Judith Chapman Berkshire Talking Therapies Clinical Development Director

Improving Access to Psychological Therapies-Long-

Term Conditions (IAPT-LTC )

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The overlap between LTCs and mental health problems in England

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The economic issue:

• 30% have LTC • 2-3 % more likely to have MH problem • Raises costs by 45% for those with both • For Berkshire:

163’800 total predicted comorbidities Costs rise by £1760 per person = an extra £288’288’000 in costs

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The Mental Health Five Year Forward View includes commitments to:

• Expand IAPT services to meet 25% of need by 2020/21. The majority of the expansion will be ‘Integrated IAPT’ services – now known as IAPT LTC co-located in and integrated with physical health services, and focused on people with co-morbid mental and physical health services

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NICE guidance • The evidence base underpinning the use of psychological

therapies in the treatment of depression and anxiety disorders can be found in the following NICE guidance:

• Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance (NICE clinical guideline 192)

• Common Mental Health Problems: Identification and Pathways to Care (NICE clinical guideline 123)

• Computerized Cognitive Behaviour Therapy for Depression and Anxiety (NICE technology appraisal 97)

• Depression in Adults: Recognition and Management (NICE clinical guideline 90)

• Depression in Adults with a Chronic Physical Health Problem: Recognition and Management (NICE clinical guideline 91)

• Generalised Anxiety Disorder and Panic Disorder in Adults: Management (NICE clinical guideline 113)

• Obsessive-compulsive Disorder and Body Dysmorphic Disorder: Treatment (NICE clinical guideline 31)

• Post-traumatic Stress Disorder: Management (NICE clinical guideline 26)

• Social Anxiety Disorder: Recognition, Assessment and Treatment (NICE clinical guideline 159)

Positive practice examples There are many examples of positive practice in IAPT services. The small selection of examples included here are not templates for whole service provision. Instead, they are selected to illustrate how services have tackled one or more specific problems. The Positive Practice in Mental Health Collaborative (PPiMH) is a user-led, multi-agency collaborative of 75 organisations, including NHS Trusts, CCGs, third sector providers and service user groups. The aim of the organisation is to facilitate shared learning of positive practice in mental health services across organisations and sectors. The Positive Practice in Mental Health Collaborative provides a directory of positive practice in mental health services. The NCCMH is working together with the Positive Practice in Mental Health Collaborative to identify and share examples of positive practice in mental health across England. Examples given of good practice on further slides

Treatment choice should be guided by the person’s problem descriptor

CBT is not a single therapy but rather a broad class of therapies. For example, the indicated CBT for PTSD is very different from that for social anxiety disorder, both of which are different from that for depression. It is essential that clinicians work together with the person to clearly identify the primary clinical problem that they want help with before selecting a treatment type.

A NICE-recommended intervention

A range of NICE-recommended CBT and non-CBT interventions should be offered This also includes the concurrent use of medication in moderate to severe (but not mild) depression.

Offer the least intrusive intervention first

The least-intrusive NICE-recommended intervention should generally be offered first. But it is important that low-intensity interventions are only offered where there is evidence of their effectiveness. For example, a person with severe depression or other types of anxiety disorders, such as PTSD or social anxiety disorder, should normally receive a high-intensity intervention first.

Treatment should be guided by the person’s choice

When NICE recommends a range of different therapies for a particular condition being treated, and where possible, people should be offered a meaningful choice about their therapy. Where treatments are on average similarly effective, giving people their preferred treatment is associated with better outcomes. Choice should include how it is provided, where it is delivered, the type of therapy and the clinician (for example, male or female).

Offer an adequate dose

All people being treated should receive an adequate dose of the treatment that is provided. NICE recommends that a person should be offered up to 14 to 20 sessions depending on the presenting problem, unless they have recovered beforehand. The number of sessions offered should never be restricted arbitrarily. People who do not respond to low-intensity treatments (and as such, still meet Caseness) should be given at least one full dose of high-intensity treatment as well within the same episode of care.

