Title: Harrow CCG IAPT Recovery Plan submitted to NHS England and current update

Transcription

1 Harrow CCG Title of Meeting : Governing Body Agenda Item 12 Paper No 12 Date of meeting: 8 September 2015 Attachment M Title: Harrow CCG IAPT Recovery Plan submitted to NHS England and current update This paper is being presented for: (delete as appropriate) Review, comment and update The Board / Committee is asked to: Review the submission made to NHS England on the 17 July 2015 The recommendation is to: For the Governing Body to support the recovery plan which includes the additional investment of 750,000 with Central & North West London NHS Foundation Trust (CNWL) to increase Access rates from 9% to 15% (with 1% delivered through the voluntary sector using, Harrow Carers) and deliver 50% Recovery. Purpose of the report The purpose of the report is provide information and assurance to the Board that actions as outlined in the plan are being implemented and complied with to deliver the Recovery Plan. In addition, to inform the Governing Body of any mitigating actions to enable informed decision making. Executive Summary (to include outcome benefits) The estimated number of people living with a common mental illness in Harrow is 24,231. To achieve the 15% target for access to talking therapies, 3,636 residents of Harrow with low level conditions will need to access the service for treatment. In late 2014/15 Harrow CCG committed non-recurrent investment to Central North West London NHS Foundation Trust (CNWL) with an agreement to increase access and capacity and to meet the quarter (4); 3.75% target for Access. Additional efforts were made to increase awareness of the IAPT service leading to the achievement of 3.90% for quarter 4. In 2015/16 Harrow CCG took the decision to meet the 15% target through commissioning 1

2 9% from CNWL and 6% through voluntary sector providers. Early in the first quarter of 2015/16 it was clear the voluntary sector would be unable to achieve this target. This approach was reviewed as it presented significant challenges for assurance to IAPT delivery and the decision was taken to invest in CNWL to provide 14% target and 1% from VSO (namely Harrow Carers). Following discussion with CNWL an investment of circ 750K has been agreed in principle (awaiting formal Board sign off) for 2015/16 to deliver the increased access of IAPT provision to 14% with CNWL. Benefits By increasing referrals and improving the conversion of these referrals to first appointments we are determined to increase capacity with the following benefits: Delivery of 15% Access Target Improved Ownership, Awareness and Uptake of IAPT Services Delivery of the 50% Recovery Target Addressing the fall in Recovery Rates Ensure delivery focus including; self-referral, LTC, Engagement with Seldom Heard Groups Increase CNWL capacity for counselling Promote the communication of the service including BWW service roll-over. Update Harrow Prevalence 24,231 15% = 3635 Access to date= 729 (June) Balance = 2906 Target 15% of the total population with a Common Mental Illness CNWL Access (14%: 3392) Harrow carers (1%: 244) 15/16 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Totals Refer Actual VSO Total

3 Target 50% Recovery Recovery (Average to date: 46.9%) 15/16 Apr May Jun Jul Target 50% 50% 50% 50% Actual 36.7% 56.7% 46.4% The recovery rate for Q1 (2015/16) is 46%. Month 2 saw its highest rate of recovery at 56.7% A dedicated piece of work is underway with CNWL to understand the drivers behind this and to take forward the learning to maintain a higher rate. Digital Access The Big White Wall online for Harrow current contract runs until the end of September The service provides an Online Support Network and Live Online counselling. HCCG are working with CNWL and BWW to develop integrated plans to increase take-up and inclusions of IAPTUS submissions. Self-referral Work is being undertaken to increase the number of self-referrals which rose from 17% to 66% in the Q4 15/15. All 35 practices in the Harrow have been requested by the Chairman to increase commitment and support to increase referral rates. GP Practices will be monitored for the number of referrals weighted by practice list size. Communications Strategy Launch Harrow CCG website has been updated to lead the communication drive. Changing the name to Talking Therapies to move away from a medical model and engage more with the public will help to reduce stigma and removes the overt reference to psychological, which acts as a barrier for many communities to accessing the service. By utilising voluntary sector and community venues we aim to provide treatment in comfortable and familiar settings that are more appealing to our population supported by multi-faith and cultural groups. Additional Investment Additional investment of 750,000 The contract value will increase to a total cost of 1,757,118. Monitoring Performance and recovery Plan - Weekly Steering Groups (Commissioner and Provider) meetings will be held with CNWL and associated providers - Outcomes and communication will be monitored in the fortnightly Mental Health Work 3

