National Audit of Psychological Therapies for Anxiety and Depression

Transcription

1 National Audit of Psychological Therapies for Anxiety and Depression Measuring access, appropriateness, acceptability and outcomes Guidance for audit sites 2010 The Royal College of Psychiatrists For further information contact 1

2 TABLE OF CONTENTS Table of Contents Introduction Background to the Audit... 5 The Audit in England... 5 The Audit in Wales The National Audit of Psychological Therapies for Anxiety and Depression... 8 Project Management... 8 The Partner Organisations... 9 Aims of the Audit Four Dimensions of Quality Assurance The Benefits of Participating Pilot Phase Eligibility Criteria What Types of Psychological Interventions are Included? What Types of Services are Included? Guidance Notes to Decision Tree Data Collection Data Extraction The Audit Timeline Ethical Audit and the College Centre for Quality Improvement (CCQI) Participation in NAPT Roles and Responsibilities NAPT Project Team Contact Details Appendix A: Audit Standards Appendix B: Data Extraction Appendix C: Pilot Sites Appendix D: Regional Leads

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4 1. INTRODUCTION Welcome and thank you for choosing to take part in the National Audit of Psychological Therapies for Anxiety and Depression (NAPT). This guide gives you background information on the audit and details of how your service can take part. NAPT has been commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit programme, at the request of the Department of Health, who have stated that: Where a provider is delivering a service or intervention covered by a national clinical audit we would expect that provider to participate, otherwise it will be impossible to assess or give assurances about the quality of care being provided locally. We therefore anticipate that all NHS-funded services that deliver psychological interventions for people s anxiety and depression in England and Wales will choose to participate in this audit. The audit is based at the Royal College of Psychiatrist s Centre for Quality Improvement (CCQI), which has been carrying out national audits with mental health services for nearly ten years. The suggestions in this guidance booklet draw on our experience of running national multi-centre, audit-based quality improvement programmes with mental health services in the UK. 4

5 2. BACKGROUND TO THE AUDIT The lack of availability of NHS funded psychological therapies has recently received significant attention from the Government and the Department of Health as a result of an influential report from Lord Layard. The London School of Economics Depression Report (2006) urged that psychological therapy should be made available to all people suffering from depression, chronic anxiety and schizophrenia. The most recent ONS Psychiatric Morbidity Survey of adults living at home (Singleton et al. 2001; Singleton et al. 2003) estimated that 16% of the population has mental health problems and that only 14% of these people received counselling or psychological therapies. THE AUDIT IN ENGLAND IAPT In response, in 2006, the Department of Health made funding available to improve the access to psychological therapy services for adults of working age in England. The programme, Improving Access to Psychological Therapies (IAPT), aims to help Primary Care Trusts implement the recommendations of the NICE guidelines for people suffering with anxiety disorders and depression. By 2011 Strategic Health Authorities will be required to have IAPT services in 50% of all PCTs. Further details can be found on the IAPT website: To view the guidance published by the National Institute for Health and Clinical Excellence on the treatment of depression and anxiety, go to: PSA Indicators From January 2009, all PCTs are being expected to meet Public Service Agreement (PSA) minimum data set requirements on the psychological therapies they are delivering. The PSA Key Performance Indicators include: 1: Number of people who have depression and/or anxiety disorder 2: Number of people who have been diagnosed with depression and/or anxiety disorders - clinical diagnosis 3a: Number of people who have been referred for psychological therapies 5

6 3b: Number of active referrals (referred for psychological therapy and awaiting initial assessment) 4: Number of people who have entered psychological therapies (attending first therapeutic session/initial assessment). The National Audit complements and aids in the collection of data that underpins the PSA targets. THE AUDIT IN WALES In October 2005 the Wales Audit Office published a baseline review of service provision of Adult Mental Health Services in Wales. This identified a number of areas in which mental health services in Wales needed to improve, including: significant gaps in key areas of service delivery; scope for greater integration and coordination of adult mental health services across different agencies and sectors; considerable variation in the approach to empowering service users and carers; and, the failure of current planning and commissioning arrangements to fully support the development of whole system models of care. 1 Participation in NAPT on a national level will aid the assessment of whether service provision for anxiety and depression has improved since the initial baseline measure was carried out. Further to this, NAPT will help contribute to the Regional Annual Operating Framework (AOF) targets. The AOF targets set out the expectations of the NHS within any one financial year. It includes the national targets, formerly known as Service and Financial Framework (Saff) targets, Efficiency and Productivity Measures as well as additional service requirements. 2 These have to be delivered at the end of each financial year. Performance measures cover a wide range of areas in NHS Wales including assessment and waiting times. Currently some but not all psychological therapies are covered by these national targets. NAPT aims to improve consistency by focusing attention on improving access to psychological therapies for anxiety and depression. 1 Adult Mental Health Services in Wales: A baseline review of service provision, Welsh Audit Office, Oct For further information see 6

