Mapping Psychological Therapy Services

1
Mapping Psychological Therapy Services

• Professor Glenys Parry
• Mental Health Service Mapping Conference
• University of Durham
• 4th July 2002

2
Summary

• Why do we need the map and why the NSF?
• Safe and Effective how to ensure it
• The context for the map
• Psychological therapies map issues concerns
• Psychological therapies map what does it show?
• What could it show?
• Future developments in service improvement

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Why we need the map

• To help monitor the implementation of the mental
  health service framework
• Monitor moves towards equity in provision
• Trends in service capacity and staffing
• Compare ways services are provided between
  different localities with similar levels of need
• Psychological therapies are a major form of
  treatment, with substantial evidence base
• Have developed piecemeal unmonitored

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Why we need an NSF

• Problems getting access to good mental health
  care, including psychological help
• Staff shortages and patchy services with long
  waiting lists
• Access is inequitable relates to age,
  socio-economic status ethnic group
• Major quality problems in some areas
• Poorly co-ordinated services
• Referrers and service users lack knowledge of
  psychological therapy
• Many mental health staff work with insufficient
  support, training supervision
• Standards 2 3 involve access to safe and
  effective psychological therapies

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How best to ensure safe effective therapies?

• Would it be a good idea to adopt US approach of
  Empirically Supported Treatments (ESTs)?
• Every therapy type is tested in RCTs
• Judged either
• efficacious 2 independent studies,
  meta-analysis
• possibly efficacious, 1 study absence of
  contrary evidence
• efficacious and specific, 2 studies over placebo
  or alternative bone fide treatment
• Analogous to licensed medicines
• Resulting list of therapies is approved for
  training, commissioning

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Whats wrong with ESTs as a way to improve
quality?

• Findings from RCTs dont generalise well
• Brand names dont predict outcome
• Equivalence of outcomes is still the usual
  finding
• Therapist factors relationship factors more
  important
• Impossible to fund RCT on every therapy method
• Allegiance effects are major problem
• ESTs do not improve practice delivery
• Danger of stifling innovation new approaches
• Divisive and adversarial

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Research
Innovative practice
Everyday Practice
Improved patient care
Theory
Generating knowledge
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Professional consensus and competence
Training, education and CPD
Clinical consensus
Research
Innovative practice
Improved patient care
Everyday Practice
Theory
Generating knowledge
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Professional consensus and competence
Training, education and CPD
Clinical consensus
Research
Innovative practice
Guidelines and protocols
Improved patient care
Everyday Practice
Judgement
Evidence based practice
Theory
Generating knowledge
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Professional consensus and competence
Training, education and CPD
Clinical consensus
Research
Innovative practice
Guidelines and protocols
Improved patient care
Everyday Practice
Clinical audit
Judgement
Evaluation
Evidence based practice
Outcome benchmarking
Theory
Generating knowledge
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Evidence based guideline on Treatment Choice in
Psychotherapy Counselling

• developed by professional group including service
  managers
• based on best available research evidence
• plus clinical consensus and user consultation
• explicit process, externally reviewed,
  time-limited, independent of funding
• indicates quality of evidence for each element
• general principles recommendations for specific
  conditions
• But NOT a list of ESTs

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Role of guidelines

• Not a commissioning guideline provides clinical
  and referral decision support
• But does list a range of bona fide therapies
  summarises state of evidence base.
• Recommends needs for psychological therapy be
  considered for people with common mental health
  problems
• Current NHS policy suggests commissioners
• invest in services that specify their appropriate
  patient groups on basis of evidence
• those that audit elements of standard practice,
  e.g. premature endings, delivery standards
• those that monitor outcomes routinely

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The context for the map

• Range of psychological therapies
• (A) provided in team as integral part of wider
  mental health service, often CMHT (integral)
• (B) a psychological therapy service without a
  single theoretical basis e.g. clinical
  psychology, counselling, often secondary care
  (generic)
• (C) a formal service by those training or trained
  to a specialist level in a specific theoretical
  approach (e.g. psychodynamic, or cognitive
  therapy), often a tertiary service