4 stream meetings Chaired by the Clinical Lead for MH - Overall reports and progress will be feed to the Monthly CCG Executive Board Meetings and Seminars; to include review, mitigation, evidence and outcomes against formal reporting Activity will also be monitored through monthly; CGG Meeting, PCE Meeting and Reports to NHS England Corporate Objectives and Board Assurance Framework: (Reference to how the organisation s objectives for year are supported by this paper) Please list BAF and Corporate Risk reference no.) Objective 1: Improve the health and wellbeing of the local residents of Harrow, in line with commissioning plans Manage resources effectively Increase access and recovery to Taking Therapies for the all groups Objective 7: Ensure people have a positive experience of care Equality and Diversity considerations and implications from which an Impact Assessment might be made: The pathway will improve access to talking therapies and levels of recovery for all groups Resource implications: The post include 6 locum Hi intensity CNWL are to employed 3 permanent PWP currently being recruited from an agency Risks Attached to this initiative (Reference to Corporate Risk Register as appropriate) (This could include legal or other statutory implications or drivers) include any clinical risks arising out of action/inaction. Referrals do not increase to the level required to utilize staff deployed. Less than anticipated take up from Big White Wall Sickness/ absence or staff turnover reduces access target delivery Referrals exceed capacity of staff Balance of referrals does not reflect step 2 and 3 split workforce proposed Quality Premium Penalty of 180,000 if targets not achieved NICE compliant therapeutic interventions not available to Harrow patients Narrow Carers unable to deliver 1% IAPT compliance interventions Agreement with CNWL to meet the 14% Patient & Public Engagement Input to and/or Impact of this initiative: Stakeholder engagement has formed a vital part of the business case development and has progressed in three elements; GP engagement, Provider Engagement (CNWL), Big 4

5 White Wall. Changes which the public will experience: The delivery of this service will be in accordance with NICE Guidelines. Services users will have access to early diagnosis and treatment Home assessment and assessment in Nursing Homes will be available Safeguarding Implications: Ensuring current IAPT workers have core skills in recognising the impact of mental health problems not only for the individual but also their dependent children including safeguarding issues There is also the opportunity to ensure that IAPT practitioners are able to identify, and act on, risks within the context of their individual work, particularly in safeguarding children and young people Staff must be trained and receive information explaining: physical, sexual, psychological, financial, neglect and discrimination Communications Strategy: (How will this initiative be disseminated) There will be more communication with GPs through Peer group Meetings, and Extranet. Clinical Director: Name: Dr Dilip Patel Job title: Clinical Director Harrow CCG Contact: Name: Lennie Dick Job title: Head of Commissioning MH, LD and Carers Harrow CCG 5

6 Page 1 Harrow CCG Recovery Action Plan Improving Access to Psychological Therapies (IAPT) Investment and increase in capacity to deliver 15% prevalence and 50% recovery targets 17 th July 2015

7 Background information Project team Project sponsor (SRO) Susan Whiting Project lead (PM) Lennie Dick Contract lead Liz Rahim Provider lead Deidre Moroney Clinical lead (CRO) Lawrence Gould Finance lead Sally England Quality & patient engagement lead Sanjay Dighe Version control Date Author Summary of changes 09/07/2015 Rahul Bhagvat 13/07/2015 Liz Rahim Reviewed and edited 14/07/2015 Lennie Dick Additional details added regarding IAPT trajectory 16/07/2015 Javina S & Sue W Final Version For PMO use Approved by Date of approval Hugh Caslake GB 7 th July, Pending BC Location of file Finance lead PMO shared Sally England Budget allocated Budget code Yes TBC Budget holder Start date Sue Whiting 01 August 2015 Page 2

8 Executive Summary 1. Harrow CCG has implemented a Recovery Plan' to ensure that the NHS England Improve Access to Psychological Therapies (IAPT) Access and Recovery Targets for are delivered. Estimated prevalence, current performance and contracted activity 2. The estimated number of people living with a common mental illness in Harrow is anticipated as 24,231. To provide access to talking therapies to 15% of these people with low level conditions equates to 3,636 IAPT appointments over one year; to be provided equally over 4 quarters of the year, achieving an average quarterly run rate of 3.75%. Table: Access Performance to date with cumulative shortfall Actuals Q1 Q3 Forecast based on current delivery rate Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Q4 Total Required IAPT Appointments Actual IAPT appointments Cumulative shortfall , The table above demonstrates the current shortfall for the first quarter. It was Harrow s intention to deliver a consistent number of 303 new IAPT cases per month to meet the access target of 15% for 2015/16. Current performance for the first 3 months of the year against trajectory is below what is required, for which a significant recovery plan has been implemented to address the shortfall and achieve the required activity target by Q4. Harrow must deliver significantly higher levels of referrals and treatment in the next 3 quarters of 2015/16. Harrow CCG in conjunction with Central and North West London NHS Foundation Trust (CNWL) the main secondary mental health care provider within the Harrow borough are collaboratively agreeing a plan to deliver the required activity that will be finalised by 31 st July Recovery Plan 4. A draft 'Recovery Plan' Trajectory has been devised to ensure Harrow achieves the 15% Access Target in 2015/16- this is illustrated in the table below: Table: Draft 'Recovery Plan' CNWL trajectory for 2015/16 Table: Draft 'Recovery Plan' Harrow Carers trajectory for 2015/16 Access Total The Recovery Plan trajectory represents a substantial, yet achievable challenge to increase the numbers accessing psychological therapies throughout the remaining 9 months. It is however a realistic trajectory that envisages a gradual increase in service delivery which reflects the reality of the incremental actions to increase the number and quality of referrals. 6. To deliver an accessible and sustainable service which will deliver the commissioned access target Harrow must continue to improve the conversion of referrals to appointments attended and increase the number of quality referrals. Page 3

