www.england.nhs.uk
• Stephen McGowan, EIP Clinical Lead for Y&H CN and NHSE (North) (Chair)
• Dr Steve Wright, Consultant Psychiatrist, TEWV (Co-Chair)
• Rebecca Campbell, Quality Improvement Manager and Sarah Boul, Quality Improvement Lead
• [email protected] and [email protected]
• Twitter: @YHSCN_MHDN #yhmentalhealth
• June 2017
Yorkshire and the Humber
Mental Health Network
Early Intervention in Psychosis Network
29 June 2017
www.england.nhs.uk
Yorkshire and the Humber
Early Intervention in Psychosis Network
Welcome! Rebecca Campbell, Quality Improvement Manager,
Yorkshire and the Humber Clinical Networks
@YHSCN_MHDN
#yhmentalhealth
Housekeeping:
HHonors
Y&H EIP Network Meetings so far…..
• 3rd March 2016, York – New Commissioning Guidance & Key Concerns
• 7th July 2016, Leeds – Prescribing for FEP & Implementing the EIP Access, CBTp Training and Waiting Time Standard Final Guidance
• 17th November 2016, Leeds – At Risk Mental State
• 2nd March 2017, Leeds – Children &Young People
Y&H EIP Network Meetings so far…..
Don’t Forget - Evaluation
Next Meeting
• 2 November 2017, 13:30-16:30, Novotel, Leeds
• Service User & Carers Involvement
13:35 National & Regional Update
– Themes from the Self-Assessment & Deep Dives
Moggie McGowan, Co-Chair, Clinical Advisor,
Y&H IRIS, Y&H Clinical Network & NHS England
North
14:00 Outcomes and Benefits – Local experiences of using a wider
set of metrics including QPR and Dialog Simon Platt & Kate Quinn, SWYFT
14:20 EIP Matrix – EIP Service Self-Assessment & Action Planning
Tool
Sarah Amani, Senior Programme Manager, EIP
Programme, South of England
14:50 Break
15:10 Introduction to Group Discussions
Dr Steve Wright, Co-Chair, Consultant
Psychiatrist, TEWV & Clinical Advisor, Y&H
Clinical Network
15:15
Group Discussion – Outcomes & Metrics
Each table to discuss:
- What are the best metrics for describing outcomes in
EIP?
- Ranking and how would you get the info?
All
16:15
Summary
Key Discussion Points – Top 10 Metrics;
Actions & Next Steps
Dr Steve Wright
16:30 Close & Evaluation Moggie McGowan
Agenda:
www.england.nhs.uk
Yorkshire and the Humber
Early Intervention in Psychosis Network
National & Regional Update
Moggie McGowan, Co-Chair, Clinical Advisor
(Y&H IRIS & NHS England North)
10
Performance against the waiting time element of the standard
• From the Unify2 data collection, the 50% standard continues to be met nationally.
• From April 2017 data, all providers in the North region continue to meet the standard except for Pennine
Care.
Data quality
• Data quality of the MHSDS is still of concern, however, we are seeing convergence of referral and
performance data.
• Had originally planned to move to MHSDS as the official source of reporting from Q1 2017/18 (this data
is published in September 2017).
• However, data coverage and completeness is still an issue. Unify2 collection will run for an additional 3
months with the last collection covering September 2017.
Recording interventions and outcomes
• Increased focus on reporting of interventions and outcome data to MHSDS through SNOMED codes.
• Guidance being developed for EIP teams – out for consultation soon.
• National work to increase use of SNOMED more widely in mental health.
Assessing NICE-concordance
• In 2016/17, all EIP teams have undertaken a self-assessment assessing the second strand of the
standard (NICE concordance).
• EIP teams provided with report on their performance along with benchmarking information.
• Review process underway for CCQI self-assessment to ensure it is linked with National Audit of
Psychosis, CQUIN etc.
• Work underway to develop the MHSDS so it will be able to collect this information through SNOMED.
Update on EIP standard - National policy team
11
Workforce issues
• Continues to be major risk for EIP teams and CCGs.
• Regional coordination and solutions needed.
Looking forward
• Expansion of services to full age range and ARMS:
• Who is commissioned to provide care to +35s and under 18s.