7 The Centre for Mental Health Services Development (CMHSD/NLIAH) is committed to undertaking an analysis of each Health Board s audit return for comparison with all other Health Boards in Wales, for report to each Health Board. The audit will therefore build on the work currently being carried out by the Wales Audit Office to help Local Health Boards to improve quality of care in the area of psychological therapies. 7

8 3. THE NATIONAL AUDIT OF PSYCHOLOGICAL THERAPIES FOR ANXIETY AND DEPRESSION The following section provides you with information about the NAPT project team and a general outline of the National Audit. PROJECT MANAGEMENT The audit is based at the Royal College of Psychiatrists Centre for Quality Improvement (CCQI). The work is being coordinated by a project team at the CCQI made up of the following staff: Dr Paul Lelliott, Director of the CCQI Dr John Cape, chair of the management board of BPS CORE and Head of Psychological Therapies, Camden and Islington Mental Health and Social Care Trust Maureen McGeorge, Implementation and Development Manager, CCQI Lucy Palmer, Project Manager, CCQI Elizabeth Hancock, Deputy Project Manager, CCQI Dr Lorna Farquharson, Clinical Advisor, CCQI Nicole Gideon, Project Worker, CCQI Darren Wooldridge, Project Worker, CCQI Miranda Heneghan, Project Worker, CCQI Lauren Howells, Project Administrator, CCQI 8

9 THE PARTNER ORGANISATIONS The audit is supported by a steering group made up of representatives of the following professional bodies and service user and carer organisations: British Psychological Society The Royal College of General Practitioners The Royal College of Nursing The New Savoy Partnership The Centre for Outcomes Research and Effectiveness (CORE) The British Association for Behavioural and Cognitive Psychotherapies The British Association for Counselling and Psychotherapy The United Kingdom Council for Psychotherapy The British Psychoanalytic Council Mind Rethink Depression Alliance No Panic The Mental Health Providers Forum Anxiety UK 9

10 AIMS OF THE AUDIT People referred to psychological therapies for depression and anxiety should be assessed and treated promptly by a therapist, who delivers appropriate therapies in an acceptable manner. The service should achieve an outcome that is acceptable and comparable with those of other therapy services. The main aim of this national project is to audit the quality of psychological therapies for people with depression and anxiety in primary and secondary care. FOUR DIMENSIONS OF QUALITY ASSURANCE NAPT will evaluate four important dimensions of quality: 1. Access who is offered therapy and how easy is it for people to take up the offer? This will consider factors that might affect access to services - ethnicity, age and gender - and will measure how long people wait to be assessed or to start therapy. 2. Appropriateness what kind of therapy is provided and is this consistent with best practice? We are looking at what types of therapies are being delivered and whether they are in line with NICE guidance. 3. Acceptability - is the type of therapy offered acceptable to the patient? We are pioneering a new patient/service user survey, which we have developed in conjunction with people who have experienced anxiety and depression in the past, to generate meaningful feedback for services. 4. Outcomes do people feel better and are they better able to cope with their anxiety and depression as a result of therapy? We are interested here in whether the therapy 'works, regardless of whether it is in line with NICE guidance. We will be looking at patients' views on therapeutic alliance, as well as outcome scores. 10

11 THE BENEFITS OF PARTICIPATING There are a number of advantages to participating in the audit: It will provide a national picture of psychological service provision across England and Wales. You will be able to benchmark your local data against similar services and the national findings. It will help you to gain a better picture of the extent to which the provision within your service is in line with NICE guidance. You will find out what service users think about your service. The final report will outline areas for improvement in your service. Involvement in this audit satisfies the Department of Health s expectation for participation in national clinical audits. Involvement in this audit satisfies the government requirements for world class commissioning. 11

12 PILOT PHASE Between September and December 2009, a detailed pilot was carried out in order to determine the most effective way of collecting data. Twenty-seven services in nine lead organisations in England and Wales participated in the pilot, including voluntary, secondary and primary care, Black and Minority Ethnic, IAPT, Older People s, Art Therapy and ccbt services. Overall, there was a good spread of both rural and urban areas in England and Wales (see Appendix C for a list of pilot sites). Pilot sites selected whether to collect data for all or only some of the elements of the audit and all participating services received reports on the data submitted. A total of three teleconferences were also held in order to discuss the service s experience of taking part in the pilot phase. The feedback received was invaluable in helping to develop simple but robust audit questionnaires that can be used to collect data across a wide range of settings. 12

13 4. ELIGIBILITY CRITERIA In order to meaningfully measure access, appropriateness, acceptability and outcomes of psychological therapies for anxiety and depression in England and Wales, NAPT aims to encourage data collection across a wide variety of different types of services, therapies and treatments. All outpatient NHS-funded primary and/or secondary care adult (18+) services delivering psychological interventions for anxiety and depression (as part of their main function or within their wider service) are eligible for participation in NAPT. All inpatient and residential services are therefore excluded from participation. Please see the decision tree and guidance notes on pages 15 and 16 for further guidance on which services to include in the audit. WHAT TYPES OF PSYCHOLOGICAL INTERVENTIONS ARE INCLUDED? For the purposes of the audit, psychological therapies / interventions include therapies, such as: CBT Psychoanalytic/psychodynamic therapy Couples therapy Counselling Behavioural activation IAPT low intensity interventions, if facilitated by a psychological therapist/worker from the target service NB Please note that this list is not exhaustive 13