9 Introduction 1. The NHS Mandate commits NHS England to playing a full part in delivering the commitments that at least 15% of adults with relevant disorders will have timely access to services, with a recovery rate of 50% by 2015". 2. In late 2014/15 Harrow CCG committed an additional non-recurrent investment to Central North West London NHS Foundation Trust (CNWL) to increase access and capacity. Additional efforts were made to increase awareness of the IAPT service leading to the achievement of 3.90% for Quarter Following a desktop review with NHSE Intensive Support Team during 2014/15, the development* of IAPT services during 2015/16 has been informed by the following recommendations from the report: Provide prompt access and equity of access, ensuring the inclusion of marginalized groups such as older adults, long term unemployed, BME and underrepresented clinical conditions Improve access rates - by increasing self-referrals and the marketing of the service in particular with GP s, and Seldom Heard communities Increase productivity: reduce DNA rate and attrition rates, increase the number of sessions to 18/20 hours per week per Therapist Align other psychological services to make them IAPT compliant Consideration of including counselling provision within the service 4. This information supported the decision to utilise the Voluntary Sector capacity to meet 5% of the delivery for IAPT access 2015/16. This was reviewed following the first months activity achievement, as it has become apparent that the use of the Voluntary Sector has presented significant challenges for assurance to IAPT delivery. Following discussion at board level an in principle decision was taken to invest in CNWL to provide 14% target, which has been discussed and agreed with CNWL and the relevant governance assurance processes are currently being undertaken. 5. Following discussion with CNWL an investment of circ 750K has been agreed in principle (awaiting formal Board sign off) for 2015/16 to deliver the required additional capacity of IAPT provision to 14% with CNWL. The additional 1% activity will be delivered via Harrow Carers with the agreed support from CNWL. *- In response to this a Joint Action Plan was drafted and was approved by the CCG Governing Body in July 2014, this is now being implemented and monitored by the IAPT Steering Group which meets on a monthly basis. Page 4

10 Purpose 1. Delivering NHS Mandate requirements The IAPT Recovery Plan is focused on achieving the following goals of the mandate: a. The Access Target for IAPT of 15% of the prevalent population b. The Recovery Target of 50% of those seen by the IAPT service c. An associated Quality Premium payment for Improving Access to Psychological Treatments, based on a CCG population of c231,000 for Harrow. 2. Increasing Local Ownership NHS Harrow CCG recognises the contribution Voluntary Sector Organisations (VSO) can make in this area including their skill at engaging with seldom heard groups in their local communities. VSOs are often referred to for advice and support. Harrow CCG and CNWL have committed to developing this opportunity and understands that only a few of these organisations have the capability to provide direct IAPT services. To provide support and maintain assurance it is deemed beneficial to co-ordinate activity via one lead provider as per the Harrow model where both Harrow Mind and Harrow Carers support the target delivery. Harrow CCG and CNWL have agreed to work with Harrow Carers, to engage with Voluntary Sector Organisations who have strong links with local communities in Harrow and who can potentially offer venues for IAPT services. Harrow CCG is committed to supporting an increase in General Practice referrals in particular through identification of patients with long-term conditions, and by increasing access to general practice premises for service delivery. Harrow CCG will set individual practice targets to provide assurance and accountability to the CCG. Enacting this plan will have internal targeted management support for delivery. The Self-care communication plan will provide on-going support to the practices through working directly with all practices in Harrow. This will also support referrals directly made from Mental Health services 3. Improving Accessibility and Quality Harrow recognises the diverse needs of its population, as demonstrated by our strategic plan for IAPT which is to create a sustainable and accessible service that meets the needs of residents. This will require increased routes to access services. We will be monitoring the uptake and usage of the selfreferral route and telephone access. An increased promotion of the online Digital Access provision, Big White Wall will (commissioned since April 2014) will support understanding as to whether residents favour this over traditional settings. The capacity of this provision includes telephone support, which can be recorded as part of the IAPT access target, and to which CNWL and primary care have direct access. Our aim is to remove the stigma from accessing psychological support and to prevent it appearing as an overly medicalised model. By promoting the service as Talking Therapies, removes the overt reference to psychological, which acts as a barrier for many communities to accessing the service. By utilising voluntary sector and community venues we aim to provide treatment in comfortable and familiar settings that are more appealing to our population supported by multi- faith and cultural groups. Page 5