A minimal wait

No person should wait longer than necessary for a course of treatment. Services should work to a high-volume specification with minimal waiting times for treatment (and within national standards), as well as facilitating movement between steps (see appropriate stepping)

Appropriate stepping

A system of scheduled reviews (supported by the routine collection of outcome measures and supervision) should be in place to promote effective stepping and avoid excessive doses of therapy. This includes stepping up when there is no improvement, stepping down when a less intensive treatment becomes more appropriate or stepping out when an alternative treatment or no treatment becomes appropriate.

Enhanced Detail: Adult Mental Health (Core – IAPT)

The key principles of effective treatment and stepped care

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Enhanced Detail: Adult Mental Health – (IAPT-LTC) Guidance and Support

The following are available: • Improving Access to Psychological Therapies

Pathway for People with Long-term Physical Health Conditions and Medically Unexplained Symptoms.

• FAQ’s, Slides and Documents from IAPT-LTC Commissioning Events

• IAPT-LTC Data Handbook • Yammer Site • Positive Practice in Mental Health

Collaborative

What is the definition of IAPT-LTC?

IAPT-LTC services provide evidence-based (NICE-recommended) psychological therapies for people with LTCs who also have depression and anxiety disorders, or who have MUS. The interventions are provided by therapists who have trained in the IAPT-LTC Top up training. While some services will be hospital-based, it is expected that most will be embedded in primary care and community settings. IAPT-LTC services are built on the same key principles that underpin the IAPT programme (see the IAPT manual).

In addition to core IAPT principles, IAPT-LTC will provide: • Case recognition methods in physical health pathways • Integrated care pathways: all therapists should be co-located with general health

care teams and primary care. This requires participation in multidisciplinary team meetings, care planning and, where required, joint working.

• Revised IAPT assessment protocols for the integrated pathways: protocols should reflect the increased complexity associated with the assessment of depression and anxiety disorders in people with LTCs and MUS

• Revised IAPT workforce: including expansion and upskilling • Sharing best practice with existing IAPT services: IAPT-LTC and existing IAPT

services would normally have shared personnel and shared management, training and supervision arrangements. This may also contribute to reduced costs. In the long-term areas should be working towards a single IAPT provision for everyone.

• Close links with the wider system: Effective links should be built with: • Core 24 liaison mental health services/integrated psychological medicine:

these services provide care in general hospital emergency departments, inpatient units and outpatient clinics and work with people with mental health problems in the context of an LTC and MUS (see the urgent and emergency liaison mental health care pathway for adults and older adults)

• Clinical and health psychology services: these services focus on the inter-relationships between behavioural, emotional, cognitive, social and biological components of physical health problems. In doing so they are involved in the promotion and maintenance of health, and the prevention, treatment and rehabilitation of illness and disability. Clinical and health psychologists help people who have an LTC and are having difficulties adjusting to the condition. They also support other clinicians in managing the person’s condition and are likely to be an integral part of the IAPT-LTC workforce

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Enhanced Detail: Adult Mental Health (IAPT-LTC)

What this means for the person* What integrating care means for the commissioner Separate services Integrated services

Delivery I go to separate professionals for my physical and mental health needs. This means that I often have lots of appointments in different places and have to travel quite far. Sometimes I struggle to attend new places and can miss my appointments.

I go to one place, which is in my local area, to receive my care. I prefer this as it makes my care more accessible.

Integrating care enhances the whole team’s capability to provide more comprehensive, accessible and holistic care. This reduces costs through encouraging the prompt uptake of treatment and decreases the likelihood of people not attending appointments.

Assessment of mental health If I go to see someone for a physical health problem, I am a physical health problem. They do not treat me as a whole person. This means that I often have multiple assessments and have to repeat myself. I don’t feel I have the opportunity to voice my mental health concerns.

All of my needs as a person are assessed and taken into account. This means that I and the staff caring for me arrive at a better and faster understanding of my mental and physical health problems.

Integrating care promotes mental health awareness. Identifying the person’s needs more quickly and accurately can potentially reduce the number of frequent attenders and repeat assessments. Ensuring the right care is delivered can also reduce the length of hospital stays and prevent unnecessary admissions.

Coordination of care I feel like it is my responsibility to manage my care. I don’t have much support. I sometimes feel confused because I hear different advice from different people.