14 The psychological therapies / interventions that are excluded are: Exercise prescription schemes if facilitated by a gym or someone other than a psychological therapist/worker from the target service Self-help/mutual support groups if unfacilitated or facilitated by someone other than a psychological therapist/worker from the target service Benefits/housing advice schemes 14

15 WHAT TYPES OF SERVICES ARE INCLUDED? STAGE 1 Is your service an NHS-funded service whose primary function or one of whose primary functions is to provide psychological interventions in the community for people with common mental health problems such as anxiety disorders and depression?* Yes Include ALL people that are being referred to this service in the audit, regardless of their diagnosis. No STAGE 2 Does your service have a dedicated worker or dedicated workers (constituting at least 1 WTE), whose primary role is to provide NHS-funded psychological therapy for common mental health problems within your wider service? Yes Collect data on all people seen by the dedicated worker(s). No STAGE 3 Do you have NHS-funded workers/therapists in your service who, as part of their role, treat people for common mental health problems (anxiety disorders No Yes STAGE 4 No data need to be collected for the national audit of psychological therapies. Do the number of people seen for anxiety disorders and depression diagnoses constitute more than 50% of the individual worker s/therapist s No No data need to be collected for the national audit, but individual therapists/workers may choose to collect and submit data on patients with anxiety disorders and depression if they wish. Yes Individual therapists/workers to collect data on all people, who are diagnosed with and treated for anxiety and depression only. * Please note that the audit does not include inpatient or residential services. In general, learning disability, clinical health psychology and prison in-reach services are also not included. Please contact the NAPT Project team for further clarification. 15

16 GUIDANCE NOTES TO DECISION TREE Stage 1: Includes services, such as NHS primary and secondary care psychological therapy services whose sole or major remit is to provide treatment for common mental health problems Voluntary sector organisations providing psychological therapies for common mental health problems if commissioned/funded by the NHS Independent/private sector organisations providing psychological therapies for common mental health problems if commissioned/funded by the NHS Graduate mental health worker and low intensity therapy services Stage 2: Includes workers/therapists, such as GP practice counsellors, if funded by the NHS individual graduate mental health workers and low intensity therapists attached to practices and funded by the NHS Individual psychologists, psychotherapists, nurse therapists and other psychological therapists working (full time or sessionally) as part of an NHS Trust community mental health service if the individual or the group of individuals constitute at least 1 WTE. Stage 3: Includes individual workers as above (see stage 2) employed to treat people with common as well as more complex mental health problems if they, within their role, treat people for anxiety disorders and depression. Stage 4: Service users are eligible to be included in the audit if they present with either: A primary diagnosis of an anxiety disorder or depression / depressive disorder, or With a diagnosis of an anxiety or mood disorder comorbid with a non-psychotic and non-organic mental health diagnosis 16

17 Therefore, all people would be eligible to be included if they have a diagnosis of depression or depressive disorder, generalised anxiety disorder, panic disorder, PTSD, OCD, agoraphobia, social phobia or other phobia, mixed depression and anxiety, or any of these diagnoses comorbid with a personality disorder, with an eating disorder, or with substance/alcohol misuse. People presenting with a primary diagnosis of schizophrenia, dementia or substance/alcohol abuse or dependence would be excluded from the data collection process at this stage. Please contact the NAPT project team if you are still unsure about which services/therapists/service users should be included in NAPT (please refer to page 24 for contact details). 17

18 5. DATA COLLECTION A series of audit questionnaires have been developed in order to measure whether the service meets NAPT s standards, which are based on relevant public guidance (please refer to Appendix A for a full list of the standards): Questionnaire 1: Service Context one-off to be completed by nominated individual in target service to gather contextual information about every service Questionnaire 2: Therapist Questionnaire one-off to be completed by every relevant therapist/worker to collect information on training, qualification and registration Questionnaire 3: Retrospective audit of people who ended therapy between 1 September and 30 November 2010 This involves an audit on everyone who has ended therapy within the specified audit period. In some services, information will be taken from case notes, in other services, data will be extracted from existing databases. To be completed by therapists or administrator Note: The NAPT project team can advise on the possibility of extracting data from existing systems (see page 20 for further information on data extraction). Questionnaire 4: Service User Survey one-off a service user survey, which includes the ARM-5 measure of therapeutic alliance 3 for self-completion. To be sent out to service users by participating service on a census date 3 Agnew-Davies R, Stiles WB, Hardy GE, Barkham M, Shapiro DA. Alliance structure assessed by the Agnew Relationship Measure (ARM). British Journal of Clinical Psychology.1988 (37), pp

