www.england.nhs.uk

Ursula James

NHS England National IAPT Clinical Delivery Manager

IAPT Workforce and Diabetes IAPT LTC-

Cheshire and Merseyside Event

5th December 2018

www.england.nhs.uk 2

• IAPT expansion into physical health

pathways

• Overview of Early Implementer work

• Local evaluations overview and specific

evaluations from diabetic pathways

www.england.nhs.uk 3

Why IAPT-LTC?

30% people with a long term physical health condition

also have a co-morbid mental health problem, mostly

anxiety and depression. In addition, up to 70% of people

with Medically Unexplained Symptoms also have

depression and/or anxiety disorders. These common

mental health disorders are detectable and treatable

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• Liaison mental health services (including core 24)

which provide care in general hospital emergency

departments, inpatient units and outpatient clinics

• Clinical and health psychology services which

work as part of healthcare teams within general

hospital

• Integrated primary and acute care systems (PACS)

which aim to improve physical, mental and social

health and wellbeing, and reduce inequalities with

general practice at their core

• Specialist physical health services which may be

based in either inpatient or community settings

4

Key partners in the expansion

include:-

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Access to evidence based psychological therapies for

people with LTC or MUS by providing;

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True Integration

Care genuinely integrated into physical health pathways

working as part of a multidisciplinary team

Therapists who have trained in IAPT-LTC/MUS top up

training

Providing evidence based treatments collocated with

physical colleagues

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By using NICE-approved psychological therapies in physical healthcare

settings and addressing mental health issues earlier, talking therapies help to

improve patients’ health outcomes so they become more able to self-manage

their condition. Seeing individuals as a whole person, with both mental and

physical health needs will deliver better patient care and improved outcomes.

• Improved outcomes

• Less reliance on services

• Promotes self management

• Co-location provides an opportunity for physical and mental healthcare

professionals to share knowledge and good practice in order to focus on

holistic care for patients

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Why integrate?

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Early Implementer Successes

• Truly integrated care

• Combined booking systems

• Increased confidence and competence in staff

• Improved quality of patient care

• GP champions

• Data linkage in primary care (is tricky)

• More appropriate referrals in to IAPT

• Reduced stigma

• Improved access for hard to reach groups

• GPs/ practice nurses/physical health care staff using screening questionnaires

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• Sites who have shared their initial local evaluation data report:-

o Reduction in GP appointments post treatment

o Reduction in doctor/consultant appointments post treatment

o Reductions in medical investigations post treatment

o Reductions in hospital admissions and A & E attendances

• Some sites reported increases in specialist nurse use – indicating better use of healthcare and condition management

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Impact on health care utilisation

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IAPT -LTC have led to reduced pressure on

the health system

Cambridgeshire and Peterborough

CCG (initial findings)

• Some of the early implementers have shared

early indications of the impact of the IAPT-

LTC service on healthcare utilisation.

• The IAPT-LTC service started October 2016

and saw 1,017 patients (to end Sept 2017).

• Results point to a reduction in healthcare

utilisation in other parts of the healthcare

system before and after intervention for

different care pathways.

Patient contact

between 1st and

2nd survey

GP Practice

Nurse

Physio-

therapy

Specialist

Nurse (Cardiac

etc)

Doctor

(other than

GP)

A&E Hospital Inpatient

Admissions

Ambulance

Usage

Cardiovascular -85% -85% -89% -95% -87% -86% -90% -91%

Diabetes -79% -97% -96% -81% -84% -83% -83% -83%

Respiratory -67% -67% -63% -77% -77% -36% -57% +47%

All Pathways -73% -80% -76% -86% -83% -61% -75% -44%

0

5

10

15

20

25

30

35

40

45

CSRI (First) CSRI (Second)

Nu

mb

er o

f p

atie

nts

A&E admission by pathway before and after IAPT-LTC

Cardiovascular

Diabetes

Respiratory

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Impact on admissions and employment

0

100

200

300

400

500

600

700

To

tal n

um

be

r o

f d

ays

off

sic

k f

rom

em

plo

ym

en

t

Reductions in days off sick from employment

pre-treatment end of treatment 3 months post 0

2

4

6

8

10

12

14

16

To

tal n

um

be

r o

f h

os

pit

al a

dm

issio

ns

pre-treatment end of treatment 3 months post

Reductions in hospital admissions

Portsmouth CCG (initial findings)

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• Proportion of men accessing IAPT-LTC is 14% higher

than core IAPT

• Recovery rate 8% higher in IAPT-LTC with truly

integrated model

• Drop out rate 3-5% lower in IAPT-LTC than core IAPT

• Those who meet recovery have demonstrated higher

cost saving (46%) compared to those who did not meet

recovery (11%) - indicating the benefits of

psychological therapy on health care savings

• In an EI site in the North West an initial local evaluation

demonstrated for every £1 spent on IAPT-LTC a saving

of £2.60 was realised.