11 Recovery Actions and Milestones A weekly steering group oversees the delivery of the work streams: The CCG has taken various steps to identify and address actions concerning Access and Recovery Rates: Increasing Access Close monitoring is being undertaken at multiple levels within the CCG to ensure IAPT performance and appropriate systems of escalation for failure in compliance. Page 6 - Weekly Steering Groups (Commissioner and Provider) meetings will be held with CNWL and associated providers - Outcomes and communication will be monitored in the fortnightly Mental Health Work stream meetings Chaired by the Clinical Lead for MH; - Overall reports and progress will be fed to the Monthly CCG Board Meetings and Seminars; to include review, mitigation, evidence and outcomes against formal reporting - Monthly Peer Group meetings with Member Practices will also monitor how each practice is performing A special focus is being placed on patients with Long Term Conditions; utilising their Generalised Anxiety Disorder (GAD) scores to ascertain suitability for referral into the IAPT service. The CCG is working closely with CNWL to set up an IAPT treatment group, which will address this opportunity. Further work is being done with a range of partners including Diabetes UK, Expert Patients, Community Health Champions, Community Specialist Nurses and colleagues in Secondary Care (monitoring outpatient clinics in specialities such as Respiratory Diseases and Cardiology) to identify patients who would benefit from Psychological support. The CCG has also been in discussion with the Harrow Patient Participation Network (HPPN) to raise awareness at patient level in primary care settings. Another significant area deemed beneficial is Social Care and discussions are in progress with the Local Authority to establish mechanisms for individuals to be referred making use of low level interventions. Increasing the scope in diversity of the patient cohort has been presented as an innovative approach to increase access in groups such as those with learning disabilities, pregnant mothers, the elderly, those living alone /socially immobile and people suffering with a low level of post-traumatic stress. These will continued to be developed as group work. During 2014/15 Harrow has made use of the Big White Wall (BWW). The uptake in the approach has been limited but has been continued into 2015/16. Harrow CCG and BWW are looking at ways to improve the uptake and clearly define the integration and data with CNWL and primary care. This is seen as a positive opportunity going forward. A significant challenge in working with seldom heard groups is being addressed via CNWL, who are committed to working with such groups in raising awareness about services /therapies on offer. Similarly, Harrow Carers have commenced in-reach programmes to target those who would benefit from IAPT services and /or potentially identify those in the community who are hesitant to present their symptoms. The CCG will convene both CNWL and Harrow Carers to share the learning from their work and facilitate the creation of a joint action plan to address outstanding areas. An innovative method to diversify the professional input via the existing provider is to promote the counselling service provision as Talking Therapy thus breaking down a long-standing taboo within primary care to refer patients directly.

12 Moreover, the integration of IAPT into primary care is paramount; clinicians should understand and utilise the service, knowing this intervention is also a form of admissions avoidance into Secondary Care by reducing likelihoods of any exacerbating events /conditions. The CCG is currently planning a series of ways to increase access rates via the following: Self Referral Targeted communication campaigns to increase awareness of Talking Therapies via marketing on the CCG website and social media platforms such as Twitter. Dissemination of publicity material in the wider community through Local Authority magazines and GP Practice newsletters/leaflets. A media campaign through the local press to coincide with seasonal messages akin to the NHS. GP Referral Identifying an internal resource to work directly with Practices to support and identify ideal patient cohorts. IAPT training and awareness presentations at GP Forum /Peer Group meetings to ensure GPs are fully informed of the service and its distinct advantages. Re-launch the communication plan through the Peer Group meetings with the GPs Recovery The Harrow CCG averaged 41% recovery rate by March The recovery rate for Q1 (2015/16) is 46.4%. In month 2 was A dedicated piece of work is underway with CNWL to understand the drivers behind this and to take forward the learning to maintain a higher rate. The Big White Wall online Mental Health resource has been extended for Harrow until the end of September 2015 with additional funding. The tool offers digital interaction for patients with an option for direct contact via a dedicated telephone line all of which contributes to increasing the level of IAPT access. Historically, there has been a low uptake of this resource and the CCG is currently undertaking analysis to establish why, along with an options appraisal to inform commissioning this beyond September Page 7

13 Benefits By increasing referrals and improving the conversion of these referrals to first appointments we are determined to increase capacity with the following benefits: 1. Delivery of 15% Access Target NHS Harrow is working towards achieving the 15% access rate by the end of quarter 4, 2015/ Improved Ownership, Awareness and Uptake of IAPT Services CNWL capacity was increased in 2014/15 to achieve 15% access rates in quarter 4. Reflecting a demand for local ownership by the community to sustain increased access, Harrow CCG has commissioned 14% of the target with CNWL and 1% with Harrow Carers. Harrow CCG have are working with CNWL to also liaise with the Voluntary Sector to ensure additional numbers especially from seldom heard groups. Based on feedback from NHS England IAPT Intensive Support Team, additional investment is likely to be required to sustain access levels in 2015/16 and beyond. There is a need to evidence the wider savings to the health economy this will achieve to justify this further investment. 3. Delivery of the 50% Recovery Target NHS Harrow CCG has been liaising and reviewing information from Boroughs in NW London to learn lessons from those who have achieved over 50% recovery. Harrow CCG recovery rate to date for 2015/16 is April (36.7%), May (56.7%), and June (45.9%). The average for the Q1 (46.4%). The CCG is reviewing the outcomes and practices with CNWL for ways to sustain and improve on these outcomes especially those in month (2). 4. Addressing the fall in Recovery Rates NHS Harrow CCG has in place a steering group which meets monthly. The group are looking at the last two months outcomes to learn lessons as to why the rate in month (3) fell below 50% for recovery. 5. Avoiding the Perverse Incentives in Recovery Rate Measures The current recovery measure target has several limitations, explored at length in Improving Access to Psychological Therapies: Measuring Improvement and Recovery, Adult Services, Version 2 (NHS England June 2014) [ These limitations have been recognised by NHS England. For 2014/15, the old indicator continues to be used to preserve the time series from The recovery measure used since 2008 sets a clinical cut-off score to count as recovered, patients must begin treatment above the cut-off, and finish treatment below the threshold. The national target is for 50% of patients completing treatment to cross this threshold. This creates a perverse incentive for IAPT services to preferentially accept patients who are the most likely to cross this threshold, over those would derive clinical benefit but might not cross the cut-off point. Therefore simply looking at movement across the threshold introduces a perverse incentive to cherry pick simple cases who may have improved even without intervention. p3 Improving Access to Psychological Therapies: Measuring Improvement and Recovery, Adult Services, Version 2 (NHS England June 2014) Page 8

