Newham Improving Access to Psychological Therapiesa partnership between

Newham Primary Care TrustEast London NHS Foundation Trust

Evidence Based Choices & ‘Complexity at the coalface’

Dr Ben WrightLead Clinician Newham IAPT

Three dimensions of complexity

• Complexity of context – (Choice & Access)

• Complexity of systems – (Treatment Choice)

• Clinical complexity– (Choice outcome)

London Borough of Newham

Very Diverse• 61% BME• 130+ Languages

Deprived• 44% live in poverty• 20% intense poverty

40% greater demand for mental health services

Access - Pathways into Service

Self Referral

Formal referralby professional

Telephone Assessment

Flexible Engagement, Full Assessment & Treatment

GP

Occupational Health

Resident in

Newham

Community Groups

Pathways to work referral

Routine screening of new IB claimants

Secondary MH

Source of Referral (n=5,064)

GP64%

Professional9%

Self22%

PW2W5%

Overall BME Access

64% of referrals from BME groups in 2008

66% of Newham residents come from

BME groups

Impact of source of referral on access

0%

10%

20%

30%

40%

50%

60%

Per

cent

age

White Mixed Asian Black Other

GP Self PW2W Other Newham 2001 census

Impact of source of referral on access for Men

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Per

cent

age

WhiteBritish

WhiteOther

Mixed Asian Black 0ther

GP Self PW2W Other Newham

Impact of source of referral on access for Women

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Per

cent

age

WhiteBritish

WhiteOther

Mixed Asian Black 0ther

GP Self PW2W Other Newham

Key points

• GP referral remain central to access process

• Must be supplemented by multiple points of access

• Different sub-groups respond differently to access points

Three dimensions of complexity

• Complexity of context – (Choice & Access)

• Complexity of systems – (Treatment Choice)

• Clinical complexity– (Choice outcome)

NICE Clinical Guideline 90 - Oct 2009 (partial update for depression guide,

Research recommendation)

• 4.8 “In people with mild, moderate or severe depression, what system of care (stepped care versus matched care) is more clinically effective and cost effective in improving outcomes?”

(Page 51)

Matched Care PathwayUsed in Phase One of National

IAPT Pilot, May 2006-07

Flexible engagement by assistant

Referral –Mainly GP

Formal High

Intensity CBT

Assessment by Qualified

Therapist

Other Services

Low Intensity

CBT

Semi-Stratified Stepped Care Pathway

Brief Telephone

Assessment(Qualified therapist)

Low Intensity (CBT Based)Assessment & Intervention

All Referrals

Formal High Intensity CBT Assessment & Intervention

Other Services

Employment Support Service

Administrator calls & offers appointments

System – care pathway flow – impact on recovery rates

0%10%

20%30%

40%50%

60%70%

80%90%

100%

2006 2007 2008 2009

percent to low intensity Column 2

System – care pathway flow – impact on recovery rates

0%10%

20%30%

40%50%

60%70%

80%90%

100%

2006 2007 2008 2009

percent to low intensity Percentage recovery

System – care pathway flow- impact on productivity

0102030405060708090

100

2006 2007 2008 2009

percent to low intensity Column 2

System – care pathway flow- impact on productivity

0102030405060708090

100

2006 2007 2008 2009

percent to low intensity Number completed treatment per month

Three dimensions of complexity

• Complexity of context – (Choice & Access)

• Complexity of systems – (Treatment Choice)

• Clinical complexity– (Choice outcome)

33%

25%

6%

36%

Completed lowintensity care anddischarged

Dropped out

Stepped up HighIntensity CBT

Stepped up toanother service

Outcome of Low Intensity Care

4%

31%

65%

Completed Highintensity care

Referred onwards

Dropped out

Outcome of High Intensity Care

Equity of outcome

• Care pathways did have slightly different treatment of some BME groups (e.g. greater proportion Asian & Asian British people going direct to high intensity) however there were similar recovery rates for different BME groups for both Low and High Intensity care

• Having Low intensity care first did not alter drop out rate for High Intensity care.

Conclusion – what is needed?

• Clinicians need regular, good quality supervision

• Clinicians need easy access to a hierarchy of in-house experts– Includes medical psychotherapy & general psychiatry

• Integrated care pathways– Disaggregation reduces access, flow & quality

• Good IT system for managing monitoring and directing patients flow through care pathways