South London and Maudsley (SLaM)

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South London and Maudsley (SLaM) IAPT-SMI
Demonstration Site for Psychosis
Professor Philippa Garety Clinical Director,
Psychosis Clinical Academic Group
Thursday 7 March 2013
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Service users want equal access to psychological
therapies Rethink survey (2010)

• Research suggests that only 1 in 10 access CBT,
  despite NICE guidance (Schizophrenia Commission,
  2012)

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The Abandoned IllnessThe Schizophrenia Commission

• Research has led to a range of evidence-based
  psychological treatments. We know much more
  about what works than we used to. . . The
  committed individuals who went into the mental
  health profession to improve lives should be
  helped to do exactly that.
• Prof Sir Robin Murray

This is where IAPT-SMI comes in
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Obstacles to access
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Dolly Sen, Service User Consultant

• I always asked for some kind of psychological
  therapy or talking therapy but was told, no, it
  was too dangerous. I had to wait 20 years for
  something that was the most beneficial thing.
  Therapy has changed my life basically.
• Talking to Norman Lamb on 19 December 2012

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69 of Trusts have funding challenges for
providing access to psychological therapies for
people with a diagnosis of schizophrenia

• 94 have encountered obstacles in making
  psychological therapies available, including
  insufficient skilled staff

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Delays in accessing CBTpPeters et al 2009(N74)

• Mean length of illness was 8 years (range 0-32)
• Mean of 2.8 in-patient admissions (range 0-20)
• 96 were on antipsychotic medication

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South London and Maudlsey NHS Foundation Trust
the context

• Core population - 4 South London Boroughs
  1.3million inner city, very high indices of
  social deprivation
• Substantially raised rates of psychosis
• Psychosis Care Pathways

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SLaM Psychosis Demonstration site Increasing
access in two care pathways
IAPT-EI
IAPT-PICuP
IAPT-SHARP
Promoting Recovery Pathway (Lambeth)
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STEP TEAM
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SHARP
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• What IAPT-SMI offers for service users
• CBT for psychosis
• weekly or fortnightly individual 1 hour sessions
• 6-9 months therapy
• Therapists receive weekly-fortnightly group
  supervision
• FI for psychosis
• Fortnightly 1 hour sessions with client and
  carer(s)
• Up to ten sessions, over a period of 3-9 months
• Therapy delivered by two trained therapists
• Therapists receive weekly-fortnightly group
  supervision

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Overcoming obstacles to access
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Work we have already done in SLaM

• Ten point charter addressing barriers and
  facilitators
• Service user involvement
• Quality criteria and staff training
• Data gathering, data systems and outcomes
• Care pathways, ensuring integrated effective care
  in Early Intervention Recovery pathways

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Psychological treatments are not a quasi -
medication
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Quality

• One key challenge has been a lack of clarity
  about quality psychological therapy is
  different from a chemical compound
• Lack of criteria have resulted in an anything
  goes approach to psychological therapy in MH
  services, and inflated estimates of provision
• We need nationally agreed criteria for training
  and competencies in CBTp and FI
• IAPT-SMI is doing this
• Locally we have already developed criteria and
  standards and established a portfolio of training
  opportunities

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Training and Supervision
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Training and Supervision

• Portfolio of training opportunities in
  psychological therapies for psychosis, in
  partnership with KCL
• Span the workforce from non-clinical to
  managerial/supervisory
• Academically accredited training and in-service
  courses
• Short courses and modules build to an award
• Supervised practice strongly emphasised
• Supervision and support for supervisors

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Training structure in the SLaM site
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Service user and caregiver involvement
co-production

• Involvement in development, design and evaluation
  of psychological therapy services
• Training design and delivery
• Co-produced workshops at SHARP and in the SLaM
  Recovery college
• Co-working in group interventions Hearing
  Voices Mindfulness Acceptance Commitment
  Therapy
• Training, supervision and support (practical,
  financial and emotional)
• Personal development CPD, co-authorship,
  conference attendance

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SLaM demonstration site strategic approach to
improving access to therapy

• A 50 increase in access with the funding
  provided
• Reduced waiting times
• Implementation of our 10 Point Charter, with
  highly trained staff, and care pathways
• Clear referral pathways, including self referral
• Regular assessment of progress in therapy
• Close and frequent supervision
• Assessing improvement in a range of outcomes and
  in health economics