14 Harrow CCG and CNWL are fully aware of this issue, but will continue to ensure that the IAPT services accept all patients who meet the eligibility criteria and are likely to derive clinical benefit. This means the challenge will remain high whilst Harrow CCG drives to achieve the 50% recovery target. 6. The recovery plan is generated to assure and increase compliance through tightly monitored and driven process. Weekly provider and commissioning meetings to monitor progress against plan, formal reporting to the CCG Board will provide help and support when required. All process have been reviewed to ensure delivery focus including; self-referral, LTC group work and commitment to engage with Seldom Heard Groups, and an understanding of increase in activity at the later part of 2014/15. Harrow CCG intends to embed these changes into the service model with continued review, monitoring and a robust deliver plan. To enhance recovery targets a commitment to increase CNWL capacity for counselling and PWP professionals has been agreed. CNWL in collaboration with HCCG and other providers to promote the communication of the service including BWW service roll-over. Page 9

15 Access Trajectories In 2015/16 CNWL will be obliged to deliver a minimum of 1,413 IAPT appointments every quarter (or 471 a month evenly spread); if they fall below this threshold performance issues will be escalated by the IAPT Steering Group to both the CNWL Borough Director and to the CCG Executive to agree remedial action. 1. Performance to date and trajectory for Quarter 4 (December figures are unrefreshed data) Actuals Q1 Q3 Forecast based on current delivery rate Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Q4 Total IAPT Appointments (471) 300 (471) 300 (471) 900 (1,413) 2. 'Recovery Plan' trajectory for Quarter 4 Recovery Plan Trajectory for Q4 Jan Feb Mar Q4 Total IAPT Appointments , /16 IAPT monthly trajectory and quarterly targets (to sustain 15% Access) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YE Total Monthly trajectory Quarterly Targets IAPT Access Tar Cum Actual Cum Access M1: 2015/16: 214: 0.88% M2: 2015/16: 141: 0.58% M3: 2015/16: 183: 0.76% Cumulative: 538: 2.22% against a target of 909 (3.75%) HCCG working with the provider to recruit and increase the number of PWP Staff i) Review the level of locum staff Page 10

16 Recovery ii) Review the level severity of illness associated with number of sessions service users are given iii) Allow improvements to IAPT delivery model to bed in. Develop the voluntary sector to maintain access target, addressing identified gap in provision at Step /16 IAPT monthly trajectory and quarterly targets (to sustain 15% Access) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YE Total Monthly trajectory Year to date activity 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% % There is significant work being undertaken via the IAPT steering group to identify and resolve the challenges to sustainability of the 50% recovery target Page 11

17 Finances Harrow CCG has an in principle agreement to investment circa 750k with CNWL to provide 14% access target. 2012/3 2013/4 2014/5 CNWL baseline 422, , ,373 CCG Investment 0 345, ,000 MIND ( via CNWL) 134, , ,000 Harrow Womens Centre 11,840 14,000 14,000 Harrow Carers 12,296 41,345 41,345 IAPTus 33,500 25,000 25,000 Twinings- Employment Suppport Non recurrent funding (carry over) Additional in principle funding agreement 40,000 40, , , ,000 TOTAL COST 754,009 1,149,118 1,759,118 Page 12