19 Services will be supplied with free-post envelopes so that service users can return the survey anonymously and confidentially to the NAPT project team. 19

20 DATA EXTRACTION During the pilot phase a number of different methods of extracting existing data were developed and tested. This included working closely with relevant experts from IAPTUS and PC-MIS (systems widely used within IAPT services), as well as IT experts who used bespoke systems from participating sites. The steps involved depend on the IT system utilized (see Appendix B for details). The NAPT project team is very happy to liaise with relevant individuals about the possibility of extracting data from different systems and respond to any queries. THE AUDIT TIMELINE January- September 2010: Recruitment of services May 2010: Data collection begins May October 2010: Submission of Questionnaire 1: Service Context July December 2010: Submission of Questionnaire 2: Therapists Questionnaire October 2010: Service to select census date for Questionnaire 4: Service User Survey September 2010 February 2011: Submission of Questionnaire 3: Retrospective Audit of Patients who Ended Therapy October 2011: Services receive final report ETHICAL AUDIT AND THE COLLEGE CENTRE FOR QUALITY IMPROVEMENT (CCQI) The CCQI runs a series of national quality improvement programmes and networks. Participating trusts occasionally enquire about whether the subject and methods of data collection by these networks necessitates research ethics approval. Neither clinical audit nor service evaluation, of the type undertaken by the CCQI, require approval from research ethics committee. However, the Centre is keen to underline its ongoing commitment to conducting its work in a responsible and ethical manner. Please follow this link for further information: audit.aspx 20

21 6. PARTICIPATION IN NAPT Although roles and responsibilities will depend on the systems and structures that are in place in your service or your PCT / MHT / LHB, the follwowing section will give you an indication of the likely responsibilities attached to the role you have in relation to NAPT. ROLES AND RESPONSIBILITIES The responsibilities attached to each role are decribed below: Regional Lead A team of regional leads has been appointed to support local teams and services (please refer to Appendix D for a full list of the regional leads and their contact details). Their responsibilities include: Assisting in mapping out local service provision Publicising and recruiting services/teams into the audit Helping local services/teams prepare for data collection Trouble-shooting during the data collection period Liaising with the NAPT project team Audit lead in your PCT / MHT / LHB Assisting with deciding whether specific services fall within the criteria of the national audit and should therefore be included Providing the regional lead and/or the NAPT project team with a list of participating services and relevant contact details Providing the names and contact details of other people who the NAPT project team will be liaising with during the audit (for example, the IT office) Acting as a central point of contact for audit leads of services within the organisation (please see role and responsibilities below) Note: A member of the NAPT project team will be your point of contact for the audit, however, you may also wish to discuss specific queries with your regional lead Audit Lead in the service Ensuring that all relevant staff are fully briefed on the audit tools and procedures 21

22 Advising on whether it is possible to adapt existing data collection systems Tracking progress and assisting with trouble-shooting during the data collection period Providing feedback to staff during the data collection period Liaising with the organisational audit lead, regional lead and NAPT project team as appropriate Ensuring timely submission of all data collection tools Individual therapists in participating services Completing an anonymous one-off, online questionnaire about their professional background and qualifications Depending on how this data is collected, providing all or some of the data for the retrospective audit of people who ended therapy during the audit period The NAPT project team will be available to support you as effectively as possible. Please find their responsibilities outlined below: NAPT project team Overall management of the audit programme Compiling and managing a national database of participating services Data management, analysis and reporting Supporting the Regional Leads, Audit Leads and individual therapists Trouble-shooting during the data collection period We hope that we have provided you with all the relevant information for a successful start to the audit. If you have any queries, please do not hesitate to contact the NAPT project team (please see overleaf for contact details). Many thanks for your participation in NAPT 22

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24 NAPT PROJECT TEAM CONTACT DETAILS Please get in contact with us if you have any queries about the audit using the contact details below: Lucy Palmer, Project Manager Tel: Elizabeth Hancock, Deputy Project Manager Tel: Lorna Farquharson, Clinical Advisor Tel: Miranda Heneghan, Project Worker Tel: Darren Wooldridge, Project Worker Tel: Lauren Howells, Project Administrator Tel: Post: National Audit of Psychological Therapies, 4 th Floor, Standon House, 21 Mansell St, London E1 8AA 24