The professionals involved with my care talk to each other and have been appropriately trained. We all work as a team to develop one care plan which covers all my conditions. I know how to access the right support at the right time, as my needs change. I also have a first point of contact who I can go to with questions at any time.

A single jointly developed care plan can lead to greater efficiencies by reducing duplication. It can also lead to improved relationships within teams and services.

Service utilisation and cost of care When my mental health needs are unmet I am more likely to be distressed by my physical health problems. This means I spend more time with my GP and the hospital more often. Estimated costs: £5,670 per person per year 45

When my mental health needs are treated effectively I know how to self-manage. This means that I don’t need to go to my GP or hospital as frequently. Estimated costs: £3,910 per person per year

Integrating care is more cost-effective. Effectively identifying and treating the person’s mental health problem can reduce their use of physical health services. This can reduce the annual expenditure per person by £1,760

Potential benefits of integrating mental and physical health care * The experiences of services in this table, written by people with lived experience on the Expert Reference Group for IAPT-LTC, have been phrased from the point of view of a service user.

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National Collaborating Centre for

Mental Health (2018).

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Evidence-based psychological therapies (informed by NICE guidance) recommended for use in IAPT/LTC services for:

• Generalised anxiety disorder • Depression • Post-traumatic stress disorder • Specific phobia • Health anxiety • Social anxiety • Obsessive compulsive disorder • Panic disorder • Chronic fatigue syndrome • Chronic pain • Irritable bowel syndrome • Medically unexplained symptoms

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How do we capture the benefits?

1. Mental health outcomes – the MDS 2. Perception of physical health – LTC specific

disorder measures 3. Disability – the WASAS 4. Healthcare utilisation – the CSRI 5. Patient reported experience measures - PEQs

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Core condition: Measures used at every session: Measures used at first and last sessions and follow up:

Diabetes (Type 1 and 2) • MDS • ADSM

• CSRI • Diabetes Distress Scale (DDS)

COPD • MDS • ADSM

• CSRI • COPD Assessment Test (CAT)

Heart disease • MDS • ADSM

• CSRI only

Chronic Pain including fibromyalgia • MDS • ADSM

• CSRI • Brief Pain Inventory (BPI)

CFS/ME • MDS • ADSM • Chalder Fatigue Questionnaire - (CFS)

• CSRI

IBS • MDS • ADSM • Irritable Bowel Syndrome Symptom Severity

Scale (IBS SSS)

• CSRI

MUS – not otherwise specified • MDS • ADSM • PHQ-15

• CSRI

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Berkshire IAPT - LTC

Co-location Talking Health

therapists

Target Frequent Attenders

Face 2Face

CBT LTC

PINC

MUS persistent symptoms

Guided self help GSH LTC Cardiac

pathway Online Silver

cloud LTC

10 min CBT

training PIPP Care

CBTi insomnia

COPD Rehab & pathway

Diabetes Pathway

ICS/CCG Co-

production Steering groups

What we’ve done so far

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Disorders and pathways across Berkshire • Diabetes, Heart Failure, CHD ,COPD and MUS.

• Frequent attenders work in GP integrated surgeries • Talking Health Clinicians embedded:

– In GP surgeries across Berks – In diabetes, COPD and heart failure pathways/clinics

• Joint training on care planning ‘House of Care’ model with nurse specialists

• Roll out of 10 minute CBT training • Training on mental health screening to all MDT members

including diabetic eye screening, podiatrists, dieticians etc.

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LTC Data – March-Dec 2017

• Referrals having a first treatment appointment – 1360

• Average recovery – 57%

• LTC Conditions – Attended sessions • Type 2 Diabetes 1848 • Heart Disease 1254 • COPD 824 • Chronic pain 490 • Asthma 517

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Early Berkshire Health Economics Evaluation CSRIs

Initial findings from 108 matched CSRIs (beginning and end of treatments)

• 26% reduction in GP appointments

• 67% reduction in ED attendances

• 60% reduction in Ambulance calls

• 50% reduction in X-Rays

• 3 months saving per patient approx £550 (& benefits lasts 26m)

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Primary Care How can we help you?:

