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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