25 APPENDIX A: AUDIT STANDARDS S 1a: The service routinely collects data on age, gender and ethnicity for each person referred for psychological therapy. S1b: People starting treatment with psychological therapy are representative of the local population in terms of age, gender and ethnicity. i S 2: A person who is referred for psychological therapy does not wait longer than 13 weeks from the time at which the initial referral is received to the time of the assessment. ii S 3: A person who is assessed as requiring psychological therapy does not wait longer than 18 weeks from the time at which the initial referral is received to the time that treatment starts. iii S 4: The therapy provided is in line with that recommended by the NICE guideline for the patient s condition/problem. iv S 5: Treatment for high intensity psychological therapy is continued until recovery or for at least the minimum number of sessions recommended by the NICE guideline for the patient s condition/problem. v S 6: The therapist has received training to deliver the therapy provided. vi S 7: People receiving psychological therapy experience and report a positive therapeutic relationship/helping alliance with their therapist which is comparable to that reported by people receiving treatment from other therapists/services. vii S 8: Patients/clients report a high level of satisfaction with the treatment that they receive. viii S 9a: The service routinely collects outcome data in order to determine the effectiveness of the interventions provided. S9b: The clinical outcomes of patients/clients receiving psychological therapy in the therapy service are comparable to those achieved to benchmarks from clinical trials and effectiveness studies and to those achieved by other therapy services. ix S 10: The rate of attrition from commencing treatment to completing treatment is comparable to that of other therapy services. x 25

26 i Respecting diversity: working in partnership with service users, carers, families and colleagues to provide care and interventions that not only make a positive difference but also do so in ways that respect and value diversity including age, race, culture, disability, gender, spirituality and sexuality (DoH, 2004b, p.13). The patient s age, sex, social class or ethnic group are generally not important factors in choice of therapy and should not determine access to therapies (DoH, 2001, p.35). The full range of psychological interventions should be made available to older adults with depression, because they may have the same response to psychological interventions as younger people (NICE, 2007b, p.19). Any service user who contacts their primary health care team with a common mental health problem should have their mental health needs identified and assessed and be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it (NHS, 1999, p.9). Psychological therapy services need to be sensitive to the needs of parents They should provide flexibility within their service to choose appointment times (Mind, 2008, p.5). Psychological services should be flexible, offering weekend and evening appointments for those who are working during the day (Mind, 2008, p.6). Any individual with a common mental health problem should be able to make contact round the clock with the local services necessary to meet their needs and receive adequate care (DoH, 2004c, p.16). Ethnic and cultural identity should be respected by referral to culturally-sensitive therapists (DoH, 2001, p.35). Psychologists have a responsibility to work with local communities to ensure that psychological therapy services provide a range of interventions that are culturally appropriate and accessible by all members of the community (BPS, 2007, p.8). Practitioners should not allow their professional relationships with clients to be prejudiced by any personal view they may hold about lifestyle, gender, age, disability, race, sexual orientation, beliefs or culture (BACP, 2007, p.6). Any service user who contacts their primary health care team with a common mental health problem should be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it (DoH, 2004c, p.12). Commissioners should be looking at the needs of the local population when commissioning psychological services and ensure that services are tailored to local needs (Mind, 2008, p. 10). Commissioning should be based on accurate assessments of the needs of particular groups of service users. These include the needs of minority groups for treatments delivered with cultural sensitivity in accessible locations (RCP & RCGP, 2008, p.30). You have the right not to be unlawfully discriminated against in the provision of NHS services including on grounds of gender, race, religion or belief, sexual orientation, disability (including learning disability or mental illness) or age (DoH, 2009, p.18). ii Maximum wait for an outpatient appointment is 3 months (12 weeks) (DoH, 2002; p.11). PCTs should engage people while they are on the waiting list and tell them how long they can expect to wait (Mind, 2008, p.7). We call on the government to ensure that PCTs record their waiting times and publish these annually (Mind, 2008, p.3). The NHS should introduce waiting time measures for access to mental health treatments (Mind, 2006, p.17) The aim is to reduce the time service users wait at any point in the health and social care process e.g. between referral and the first appointment and any referrals to internal services (CSIP, 2006, p.30). We strongly support the IAPT programme s aspiration that urgent therapy be available within three to 10 days (Mind, 2008, p.3). All referrals should be acknowledged within the agreed service standard number of days of receipt by the psychologist (DCP, 2004, p.22). The NHS commits to provide convenient, easy access to services within the waiting times set out in this Handbook to the NHS Constitution (DoH, 2009, p.20). iii Maximum wait for an outpatient appointment is 3 months (12 weeks) (DoH, 2002; p.11). The treatment of choice is available promptly (NICE, 2007, p.46). (Anxiety audit criteria). PCTs should engage people while they are on the waiting list and tell them how long they can expect to wait (Mind, 2008, p.7). We call on the government to ensure that PCTs record their waiting times and publish these annually (Mind, 2008, p.3). The NHS should introduce waiting time measures for access to mental health treatments (Mind, 2006, p.17) The aim is to reduce the time service users wait at any point in the health and social care process e.g. between referral and the first appointment and any referrals to internal services (CSIP, 2006, p.30). We strongly support the IAPT programme s aspiration that urgent therapy be available within three to 10 days. (Mind, 2008, p.3). From the end of December 2008, patients can expect to start their consultant-led treatment within a maximum of 18 weeks form referral for non-urgent conditions unless they choose to wait longer or it is clinically appropriate that they do so. Although the maximum is 18 weeks many patients will receive treatment much sooner than that (DoH, 2009, p.20). 26