• Data from MHSDS provides greater transparency.
• Further scrutiny on CCG baseline funding.
• Role of STPs in supporting expansion, workforce and delivery.
• Focus on care quality and outcomes as RTT data quality improves.
Mental Health Dashboard
• The dashboard is intended to help
monitor progress against the delivery of
the Five Year Forward View for Mental
Health.
• https://www.england.nhs.uk/mental-
• health/taskforce/imp/mh-dashboard/
Update on EIP standard - National policy team
Regional Update
• Deep Dive feedback and Review
• Agreed actions
• Review of CCQI Audit
• Workforce Calculator update
• Data Quality
• Training update
• Incidence/Demand
• Service User Involvement
Provider
1
Provider
2
Provider
3
Provider
4
Provider
5
Provider
6
Provider
7
AWT performance and MHSDS data
flow
Quality Self-Assessment: Good
practice and areas that require
improvement
Summary of gap analysis (from
refreshed workforce calculator) -
workforce recruitment and skills
Development and Investment plans,
milestones and funding (in relation to
5YFVand NHS Improvement
monitoring)
Areas of best practice which could be
shared across the region
Are there any concerns to
escalate/raise with the regional mental
health operations group?
Summary of Post-Review themes
• Shortages of CBTp practitioners in a number of teams and uncertainty about whether free training would continue to be available
• Similar re IPS training • Meeting the physical health baseline is a challenge in many teams and most
needed to improve take-up of interventions for weight gain and smoking • Bringing QPR and DIALOG into use is ongoing in most teams • At Risk Mental State (ARMS) interventions are in their infancy in most teams • Many teams have received investment to increase their workforces and
appear to have reasonable capacity now. • Some haven’t • There are also real concerns about rising demand • At most meetings we managed to get providers and commissioners to agree
to a joint review of referral rates after the summer so any requirement for further funding could be fed into contracting reviews
• Poor appreciation of the 5YFV funding plans in most places and a great deal of interest in the IRIS illustration by CCG that had been presented elsewhere in the North Region
Next Steps
Written feedback to CCGs/Providers
Follow up by regional mental health operations group
Return visits on invite (CL/CN/DCO) in the autumn
Regional (North) summary of common themes to
ensure a ‘do once and share’ approach to
resolution/actions
Funding illustrations circulated through commissioner’s
network
Y&H EIP Network to address the outcomes/themes.
EIP Announcement in 5 Year Forward View
17/18 18/19 19/20 20/21
New 11m 9m 10m 40m
Total 11m 20m 30m 70m
Estimate of CCG Investment
Year Population of CCG*
Population of
England*
New EIP Investme
nt for England
New Funding in CCG
17/18 283193 58m 11m 53548
18/19 285029 58.5m 9m 43781
19/20 286855. 59m 10m 48620
20/21 288685 59.5m 40m 194393
www.england.nhs.uk
Review
Team leaders were asked to rank order the current standards as either higher, medium or lower importance:
MOST IMPORTANT CBT for Psychosis; Family Interventions; Assessment within 2 weeks; Physical health reviews; Care coordinator caseloads of 15; Stand-alone holistic multidisciplinary team; Crisis and relapse prevention planning; Personal recovery planning; Antipsychotic medication; Supported employment and education programmes. IMPORTANT Carer-focussed education and support programmes; Children have access to CYPMHS expertise; Monitoring take up of physical health interventions for weight management; Monitoring the no. of staff trained to deliver FI; Outcome measurement; Access to specialist drug and alcohol services; CBT for ARMS; Service users are offered/receive clozapine. LESS IMPORTANT Monitoring clinical supervision for CBT & FI; Monitoring the percentage of people who were not in work, education or training; Monitoring the no. of staff trained to deliver CBTp; 3-year treatment package; Detailing the types of supported employment programmes available; Counting the number of service users that disengaged; Monitoring take up of smoking cessation interventions.