18 Risk Management Risks Likelihood Impact Total Mitigation Referrals do not increase to the level required to utilize staff deployed. Less than anticipated take up from Big White Wall Sickness/ absence or staff turnover reduces access target delivery Referrals exceed capacity of staff Balance of referrals does not reflect step 2 and 3 split workforce proposed Quality Premium Penalty of 180,000 if targets not achieved Increasing referrals is a joint responsibility and target is agreed and tracked with mitigations agreed with CCG Expected to be similar but with some increase from last year Staff will provide additional hours to bridge the gap New referral pathways will be opened up in stages and monitored with GP referral prioritised and new referrers kept informed of availability and waiting times monitored and managed Staff turnover could enable workforce balance to be adjusted to reflect referrals. If more step 3 referrals are received workshop step 2 interventions as a first stage will be increased to maintain delivery. Currently the whole range of therapies are not available; increased funding will allow for the relevant staff training to take place NICE compliant therapeutic interventions not available to Harrow patients Support made available from Voluntary Service support organisations/bacp/cnwl Narrow Carers unable to deliver 1% IAPT compliance interventions Agreement with CNWL to meet the 14% Increasing referrals and support from CCG, CNWL and other VSO to ensure the delivery Additional Investment has been provided to CNWL to meet the target Page 13

19 Annex 1: The BHH/CNWL Joint IAPT Action Plan WHAT HOW WHO WHEN 1 Commissioners define the core IAPT SERVICE (Clusters 1-4) and review in terms of the primary care mental health stepped care model 2 Commissioners agree the investment and trajectories 2014/5 2015/6 Page 14 Develop service model in consultation with stakeholders Link with MHT tariff work CNWL and commissioners to agree funding and activity plans as part of the 2014/5 contract 3 Service redesign- processes and governance systems established This is through the individual CCG and CNWL governance structure. Commissioner led with CNWL Commissioners Commissioner led, with CNWL 4 Extend the range of venues available for the IAPT service Discussion with Local Authority and Community groups Commissioners/CN WL 5 Marketing plan- engaging with stakeholders to promote services to under served groups: Older Adults BME Carers Children/perinatal MUS Pain LTC Through a market engagement exercise Commissioners to use existing networks eg Local Authorities, third sector, CCG colleagues, NHS providers 6 Review/publicise self referral/guided self referral Links to risk assessments for patients Communication teams Co-production Commissioners Commissioners/CN WL Commence July July Completed September Commence July Commence July 7 Improve links with Public Health- well-being/preventative Establish links with Public health Commissioners/CN Commence July WL 8 All first treatment appointments within 4 weeks of referral Monitor through performance reports Commissioners/CN On-going WL 9 Undertake GP practice audit Performance reports CNWL On-going 10 Improve Productivity so that current investment reaches- Brent - 9.5% Hillingdon 10.5% Hillingdon 10% By: Reduce DNA rates Reduce attrition rates Therapists undertaking 20 hours of therapy per week This is being undertaken by CNWL- although there is challenge to the NHSE assumption that Therapists should undertake 20 hours of therapy per week CNWL On-going

20 11 Workforce review Review staffing levels including no of Hi Intensity and PWP staff CNWL 12 Increase range of therapies offered In place except in Hillingdon due to current funding levels- to CNWL be discussed with Commissioners in Hillingdon 13 Review paper by Alex Thomson (Brent) Forwarded to Brent commissioners for consideration Commissioners/CN WL 14 MH Tariff-clustering of patients Reports to commissioners CNWL From December Performance reporting: Access rates Ethnicity Age Postcode Number of assessments GP Practice referral rate, recovery Attrition rates No of Sessions at step 2 No of Sessions at step 3 No sessions and outcomes Recovery rates Co-morbidity/LTC Care cluster CNWL On-going On-going 15 Review other services to ascertain whether they can be included into the IAPT performance Map all other similar services Meet to discuss Commissioners July Page 15

21 Annex 2: IAPT Referrals by GP Practice IAPT Referrals from Harrow CCG Practices (weighted to practice size) Organisation Name Practice List Size List Size % IAPT Appointments by Practice (Weighted) NHS Harrow CCG THE CIRCLE PRACTICE % KINGS ROAD SURGERY % SIMPSON HOUSE MEDICAL CENTRE % ENDERLEY ROAD MEDICAL CENTRE % BACON LANE SURGERY % STREATFIELD HEALTH CENTRE % ROXBOURNE MEDICAL CENTRE % THE PINN MEDICAL CENTRE % HONEYPOT MEDICAL CENTRE % THE PINNER ROAD SURGERY % THE NORTHWICK SURGERY % HATCH END MEDICAL CENTRE % THE STANMORE MEDICAL CENTRE % GP DIRECT % ELLIOTT HALL MEDICAL CTR % THE SHAFTESBURY MEDICAL CENTRE % CHARLTON ROAD MEDICAL CENTRE % THE RIDGEWAY SURGERY % BELMONT HEALTH CENTRE % PINNER VIEW MEDICAL CENTRE % HARNESS HARROW PRACTICE % KENTON BRIDGE MEDICAL CENTRE DR GOLDEN % THE CIVIC MEDICAL CENTRE % Page 16

22 THE STREATFIELD MEDICAL CENTRE % KENTON CLINIC % ZAIN MEDICAL CENTRE % THE STANMORE SURGERY % ASPRI MEDICAL CENTRE % KENTON BRIDGE MEDICAL CENTRE DR LEVY % HEADSTONE LANE MEDICAL CENTRE % HEADSTONE ROAD SURGERY % SAVITA MEDICAL CENTRE % ST. PETERS MEDICAL CENTRE % THE ENTERPRISE PRACTICE % Page 17