27 iv The NHS will do more to clarify what high-quality care looks like, by supporting NICE in developing quality standards that can be used by commissioners and providers to assess current practices and to inform the commitments they make to patients about what quality of services to expect (DoH, 2009, p.31). Anxiety A patient with panic disorder is offered any of the following types of intervention, and the person s preference is taken into account: psychological therapy, pharmacological therapy, self-help (NICE, 2007, p.46) A patient with longer-term generalised anxiety disorder is offered any of the following types of intervention, and the person s preference is taken into account: psychological therapy, pharmacological therapy, self help (NICE, 2007, p.46) Depression Depressive disorders may be treated effectively with psychological therapy with best evidence for cognitive behaviour therapy and interpersonal therapy, and some evidence for a number of other structured therapies, including shortterm psychodynamic therapy (DoH, 2001, p.37). Anxiety disorders with marked symptomatic anxiety (panic disorder, agoraphobia, social phobia, OCD, simple phobias, GAD) are likely to benefit from CBT (DoH, 2001, p.37). Generic counselling is NOT recommended as the main intervention for severe and complex mental health problems or personality disorders (DoH, 2001, p.37). The following structured therapies, delivered by appropriately trained practitioners, are effective for some people with depression: CBT, behaviour therapy, interpersonal therapy, structured problem-solving (WHO, 2005; NICE, 2009b, 15). When considering individual psychological treatments for moderate, severe and treatment-resistant depression, the treatment of choice is CBT or IPT or BA. (NICE, 2009b, p.15). People with a persistent subthreshold depressive symptom or middle to moderate depression, consider offering one or more of the following interventions, guided by the person s preference: individual guided self-help based on principles of CBT, ccbt, structured group physical activity programme (NICE,2009a, 183). ccbt should be provided via a stand-alone computer-based or web-based programme, include an explanation of the CBT model, be supported by a trained practitioner who provides limited facilitation, take place over 9-12 weeks (NICE,2009a, 183). Physical activity programmes for people with persistent subthreshold depressive symptoms or mild to moderate depression should be delivered in groups supported by a competent practitioner, typically consist of 3 sessions per week of 45mins-1hour over weeks (NICE,2009a, 184). Offer people with depression advise on sleep hygiene if needed (NICE, 2009a, 183). People with a persistent subthreshold depressive symptom or middle to moderate depression who have not benefited from a low intensity psychosocial intervention should be offered CBT, IPT, or BA (despite less robust evidence) or couples therapy if they have a regular partner (NICE, 2009a, p ) Group CBT should be offered to patients with moderate or severe depression who do not take or who refuse antidepressant treatment or low intensity psychosocial interventions (NICE, 2009a, p.250). People with depression who decline an antidepressant, CBT, IPT, BA and behavioural couples therapy should be offered counselling or short-term psychodynamic psychotherapy (NICE, 2009a, p.251). For people with moderate or severe depression, provide a combination of antidepressant medication and a highintensity psychological intervention (CBT or IPT) (Nice, 2009, p. 251). The choice of intervention should be influenced by the duration of the episode of depression and the trajectory of symptoms; previous course of depression and response to treatment; likelihood of adherence to treatment and any potential adverse effects; person s treatment preference and priorities (NICE, 2009a, p. 251). Mindfulness-based CBT, usually delivered in groups of 8-15 for the prevention of relapse (NICE, 2009a, p.254). For a person whose depression has not responded to either pharmacological or psychological interventions, consider combining antidepressant medication with CBT (NICE, 2009, p. 252). Panic disorder: Cognitive behavioural therapy (CBT) should be used. Briefer CBT should be supplemented with appropriate focused information and tasks. Where briefer CBT is used, it should be around 7 hours and designed to integrate with structured self-help materials. For a few people, more intensive CBT over a very short period of time might be appropriate. (NICE, 2007, p.16). Anxiety: CBT should be used. Briefer CBT should be supplemented with appropriate focused information and tasks. Where briefer CBT is used, it should be around 8 10 hours and be designed to integrate with structured self-help materials. (NICE, 2007, p.24). Interventions should be made available to older adults with depression, because they may have the same response to psychological interventions as younger people (NICE, 2007b, p.19).* Recommendations on older adults were not updated in 2009 due to dearth of new evidence. Follow-up/relapse: 27