20
35
100
160
80
40
105
10
40
90
0
110
60
45
15
90
175
71
92
56
67
25
101
13
43
132
40
107
88
115
51
91
157
5 BOROUGHS PARTNERSHIP NHS FOUNDATION TRUST
BRADFORD DISTRICT CARE NHS FOUNDATION TRUST
CHESHIRE AND WIRRAL PARTNERSHIP NHS FOUNDATIONTRUST
COMMUNITY LINKS (NORTHERN) LTD
CUMBRIA PARTNERSHIP NHS FOUNDATION TRUST
GREATER MANCHESTER WEST MENTAL HEALTH NHSFOUNDATION TRUST
NAVIGO
HUMBER NHS FOUNDATION TRUST
LANCASHIRE CARE NHS FOUNDATION TRUST
MERSEY CARE NHS TRUST
NORTHUMBERLAND, TYNE AND WEAR NHS FOUNDATIONTRUST
PENNINE CARE NHS FOUNDATION TRUST
ROTHERHAM DONCASTER AND SOUTH HUMBER NHSFOUNDATION TRUST
SHEFFIELD HEALTH & SOCIAL CARE NHS FOUNDATION TRUST
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATIONTRUST
TEES, ESK AND WEAR VALLEYS NHS FOUNDATION TRUST
Jan_Mar_16/17 Unify Entering EIP Treatment (rounded) Jan-Mar_ 16/17 MHSDS Entering EIP Treatment
Data Quality
• Training update
• Incidence/Demand
• Service User Involvement
www.england.nhs.uk
Yorkshire and the Humber
Early Intervention in Psychosis Network
Outcomes and Benefits:
Local experiences of using a wider set
of metrics including QPR and Dialog Simon Platt & Kate Quinn (SWYFT)
Demonstrating
Outstanding
EI Services through
Outcomes
Kate Quinn (Wakefield EI) &
Simon Platts (Barnsley EI)
Rationale for Chosen Outcomes
• Try to crystallise what is most important for clients, service and targets
• Consideration of what we already collect on RiO • Minimise impact of paperwork on Care Coordinators • Ideally implemented with support of Assistant
Psychologist • Time points – initial, 6 months, 1 year,
annually thereafter, discharge
Key things for Outcomes: Care Coordinators
• Estimated Duration of Untreated Psychosis • First outcome form only and on CAARMS • Broad categories (<1/3/6/12 months; >12 months)
• Engagement • Service User • Family (in wider definition of ‘family’)
• Admissions/relapses (some data also via RiO) • Death (where applicable)
Key things for Outcomes: On Rio
• Waiting time (referral to treatment) • Source of Referral • Physical health: cardiometabolic assessment
• BMI • Smoking
• Discharge destination • Experience based issues – from HoNOS (items 1, 2, 3, 6, 9)
• Psychotic experiences • Overactive, agitated, aggressive and criminal behaviour • Non-accidental self-injury • Problem drinking or drug taking • Relationships
Key things for Outcomes: On Rio
• Accommodation: PSA ‘Housing Status’
• Vocational (training and occupational): PSA ‘Job Status’
• Friends and Family Test
• Self-reported recovery (QPR)
• Self-reported satisfaction (DIALOG)
DIALOG Totally dissatisfied Very dissatisfied Fairly dissatisfied
In the middle Fairly satisfied Very satisfied Totally satisfied Additional help wanted - Yes/No
How satisfied are you with your mental health?
How satisfied are you with your physical health?
How satisfied are you with your job situation?
How satisfied are you with your accommodation?
How satisfied are you with your leisure activities?
How satisfied are you with your friendships?
How satisfied are you with your partner/family?
How satisfied are you with your personal safety?
How satisfied are you with your medication?
How satisfied are you with the practical help you receive?
How satisfied are you with consultations with mental health professionals?
DIALOG: What is meaningful change?