23 What is the problem and what are we trying to achieve? Why is it occurring? What would impact and Why? Harrow CCG 2015/16: Sustaining IAPT Access Delivery, and Recovery Rates Action plan assurance Harrow CCG full year 2014/15 recovery rate was 40.9% (baseline for this plan) against the target of 50%. Recovery rates fluctuate. Recent activity: Mar 40.4%; Apr 36.7%; May 56.7%; Jun 46.43% Aim is to achieve national target recovery rate (50%), Harrow CCG Q4 2014/15 access rate was 4.39% against a target of 3.75% Access rates fluctuate. Recent activity: Mar: 2.48% Apr: 0.88% May: 0.58% June: 0.76% Aim is to achieve national target access rate of 15% Recovery Recovery potential limited Low number of experience therapist (high intensity), and high staff turnover rates High DNA Rate Access Low referral rates Acuity of referrals present higher challenges for the service Low self-referral rate of around 18% CCG model of service was to deliver 9% with CNWL and 6% with VSOs: inability to mobilise VSOs quickly Increasing referrals including self-referrals: To attract more mild to moderate cases, motivation to stay in therapy Improving GP referral tools and case discussions: To identify more mild to moderate cases Increase diversity in case mix including long term conditions Increasing local venues and online support: to reduce logistical barriers to increase diversity of access Assertive follow up of those that DNA: to re-engage patients to complete therapy Commission main provide: Experienced, progressive development potential, tested Work streams What will we do, by when and by whom? What Impact will it have and by when? Sustaining capacity Q1: Take forward learning from Q4 2014/15 CCG, CNWL, VSOs, Big White Wall (BWW), IAPT Steering Group Removing logistical barriers Q2: Increase diversity, accessibility and capacity of service. CCG, CNWL, VSOs, Big White Wall (BWW) Q1: Define required changes to commissioned service model, Q2: Realign model for target delivery(access and recovery)submit a revised BC for additional capacity with CNWL Q2: Increase access for low/moderate cases Q2: Continue to use BWW and develop integrated working between Primary Care, CNWL, BWW and VSOs Reducing DNA rates Promoting IAPT selfreferral (inc older people & LTC) Q2: Strengthen Follow-up processes All Stakeholders Q2: Increase CNWL capacity for counselling and PWP professionals Q2: Increase recovery rates +2% Q2: Increase access for low/moderate cases Q3: Increase recovery +1%

24 Access Harrow CCG 2015/16: Sustaining IAPT Access Delivery, and Recovery Rates IAPT Access Tar Cum Actual Cum Access Cum. 538 (2.22%) against target 909 (3.75%) M1: 214 (0.88%) M2: 141 (0.58%) M3: 183 (0.76%) Self-referral commenced in April 2014, low rate of uptake. Positive outturn at the end of the last quarter 2014/15 moving from 15% to over 50%. Limited resource for counselling; the rate of referral for mild moderate presentation is lower than anticipated. Additional investment will add counselling to overcome this shortfall. Under representation of adults into IAPT from seldom heard communities is being addressed through collaboration with CNWL and VSOs Current IAPT provision is primarily based on acute hospital site, community based provision to be increased

25 Harrow CCG 2015/16: Sustaining IAPT Access Delivery, and Recovery Rates Understanding Harrow IAPT Recovery Performance (2014/15) In trying to understand why the recovery rate is not achieving 50% HCCG and CNWL are reviewing activity and complexity. The overall recovery rate for 2015/16 was 40.9% with a significant rise (57%) in May The table below shows the significant numbers of patients both being referred to the service and those that gain access. However, only 12% of those that complete effectively meet recovery and only 7% that gain access. Q1 % Q2 % Q3 % Q4 % Recovery 2014/15 Recovery Completion % % % % Access % % % % Referrals 796 5% 891 5% 892 4% % 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Q1 Q2 Q3 Q4 Recovery Completion Access Referrals Provider Data and Analysis HCCG and CNWL are reviewing the data looking at the types of referrals (Depression/Anxiety). The main focus areas include; source of referral (GP/Self), Step, Step 3, and Carers. This will also be evaluated alongside the workforce in terms of locums, qualified and PWP professionals, intensity of the sessions and number of sessions. Harrow is also liaising with other Boroughs in NW London gain from lessons learnt.