28 People with depression who are considered to be at significant risk of relapse should be offered individual CBT (if relapses despite anti-depressant/and or have significant history of depression)/ mindfulness-based cognitive therapy if currently well but have experience 3 or more previous episodes of depression (NICE 2009, p. 254). For all people with depression who are having CBT for relapse prevention, the duration of treatment should typically be in the range of sessions over 3-4 months If the duration needs to be extended, it should consist of 2 sessions per week for the first 2 to 3 weeks of treatment. Additional follow-up sessions should typically consist of 4-6 sessions over the following 6 months.(nice, 2009, p.254). Mindfulness-based CBT, usually delivered in groups of 8-15 for the prevention of relapse (NICE, 2009a, p.254). v Therapies of fewer than 8 sessions are unlikely to be optimally effective for most moderate to severe mental health problems. Often 16 sessions or more are required to achieve lasting change in social and personality functioning (DoH, 2001, p.35). Depression For people having individual CBT duration of treatment should typically be in the range of sessions over 3 to 4 months providing 2 sessions per week in the first 2-3 weeks for people with moderate to severe depression and including follow up over 3-6 months(nice, 2009a, p.252). For people having IPT treatment should typically be in the range of sessions over 3 to 4 months providing 2 sessions per week in the first 2-3 weeks for people with moderate to severe depression and including follow up over 3-6 months(nice, 2009a, p.252). Behavioural couple-focused therapy for depression should normally be based on behavioural principles, and an adequate course or therapy should be 15 to 20 sessions over 5 to 6 months. (NICE, 2009a, p.252). For all people with persistent subthreshold depressive symptoms or mild to moderate depression having counselling, the duration of treatment should be typically in the range of 6-10 sessions over 8-12 weeks.(nice, 2009a, p.252). For all people with mild to moderate depression having short-term psychodynamic psychotherapy, the duration of treatment should typically be in the range of sessions over 4-6 months. (NICE, 2009a, p.252). Duration should normally be within the limits outlined in NICE guidance reduced if remission achieved and increase if progress being made but there is agreement between practitioner and person with depression that further sessions are required (NICE, 2009a, p. 253). Panic disorder: CBT in the optimal range of duration (7 14 hours in total) should be offered. For most people, CBT should take the form of weekly sessions of 1 2 hours and should be completed within a maximum of 4 months of commencement. Where briefer CBT is used, it should be around 7 hours and designed to integrate with structured self-help materials. For a few people, more intensive CBT over a very short period of time might be appropriate (NICE, 2007, p.16). Anxiety: CBT in the optimal range of duration (16 20 hours in total) should be offered. For most people, CBT should take the form of weekly sessions of 1 2 hours and be complete within a maximum of 4 months from commencement. Where briefer CBT is used, it should be around 8 10 hours and be designed to integrate with structured self-help materials (NICE, 2007, p.24). vi The attainment and maintenance of ethical standards in behavioural treatment, informal or formal are dependent upon appropriate attitudes to patient care and a high level of proficiency. For the achievement of both it is necessary that at least as great a priority is given to training in these treatments as is given to training for other types of therapy (RCP, 1997, p.14). The practitioner is responsible for learning about and taking account of the different protocols, conventions and customs that can pertain to different working contexts and cultures (BACP, 2007, p.8). A commitment to good practice requires practitioners to keep up to date with the latest knowledge and respond to changing circumstances (BACP, 2007, p.5). It is important that counsellors are aware of the evidence base that underpins their work and that they are able to respond to it appropriately. This means that practitioners should not only keep up with the latest research but also be a critical reader of it (BACP, 2004, p.38). Research is a complex process of critical and scientific enquiry and it is considered essential for counsellors to inform and validate their practice (BACP, 2004, p.38). Personal development and learning: Keeping up-to-date with changes in practice and participating in life-long learning, personal and professional development for one s self and colleagues through supervision, appraisal and reflective practice (DoH, 2004b, p.18). Practitioners have a responsibility to monitor and maintain their fitness to practise at a level that enables them to provide an effective service (BACP, 2007, p.7). [Therapists] must keep your professional knowledge and skills up to date (HPC, 2008, p.3). BACP recommends that counsellors in the NHS undertake 30 hours of CPD a year post qualification, and become familiar with portfolio learning and all that it means (BACP, 2004, p.38). 28