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Effectiveness
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Clinical outcomes Service-user reported
symptoms
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Evidence of clinical outcomes with medium-large
effect sizes voices and delusions
89 (voices) 90 (delusions) have paired data
at end of therapy
This graph shows a reduction in psychotic
symptoms voices (effect size .73) and
delusions (effect size .59) following therapy
(PICuP)
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Evidence of clinical outcomes with medium-large
effect sizes anxiety and depression
85 have paired data at end of therapy
This graph shows a reduction in emotional
problems anxiety (effect size .47) and
depression (effect size .55) following therapy
PICuP
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Evidence of clinical outcomes with medium-large
effect sizes quality of life (QoL) and recovery
85 (QoL) 67 (CHOICE) have paired data at end
of therapy
This graph shows an increase in peoples quality
of life (measured on the Manchester Short
Assessment of Quality of Life effect size .51)
and recovery ratings (measured on the CHOICE
effect size .79) following therapy
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Cost-effectiveness
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Randomised Controlled Trial (Peters et al, 2010)
therapy costs are off-set by fewer inpatient
costs at 3 months follow-up
(N 74)
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Reduction in service-use costs (admissions home
treatment team days) in the year following
therapy, compared to the year prior to therapy
(Wilcoxon test p lt.05)
Data obtained from ePJS, Jan 2012
N 70
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Progress and preliminary outcomes
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New clients - demographics
Variable New clients in the service
Age distribution Mean 38 years (18-70)
Gender 43 male, 57 female
Ethnicity 36 white, 64 BME
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Demonstration site CBTp FIp referral targets
are being achieved
Existing Existing Projection Projection Monthly Referral Target (over 12m) Monthly Referral Target (over 12m) Progress at 4 months Progress at 4 months
CBT FI CBT FI CBT FI CBT FI
106 15 50 10 14 2-3 95 11
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Waiting times are reduced (in days)
Referral received to opted-in Opted-in to assessed Assessed to receiving therapy Total reduction in waiting times
35 7 23 57 60
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Health Utilisation data
Service Mean number of days in 12m before therapy
Mental health admission 10.5 (0-126)
Crisis team / home treatment 0.7 (0-23)
Psychiatric liaison (AE) 0.1 (0-2)
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IAPT-SMI CBT assessments
Short CHOICE weekly
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IAPT-SMI Carer assessments
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Patient Reported Outcome Measures
Measure Completion rate
Session by session short CHOICE 81 of attended sessions
Pre-therapy PSYRATS Questionnaires 98 100
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London Tonight report from 19 December 2012
visit to SLaM by Norman Lamb, Care and Support
Minister and the official launch of the IAPT-SMI
demonstration sites http//www.itv.com/news/lond
on/update/2012-12-20/maudsley-hospital-pioneers-me
ntal-health-therapy-scheme/
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Operational Group
Dr Louise Johns, Project Lead
Rosanna Michalczuk Bina Sharma
Psychology Assistants
Dr Miriam Fornells-Ambrojo, IAPT-EI Lead
Dr Suzanne Jolley, Lambeth Recovery Psychology
Lead
Dr Craig Milosh, Clinical Psychologist,
SHARP Devon Elliott, Business Intelligence
Analyst
Dr Juliana Onwumere, FI Lead
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Steering Group

• Lucy Canning, Psychosis CAG Service Director
• Prof Philippa Garety, Psychosis CAG Clinical
  Director
• Jonathan Beder, Psychosis CAG Deputy Director,
  Business and Performance
• Dolly Sen and Garry Ellison, Service User
  consultants
• Roger Oliver and Lorna Wilkinson, Carer
  consultants
• Prof Tom Craig, Consultant Psychiatrist, SHARP
• Marieke Wrigley, Team Leader, SHARP
• Prof Elizabeth Kuipers, NICE Schizophrenia
  guideline lead
• Dr Emmanuelle Peters, PICuP Director
• Adrian Webster, CAG Psychological Therapies Lead
• Jo Lawrence, Clinical Service Lead, EI
• Dr Sarah Dilks, Lead Psychologist, Promoting
  Recovery pathway
• Dr Eric Morris, Lead Psychologist, Early
  Intervention pathway
• Penelope Fell, Head of Business Development
• Dorothy Abrahams, Administrator

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Thank you for listening! You are welcome to our
SLaM Demonstration Site Visit
Monday 1 July 2013 1.00-5.00 pm Louise.johns_at_slam
.nhs.uk