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Other interesting findings

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Cambridgeshire & Peterborough

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The evaluations were taken from the first cohort of patients allowing 3 month follow up

and therefore the evaluation is based on 103 diabetes patients who have completed both

the first (at start of treatment) and second (at end of treatment) CSRI

Financial Savings

GP (NHS

Channel Shift

Method)

Physiother

apy

Specialist Nurse

(Cardiac etc) A&E attendances

Hospital

Inpatient

Admissions Total

Diabetes £5,775.00 £1,224.00 £16,730.00 £1,120.00 £31,360.00 £56,209.00

All Pathways £22,650.00 £5,253.00 £37,205.00 £5,376.00 £122,434.00 £192,918.00

www.england.nhs.uk

Coastal West Sussex, Horsham and

Mid Sussex, and Crawley CCGs

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www.england.nhs.uk

Herts Valleys CCG and West Essex CCG

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CSRI: Average no. physical health appointments pre and

post IAPT treatment

4.8

3.4

0

1

2

3

4

5

6

Time 1 Average Number ofPhysical Health Appt. prior to

treatment

Time 2 Average Number ofPhysical Health Appt. post

treatment

CSRI: % of people showing change in number of

physical health appointments following IAPT treatment

40%

48%

11% increase in number ofappointments

decrease in number ofappointments

no change

Recovery rates for the Herts Wellbeing LTC team currently stand at 57%

CSRI: Magnitude of change is greater for population

which showed decrease in appointments following

IAPT

-6

-4

-2

0

2

4 2.8

-5.2

Av

era

ge

nu

mb

er

of

ap

po

itn

men

ts

appt increase(40% of cohort)

appt decrease(48% of cohort)

*increase in number of appointments can be positive sign of

self management of condition and includes specialist condition

specific nurse appointments. This is evidenced on next slide

case study.

No o

f appoin

tments

Diabetes Distress Scale at start and end of IAPT

treatment

0

10

20

30

40

50

60

Assessment End of treatment

Dia

be

tes d

istr

ess s

ca

le s

co

re

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Meet Amanda*

Amanda is 22. She is a single mum to a 4 year old daughter. She

works in a bank, is in a relationship with a new partner and has a

good social life. In her spare time Amanda enjoys swimming and

horse riding. Life was good for Amanda until 2017 when she was

diagnosed with type 1 diabetes (DM1). This was extremely distressing

and problematic for her because she suffered with a pre-existing

blood-needle-injury phobia.

Amanda was referred to the Wellbeing Team for treatment of needle

phobia by the RAID Team at the General Hospital. She had presented

in A&E due to severe dehydration and high risk of Diabetic

Ketoacidosis. Her HbA1c level was 104 mmol/mol.

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Amanda’s goals:

Amanda’s compliance with self-management of her DM1 was good in

most areas: She adhered to her diet plan, enjoyed a good and varied

exercise regime and was able to carry out finger pricks to test blood

glucose levels.

At the time of referral she was prescribed 5 insulin injections per day.

She was unable to comply with this and at best managed one injection

per day. Prior to coming into treatment she might not inject for weeks at

a time.

Her goal for therapy was to overcome her fear of injections such that

she could manage her DM1 well.

What did the psychological therapy entail?

Psychological formulation considers how early life experiences can lead to unhelpful belief systems. Amanda recalled how as a child she had

been forcibly held down when inoculated, instilling a fear of injections. She recalled subsequently avoiding blood tests by crying and violently

protesting. As a consequence she successfully avoided needles for most of her childhood and adolescence and never really learnt that, while

unpleasant, injections were not dangerous.

The formulation identified beliefs in the here and now which were prohibitive: “I will be sick; I will faint”. It also identified how she would generate

“permissive thoughts” to avoid injecting “I do not need to do this, I am well”. Her therapist helped her see how her very strong all or nothing beliefs

(“I must do everything perfectly/completely or not do it at all”) were maintaining the problem: “If I miss one injection I might as well not do any”.

Therapy explored how combined these thoughts and beliefs triggered unhelpful behaviours (avoidance, procrastination). She learnt that while in

the short term avoidance of injections reduced her anxiety, in the long term avoidance maintained her fear and compromised her health. As a

consequence her fasting blood glucose remained chronically high.

Therapy included learning applied tension techniques (to combat feelings of faintness) alongside a programme of graded exposure which included

watching videos of people with diabetes self-injecting and culminated in Amanda doing an injection in session. Cognitive work focused on

developing adaptive beliefs and challenging her all/nothing thinking.

Outcome of treatment –As therapy progressed Amanda overcame her debilitating fear and is now administering 5 insulin injections a day. This

resulted in blood glucose (from finger prick tests) reducing from over 30 to between 4 and 10). Amanda has also changed her thoughts from “I do

not need to do this, I am well” to “I need to do this to live the life I want to live.”. She feels empowered. She no longer feels defined by her

diagnosis but is living with a condition that she is proud of managing well.

Considerations and learning

This was not a straightforward piece of work. There was a significant level of medical risk and so it was essential to work closely with Amanda’s

Diabetes Specialist Nurse (DSN) and keep her informed at all times. Through this co-working the therapist gained additional knowledge around

her condition and so for instance was taught to check that Amanda was using long-acting insulin when she was only injecting once every 2 days in

the early stages of therapy. Overcoming a lifelong fear required considerable courage and at one stage Amanda dropped out of treatment. Once

re-engaged her therapist’s compassion and encouragement to persevere (“I am not giving up on you”) helped Amanda to not give up on herself

either. If anything, overcoming this temporary set-back provided powerful learning and helped drive towards a successful outcome..

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• IAPT-LTC Pathway

• A competence framework for psychological interventions with

people with persistent physical health problems.

• A map to show the locations of the wave one Integrated IAPT

early implementers. These sites were launched in September

2016 and are supported by additional funding to develop mental

health services within long term condition care pathways.

Included in this wave are services for people with diabetes,

respiratory, cardiac and medically unexplained conditions.

• Descriptions of early implementer sites projects

• Announcement of second wave of integrated IAPT sites

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Resources