessment and advice,

rather than a course of therapy;

Reduce the average number of sessions that are given to those people who have a

course of therapy;

Introduce artificial treatment starts where patients have an early appointment but are

then put on an ‘internal’ waiting list. Monitoring of contextual indicators with a time series analysis to set the historical context

and determine variance; enabling quality assurance of service provision. These include:

Average number of sessions

Numbers completing treatment as a percentage of those who entered;

Case mix variance, both in terms of provisional diagnosis and also severity of

symptoms

Waits between first and second appointment to visualise long waits ‘hidden’ from

nationally reported waits

Additional reports commissioned from the HSCIC by NHS England to be available by Q4

2014/15. Further Reports will be commissioned for 2015/16 and will be available from

October 2015.

Using the implementation fund of £10m in order to eliminate variation will

focus on two discrete areas of investment in 2015/16. Allocation of funds to

these two areas:

• Waiting list validation i.e. activity to confirm the accuracy of current

waiting lists. The waiting list validation fund will be available to all

CCGs but allocated to reflect capitation, scale of waits and bundled

to CSUs where appropriate.

• Additional / enhanced capacity i.e. in order to provide assessments /

treatments. Allocation of the above will require careful design and a

reasonably flexible approach i.e. to target areas with high waits but

not reward inefficiency or low investment.

• Therefore allocation will be made according to a clear set of

criteria which demonstrate that the issues that have led to the

waiting list occurring in the first place have been identified and

the additional capacity allocation will move services towards a

sustainable long term solution.

• HEE & Clinical Networks for additional training commissions,

provider leadership and transformation development

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National resources to support implementation

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0.0 5.0 10.0 15.0 20.0 25.0

NHS Chorley and South Ribble CCG

NHS Blackburn With Darwen CCG

NHS Bolton CCG

NHS West Lancashire CCG

NHS Trafford CCG

NHS Fylde & Wyre CCG

NHS East Lancashire CCG

NHS Lancashire North CCG

NHS Wigan Borough CCG

NHS Oldham CCG

NHS Stockport CCG

NHS North Manchester CCG

NHS Heywood, Middleton and Rochdale CCG

NHS Central Manchester CCG

NHS Greater Preston CCG

NHS South Manchester CCG

NHS Bury CCG

NHS Salford CCG

NHS Blackpool CCG

NHS Tameside and Glossop CCG

Clearance times - Weeks of activity in the backlog

Clearance times in weeks suggests the scale of the backlog to be cleared irrespective

or the actual numbers and the size of the service. It is the number of weeks it would

take to clear the waiting list if no new referrals arrived

Backlog = nr patients waiting for first treatment reported to HSCIC (End January 2015)

Activity = nr first treatments delivered per week in this CCG (Q4 plan 15-16)

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Good Waiting List Management (checklist summary)

The following actions are required when planning delivery of the waiting time standards:

• A good understanding of the sustainable position i.e. the run rate, ( referrals/ opt ins / first treatments to achieve a15% of prevalence

• Ensuring the necessary capacity is in place that will deliver the necessary volume of patients, separate from any discussion on clearing backlogs that will deliver that run rate with appropriate performance trajectories and contract levers put in place

• Agree with providers the backlog to be cleared i.e. the reduction in numbers waiting for first treatment (incomplete pathways) with time scales and identify whether this will be achieved within existing resources or requires additional funding.

• Waiting List management - Establish Patient Tracking Lists (PTL) Reports by Step, by site, by Therapy type,

NOTE OF CAUTION: At first glance very few CCGs have made the connection between reducing backlog and access rates that will ensure sustainability in their plans

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Example PTL Reports. The number of patients waiting on a particular date

by weeks waited – Develop by Site, by Therapy Type, dated and undated,

0-1

Weeks

1-2 Weeks 2-3 Weeks 3-4 Weeks 4-5 Weeks 5-6 Weeks 6-12

Weeks

12-18

Weeks

18+

Weeks

Dated 5 20 74 60 40 22 10 9 5

Undated 94 83 15 8 2 7

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Intensive support offer 2015-16 • Initial focus on understanding the scale of backlogs to be cleared and on

assuring the SDIPs plans jointly with the national and local delivery teams

and targeting financial support.

• The IST focus will shift from supporting fairly large numbers of localities with

desk top reviews to more in depth and ongoing support to localities that are

particularly challenged on waiting times.

• Joint working with SCNs and other networks to:

• provide all day or half day workshops on capacity and demand, good

waiting list management, PbR.

• Produce a package of support on improving recovery.

• Targeted transformation and leadership support following on from the

Greater Manchester and Lancashire leadership and transformation

Series piloted in 2014-15.

• An offer of Monthly meetings with (sub)region and SCN delivery teams to

ensure we triangulate support., in line with the IST model for Cancer/18W.

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Questions

Els Drewek

IAPT Intensive Support Team

els.drewek@nhs.net

07810 030100