• Joint working and co-location • Cost savings

• Improved engagement/MDT • Increased self-management for patients • Reduced use of services

• Training provision for Primary Care and resilience training

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How to refer

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• It takes time to build relationships and integrate into GP

practices and existing pathways • Need to be creative & flexible AND use IAPT structure and

processes (centralise referral processes) • Co-working with GP leads and MH & LTC CCG is invaluable • National data cycles mean that you are normally working blind

for approaching 3 months • Training places may not be available when you need them • There is a high turnover of PWPs, its an entry level role and

people quickly move onwards and upwards and IAPT-PWP trainees completed CPD have moved to help set up other non pilot sites

Key Learning

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Thames Valley Early Implementer

IAPT-LTC services Clinical and health economics

evaluation PLEASE NOTE: Findings from Cohort 1 ONLY

starting treatment between 1st June 2017 and 31st August 2017

September 2018

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Thames Valley IAPT-LTC study: background The project: Does psychological therapy provided by the IAPT-LTC programme reduce health care utilisation and associated health care cost? Pragmatic evaluation using a stepped-wedge design of adults with anxiety and/or depression and comorbid long-term physical health conditions. In partnership with Professor David Stuckler, University of Bocconi and the Anxiety and Depression Network, Oxford AHSN Based on 2 cohorts starting at different times across TV This report is based on Cohort 1 only as it was not possible to include cohort 2 patients by the due date of this report

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June 2018

March 2017

April

May

June

July

August

September

October

November

December

January 2018

February

March

April May

June 2018

March 2017

April

May

June

July

August

September

October

November

December

January 2018

February

March

April May

Phase One (3/12 follow up from start of treatme Stepped wedge SUS data A

COHORT 1

COHORT 2

Stepped wedge SUS data A

Pre-intervention period 2

Pre-intervention period 1

Pre-intervention period 1

Stepped wedge SUS data B

Stepped wedge SUS data B

Stepped wedge SUS data C

Stepped wedge SUS data C

Recruitment and start of Intervention

period

Recruitment and start of Intervention period

SUS data lag time

Intervention period

Intervention period

SUS data lag time

Stepped wedge SUS data D

Stepped wedge SUS data D

Cohort 1 first SUS data extraction, available from March 2018

Cohort 2 first SUS data extraction, available from June 2018

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Clinical outcomes Recovery rate Reliable

improvement rate

PHQ-9 change

GAD-7 change

2 or more treatment sessions

THAMES VALLEY

Overall

56.9% 59.3%* 4.5 drop 4.1 drop 72%

Oxfordshire 53.9% 60.4% 5.4 drop 4.5 drop 67%

Buckinghamshire 56.6% 64.1% 5.5 drop 4.2 drop 68.4%

Berkshire

62.1%

49.5%*

3.8 drop

3.3 drop

84%

*NB: we are currently investigating the differences between the services which may be due to inclusion criteria differences

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Summary of health economics findings cohort 1

Total primary care n=462

Total secondary care n=462

Total savings cohort 1

Per patient average primary care

Per patient average secondary Care

Total per patient

Healthcare services utilisation cost reduction over 3 months (compared 3 months pre to 3 months post IAPT)

£54,000 £98,000 £152,000 £117 Based on a sub-group of paired, high quality CSRIs n= 57

£212 Based on actual SUS costs

£329

Healthcare services utilisation activity reduced over 3 months (compared 3 months pre to 3 months post IAPT)

From 6.72 appointments pre-IAPT treatment to 4.29 post-IAPT treatment, evenly spread across primary care

From 3.62 contacts pre-IAPT treatment to 3.27 post-IAPT treatment with greatest reduction in-patient

NB: these are patients with 2 or more IAPT treatment sessions (excluding 9 with >10k SUS data) 471-9 = 462. We are looking separately at patients with only 1 session

Health economics conclusion Patients who go through the IAPT-LTC treatment programme are, on average, and after IAPT treatment costs have been taken into account, estimated to save the health system

17 x £110 = £1,870. * NB: this calculation is based on an assumption that the same cost savings are realised consistently and evenly over the 24 months quoted

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Thankyou Any questions?