• Mean scores of clinical samples are usually between 4 and 5 • mean scores of <4 are rare (inpatient groups in crises; depressed samples)
• Shift of 0.25 mean score would reflect a medium effect size • Roughly equates to higher satisfaction in three life domains (or a shift in
one domain by three points)
• Mean score of >5 should be seen as sufficient QoL (with absence of dissatisfaction with single life domains)
• No further need for EI involvement, unless specific reasons
• Every single step on every single item of DIALOG can reflect a meaningful change
• Any improvement is worth having
• At all stages, expect ‘satisfaction with treatment’ subscale score to be >4
PROCESS OF RECOVERY QUESTIONNAIRE
0. Strongly disagree
1. Disagree 2 Neither agree or disagree
3. Agree 4. Agree strongly
1) I feel better about myself
2) I feel able to take chances in life
3) I am able to develop positive relationships with other people
4) I feel part of society rather than isolated
5) I am able to assert myself
6) I feel that my life has a purpose
7) My experiences have changed me for the better
8) I have been able to come to terms with things that have happened to me in the past and move on with my life
9) I am strongly motivated to get better
10) I can recognise the positive things I have done
11) I am able to understand myself better
12) I can take charge of my life
13) I can actively engage with life
14) I can take control of aspects of my life
15) I can find the time to do the things I enjoy
QPR: What are we interested in?
• No current norms that we’ve been able to get hold of
• Do not think that intra- and interpersonal scales from longer version are applicable
• ? Slightly vague hope that scores improve
• We may be interested in some questions particularly, as they relate to client’s psychological and social recovery
• I feel I am able to develop positive relationships with other people
• I feel part of society rather than isolated
• I feel that my life has a purpose
• I feel I have come to terms with things that have happened to me in the past and move on with my life
Client Example – Wakefield, about to be
discharged after full EIP service
• Estimated DUP: 3 months as reported by parents
• Referred by GP to CMHT: assessed & passed to EI
• Waiting time 1 month from referral to allocation in EI
Physical Health Markers
• Smoker • 2014 – smoking 20 cigarettes per day • 2017 – smokes 1-5 cigarettes per day with
additional e-cigarette
• BMI 2014 – 25.2 • BMI 2017 – 22.9
HONOS 3 – ‘marked dependence’ to ‘no problem’
Engagement
• Client Engagement • 2014 – 3 ‘moderate problem’ • 2017 – 0 ‘very good’
• Family Engagement • 2014 - 1 ‘good’ • 2017 – 1 ‘good’
HONOS 9 – ‘mild problem’ to ‘no problem’
HONOS 6 – Problems with Hallucinations and
Delusions ‘mild problem’ to ‘minor problem’
Relapses
• 2 admissions under the MHA • 1st admission 65 days (start of treatment) • 2nd admission 49 days • 1 period under home treatment 23 days • 1 DATIX re: admin processes
HONOS 1 – ‘mild problem’ to ‘no problem’
HONOS 2 – Non-Accidental Self Injury –
‘mild problem’ to ‘no problem’
Housing
• No changes • Settled accommodation with family
Employment
• Long term sick/disabled on entry to service • Now about to go to uni
QPR on Admission
QPR: total score of 10 (average 0.6)
• I feel I am able to develop positive relationships with other people: 0 (strongly disagree)
• I feel part of society rather than isolated: 1 (Disagree) • I feel that my life has a purpose: 0 (strongly disagree) • I feel I have come to terms with things that have happened to
me in the past and move on with my life: 0 (strongly disagree)
QPR at discharge
QPR: total score of 30 (average 2)
• I feel I am able to develop positive relationships with other people: 3 (Agree)
• I feel part of society rather than isolated: 3 (Agree) • I feel that my life has a purpose: 2 (neither agree or
disagree) • I feel I have come to terms with things that have happened to
me in the past and move on with my life: 4 (Agree strongly)
Other positives: • Feeling better about self • Engagement with life • Control
Challenges: • Assertiveness • Sense that experiences have ‘changed me for the better’
DIALOG on Admission
DIALOG – Total 34 (3)
(Mean score of >5 should be seen as sufficient QoL)
DIALOG at discharge
DIALOG – Total 48 (4.36)
QoL 32 (4), Treatment Satisfaction 16 (5.3)
High satisfaction with: • Safety • Practical help • Contact with MH services