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The context for the map

• Provided by a multi-disciplinary workforce
• (A) mental health nurses, doctors, social workers
• (B) clinical psychologists, some mental health
  nurses, counsellors, art therapists
• (C) psychiatrists, psychologists and mental
  health nurses with post qualification specialist
  training
• In a range of models of service delivery
• Clinical psychologists in CMHTs separate
  psychotherapy dept
• Counsellors employed in PCTs or via Trust
• Integrated psychological therapies services
• Consulting support services

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Psychological therapies mapping concerns issues

• Potentially, hugely valuable dataset, really
  worthwhile
• Current data are very inaccurate extremely high
  rate of errors, many examples
• services missing
• services wrongly included
• service type inconsistently reported
• Definitional problems
• primary, secondary tertiary services unclear
• CBT - specialist or not?
• Role of clinical psychologists
• Are unreliable or erroneous data better than no
  data?

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Psychological therapies mapping concerns issues

• General hospital settings particularly
  inaccurate
• Orientation is much less meaningful for type
  AB therapies (integral generic) than type C
  (formal), but this isnt given
• Distinction between Behavioural CBT is not
  useful
• Capacity data are very incomplete
• No category for other therapies (e.g. CAT,
  systemic)
• Skill range is enormous, but no details given of
  staff numbers, professions, skill levels etc.
• properly trained and qualified is left undefined

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Psychological therapies map what does it show?

• Patchy provision some LITs seem to have none!
• Annual referrals rates suggest only a small
  minority of people with mental health problems
  are in receipt of psychological service
• Absence of services in psychiatric settings
  suggest under-provision for people with psychosis
• CBT is probably under-provided
• For LITs with no specialist provision
  particularly, issues of supervision and training

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What could it show?

• Referrals/year by geographical area would be
  useful handle on access and equity
• Could be linked to socio-demography, e.g. at LIT
  level, of mental ill health, ethnic mix, age
  structure and social deprivation indices
• Track development of psychological services for
  common mental health problems in PCTs
  supplementing counselling with CBT, stepped care
  other approaches (e.g. CAT, systemic)
• Is it possible to tweak the definitions?

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Future developments in service improvement

• Improving accuracy of service maps
• NHS RD agenda
• User views of services user-led quality
  improvement initiatives
• HAS good practice framework
• Routine outcome monitoring e.g CORE
• Feedback on clinically significant and
  statistically reliable change
• and Expected Treatment Response

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One proposed research programme

• Northern collaboration under NHS RD funding for
  Priorities and Needs
• 17 NHS Trusts, 5 Universities, NCMH
• Research team includes
• Michael Barkham, Glenys Parry, Else Guthrie, Mark
  Freeston, Chris Leach, David Shapiro, Mike
  Lucock, Roger Paxton, Jake Lyne, Frank Margison,
  Dawn Bennett, Gillian Hardy, Ian Kerr, Tom
  Ricketts Derek Milne.
• Plus over 20 research aware psychological
  therapists
• Pool existing investment in psychotherapies RD
  take strategic approach

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Themes within the programme

• Effective therapy in complex mental health
  problems, e.g. personality disorder
• Establishing effectiveness of psychological
  therapies in routine practice
• Measures development
• Change processes in psychological treatments
• Developing good practice, e.g guidelines,
  training
• Extending availability of psychological
  therapies, e.g. stepped care, guided self-help

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End of therapy
Intake score
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End of therapy
Intake score 20
End of therapy score 10
Intake score
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End of therapy
Intake score
25
No change line
End of therapy
Intake score
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End of therapy
Intake score
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Expected treatment response

• Using standardised outcome measure on large
  datasets
• For given client group, plot average response to
  therapy over time
• And upper and lower quartiles
• Able to define gold standard outcomes
  pragmatically
• And to sound alarm for likely deterioration
• More utility than effect size benchmarking
  against RCTs

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75th percentile
Mental health index score
25th percentile
Number of sessions
29
75th percentile
Mental health index score
25th percentile
Number of sessions
30
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