29 All applicants for BACP individual practitioner accreditation are required to have had 40 hours of personal therapy experience (BACP, 2004, p.30). vii Effectiveness of all types of therapy depends on the patient and therapist forming a good working relationship (DoH, 2001, p.35). Working in partnership: Developing and maintaining constructive working relationships with service users, carers, families, colleagues, lay people and wider community networks (DoH, 2004b, p.3). Patient preference should inform treatment choice, particularly where the research evidence does not indicate a clear choice of therapy (DoH, 2001, p.36). Psychologists should respect the knowledge, insight, experience and expertise of clients, relevant parties, and members of the general public (BPS, 2006, p.10). Patient preference and the experience and outcome of previous treatment(s) should be considered when deciding on treatment (NICE, 2007b, p.12). The patient shares decision-making with the healthcare professionals during the process of diagnosis and in all phases of care (Audit criteria in NICE). To facilitate shared decision-making, evidence-based information about treatments should be available and discussion of the possible options should take place (NICE, 2007, p.10). [The therapists] must act in the best interest of service users (HPC, 2008, p.3). The patient shares decision-making with the healthcare professionals during the process of diagnosis and in all phases of care (NICE, 2007, p.45). Increase the reliability of therapeutic interventions by enabling service users and carers to be at the centre of decision-making and establishing systems that support meaningful service user and carer involvement and participation (CSIP, 2006, p.26). viii It is important that people wishing simply to comment on services should have a distinct route to do so without having their input [it] as a complaint. (DoH, 2001b, p.99). Incorporate routine measures of outcome in psychological therapies service, including quality of life and service user satisfaction, waiting times, clinical outcomes, quality of life, service user and carer satisfaction, governance (DCP, 2007, p.19). ix The success of the IAPT programme will rest on its ability to demonstrate good clinical outcomes. Psychologists have an important role in advising local services as to routine clinical data collection, and how to guarantee and monitor good and appropriate clinical outcomes (BPS, 2007, p.10). [anxiety] Outcomes are monitored using short, self-complete questionnaires (NICE, 2007, p.47). All clinical psychologists should be responsible for monitoring and evaluating their work (DCP, 2004, p.35). Explore means to measure outcomes routinely, including quality of life and service user satisfaction (DoH, 2004, p.40) Short, self-complete questionnaires (such as the panic subscale of the agoraphobic mobility inventory for individuals with panic disorder) should be used to monitor outcomes wherever possible (panic disorder & GAD) (NICE, 2007, p.33). There should be a process within each practice to assess the progress of a person undergoing CBT. The nature of that process should be determined on a case-by-case basis (NICE, 2007, p.32). [outcome assessment] instruments should be implemented by counsellors skilled and trained in using them (BACP, 2004, p.40). All psychology departments should regularly evaluate their work using clinical audit techniques, outcomes measures and quality monitoring tools (DCP, 2004, p.35). Commissioning decisions should focus on outcomes rather than process and in particular services need to be able to demonstrate acceptability, accessibility, equity, effectiveness, efficiency, and safety (DCP, 2007, p.18). x There are positive advantages of services based in primary care practices (for example, lower dropout rates) and these services are often preferred by patients (NICE Anxiety quick reference guide amended, p.4) 29

30 APPENDIX B: DATA EXTRACTION PC-MIS PC-MIS can provide a customised report for NAPT A nominated person within the service will need to run the customised report All relevant data will be exported into an Excel spreadsheet in an anonymised format Data will have to be ed to the NAPT project team for analysis IAPTUS Following registration, a nominated person within the service will need to contact IAPTUS and advise of the service s participation in NAPT IAPTUS will remotely install an icon on the service s IT system The nominated individual can click on the icon to run the customised report for NAPT All relevant data will be exported into an Excel spreadsheet in an anonymised format Data will have to be ed to the NAPT project team for analysis Other systems (e.g. bespoke Access database) IT manager will needs to contact NAPT project team to express interest in data extraction The NAPT project team will provide IT contact with an Excel spreadsheet outlining the relevant required data fields If all relevant items are available on the IT data collection system, IT contact sets up queries to extract the relevant data in the Excel spreadsheet Data will have to be ed to the NAPT project team for analysis 30

31 APPENDIX C: PILOT SITES Abertawe Bro Morgannwg University HB Swansea/Abmu Wellbeing Service Swansea/Abmu Psychological Therapy Service Bridgend Psychological Therapy Service Neath Port Talbot Psychological Therapy Service Bristol PCT Womankind Counselling Service Avon Sexual Abuse Centre Cruse Bereavement Care Cambridgeshire and Peterborough NHS Foundation Trust Cambridgeshire IAPT Service Mid Essex IAPT Service Knowsley PCT Knowsley Primary Care Mental Health Service Sheffield PCT Sheffield IAPT Service South London and Maudsley Mental Health Trust Southwark Assessment and Brief Treatment (ABT) Teams Southwark Psychological Therapies IAPT Service Southwark Psychological Therapy Service for Older People Lambeth Mental Health of Older Adults Psychological Therapy Service Lambeth South-West Sector ABT Team North Lambeth ABT Team Lambeth South-East sector ABT Team Surrey and Borders Partnership NHS Foundation Trust Community Health Psychology Service Shaw s Corner Primary Care Mental Health Team Arts Therapy Service Psychotherapy Service Trafford PCT Trafford ccbt Service/Self Help Services Wrexham LHB Wrexham & Flintshire Psychological Therapies Wrexham & Flintshire Primary Care Counselling First Access Conwy & Denbighshire Psychological Therapies Conwy & Denbighshire Primary Care Counselling 31

32 APPENDIX D: REGIONAL LEADS North East Esther Cohen-Tovee PA Jo-Anne Young North West Tricia Hagan Yorkshire and the Humber Chris Powell West Midlands and South East Coast Pavlo Kanellakis East of England Carole Slater London John Cape Suchi Bhandari South Central and South West Amanda Stafford East Midlands Brenda Wilks North Wales George Pidgeon South Wales Amanda Hall 32

33 Reg Morris 33