Less satisfied with: • Accommodation • Leisure activities • Physical health
Family Satisfaction
Client and Family report they would recommend the service to family and friends (F&F Test)
Discharge Destination
Back to GP
Qualitative Feedback
Client: ‘Very happy with the level and content of current support provision and medication (thinking is much clearer). Feel comfortable to discuss issues with the team, talking about or around the issues helps a lot. I feel much better at letting go of distressing memories and I’m able to mindfully be in the moment much more’
Parents: ‘Team have been well organised and professional especially Cat, she has been our life line in helping us to get our son better. Nothing is too much trouble for her, we can’t thank her and Insight enough for all their help’
Discharge Destination
Good Outstanding
60 15
5
20
GP
transfer to secondary care
forensic
disengaged
80
10
1 9
GP
transfer to secondary care
forensic
disengaged
Barnsley EIT: Discharge Destination
Good Outstanding
60 15
5
20
GP
transfer to secondary care
forensic
disengaged
56%
19%
12%
2%
1%
0%
10%
Discharge Destination
GP/Primary Care
CMHT- Caseload
CMHT- OutpatientonlyAOT
Substance Misuse
Forensic Services
2010-2016 (190 clients)
69%
18%
4%
0% 0% 0%
9%
GP/Primary Care
CMHT- Caseload
CMHT- OutpatientonlyAOT
Substance Misuse
Forensic Services
2015 – 2016 (47 clients)
0%
20%
40%
60%
80%
100%
Entry Exit
None
Occasional
Regular
Serious
0%
20%
40%
60%
80%
100%
Entry Exit
None
Cannabis(solely)
Poly Drug Use(Inc. Cannabis)
Self-Harm & Substance Use
Ongoing Issues
Getting people to use the measures! Making the sessions accessible/available Making the measures relevant to practice and useful: helps client work and improves outcomes Debunking myths/expectations that clients won’t complete the measures (Lancashire SMI-IAPT used earliest/latest and sessional measures and people completed them)
Getting prompt feedback to care coordinators/clients re: scores/change, so see purpose to outcomes framework
Create outcomes feedback and combine with narrative accounts at discharge
Employ Trust-wide Assistant Psychologist to help with above?
South Region Early
Intervention in Psychosis
(EIP) Programme
Sarah Amani
Senior Programme Manager
@S_Amani
All slides and videos can be accessed here:
https://www.slideshare.net/sarahamani1/early-intervention-in-psychosis-programme-briefing-march-2017
Thank You
For more information please visit our information sites at:
https://time4recovery.com
@Time4Recovery
Hosted by
www.england.nhs.uk
Yorkshire and the Humber
Early Intervention in Psychosis Network
Time for a break?
Early Intervention in Psychosis
Network - June 29th 2017
Group Discussion:
Outcomes & Metrics
Steve Wright
NHS England (North) Yorkshire & the Humber EIP Network
Outcomes & Metrics (1)
• Why do we need to measure outcomes?
• Because we are good at it
Outcomes & Metrics (2)
• What are the best metrics for
describing outcomes in EIP?
• How would you rank them in terms of
relevance, importance and feasibility?
• How would you get the info?
• How can data collection be embedded
in current work with minimum impact
on workload?
Outcomes & Metrics (3) - SMART
• Improved person/family experience, WT
• Personalised – recovery star, DIALOG
• Functional - SOFA, QPR, SWEMWBS
• Clinical – symptom, PANSS,
• Social – education, employment, networks
• Physical Health – blue or green on Lester
• Service thresholds – MHA, IP days, datix, discharge destinations, re-referrals etc.
• Long term vs short term, QALY
Outcomes & Metrics – why?
• To make sure we are doing what we say we are doing?
• Improve services
• Evidence effectiveness (including costs across the system)
• Visibility walls for teams
• Visibility walls for users/carers
(ownership & accountability)
www.england.nhs.uk
Each locality table to discuss:
• What are the best metrics for describing outcomes
in EIP?
• Rank the metrics in priority order and then discuss
how you would get the information required?
Group Discussion:
www.england.nhs.uk
Yorkshire and the Humber
Early Intervention in Psychosis Network
Summary • Key Discussion Points – Top 10 Metrics
• Actions & Next Steps
Dr Steve Wright, Co-Chair, Consultant Psychiatrist, TEWV & Clinical Advisor,
Y&H Clinical Network
www.england.nhs.uk
• Thursday 2 November 2017, Novotel, Leeds, 13:30-
16:30
Date of the Next Meeting…
www.england.nhs.uk
Yorkshire and the Humber
Early Intervention in Psychosis Network
Thank You for Attending!
Don’t forget to fill out your evaluation!