26 Harrow CCG 2015/16: Sustaining IAPT Access Delivery, and Recovery Rates ACTION PLAN SUMMARY STRATEGIC OVERVIEW NHSE Quarterly Assurance updates Governing Body and Executive Committee (Monitoring and Updates) Fortnightly Work Stream Meetings (Chaired by Clinical Lead for MH) Weekly IAPT Steering Group Meetings (Harrow CCG and CNWL (Harrow Carers & Harrow Mind) NHS Operating Plan requirements Recovery Rate Action Plan Performance Activity Data Referral Routes summary Risk Register PROVIDER LEVEL OVERVIEW Improving GP referrals Promoting IAPT self-referral and awareness Sustaining capacity and reducing DNA rates GP Peer Group meetings GP Level Referral monitoring Access trajectory- local and practice level GP action plan delivery Supporting Long Term Conditions PHQ4 profiles CNWL learning sessions General feedback Communication and engaging with wider groups and agencies Communication Strategy being developed for IAPT Outreach activities Community venues attendance Self-referral by postcode Big White Wall Engagement CNWL and BWW Integration Weekly HCCG and CNWL Steering Group Meetings Improve GP and self-referrals Access Recovery Reducing DNAs Increasing Step 2 and Step 3 Recruitment additional of PWP Professionals Inclusion of Big White Wall Data Activity DNAs Access Support with IAPTUS

27 Project Plan what are we doing? Harrow CCG IAPT Access Delivery and Recovery Assurance Action Plan 2015/16 No: Plan Action(s): Who is accountable? 1 Sustain and improve performance to achieve 50% recovery rate for 2015/16 Continuous monitoring of performance of HCCG/CNWL recovery target 2015/16 Monitor RAP to support agreed trajectories as required 2 Review positive outcome from May 2015 recovery outturn of 56.7% Liaise with other NW London CCGs on their successful recovery delivery 3 Participate in NHS E review of improving recovery rates within challenge to London achievement HCCG/CNWL HCCG/CNWL Status End date: Contribution to recovery In Progress In Progress In Progress 31 March March 2016 TBC with NHS E Respond proactively and reduce deviation Implement lessons learnt Q1: Increase recovery: + 2% (44%) Q2: Increase recovery: +3% (47%) Q3: Increase recovery: +1% (48%) Q4: Increase recovery: +2% (50%) Increase range of provision and target Seldom Heard groups Increase community capacity and locations for service delivery- Care Closer to Home 5

28 Project Plan what are we doing? Harrow CCG IAPT Access Delivery and Recovery Assurance Action Plan 2015/16 No: Plan Action(s): Who is accountable? 4 Increase Invest 750k in CNWL to support sustainment of 3.75% run rate achieved Increase capacity commissioned from CNWL, to maintain 14% (and support Harrow Carers to deliver 1%) Promote self-referral across the Harrow population 5 access Work with GPs and all identified stakeholders to increase all referrals HCCG/CNWL HCCG/CNWL Status End date: Contribution to recovery In Progress In Progress 31 Sept Mar 2016 Increase capacity to deliver national targets to achieve access for 15% of IAPT prevalence Increase self-referral Development of counselling provision Increase awareness and knowledge of the service 6 to Communicate and promote service with GPs and stakeholders to increase referrals- in particular with reference to IAPT low- moderate mood and Seldom Heard groups HCCG/CNWL In Progress 31 March 2016 Encourage integrated working to deliver a responsive service Increase diverse provision across the Borough services 7 Publicity communicate and distribute materials widely HCCG/CNWL In Progress 31 March 2016 Build future delivery capacity across a range of providers 8 Continue to scope, develop and review additional voluntary sector ability to provide additional capacity HCCG/CNWL In Progress 31 Mar 2016 Increase awareness and users from Seldom Heard groups 6

29 Project Plan what are we doing? Harrow CCG IAPT Access Delivery and Recovery Assurance Action Plan 2015/16 No: Plan Action(s): Who is accountable? 9 Work with GPs to share practice and learning: pathways, referral, outcomes, case discussions especially in respect of identification of low to moderate need HCCG/CNWL Status End date: Contribution to recovery In Progress 31 Mar 2016 Develop support, learning for GP s and Harrow stakeholders 10 Work with GPs to GPs to monitor patient uptake following increase referral; identify and address reasons why access and patients DNA: individually and collectively improve 11 outcomes for Work with GPs to identify and address patients other barriers to achievement of the targets, e.g. practice group work supporting LTC management and community service locations 12 Support development of an IAPT partnership focussed on improving access and Extend Harrow IAPT steering group to include GPs, providers, service users and Big White Wall 13 Work with the IAPT partnership to promote IAPT services across the Harrow population, prioritising under represented groups. 14 outcomes Implement monitoring weekly steering which group, peer groups, monitoring through includes work stream and escalation to CCG service Board users. GPs/Peer Groups In Progress 31 Mar 2016 HCCG/CNWL In Progress 31 Mar 2016 HCCG/CNWL Due to 31 Mar 2016 commence 1/8/2015 HCCG/CNWL In Progress 31 Mar 2016 HCCG/CNWL In Progress 31 Mar 2016 Provide education and shared learning that will support co production of service development across Harrow Increased community locations for IAPT service delivery Co production of service development opportunities Support the development of annual commissioning intentions High visibility of clinical leadership and commitment from CCG Support the IAPT partnership to work with IAPT patients to identify and address other barriers to achievement of the targets 7

30 Managing the Risks to IAPT Access, Delivery and Recovery Rates Risk Description Likelihood Impact Total Mitigation Referrals do not increase to the level required to utilize staff deployed Less than anticipated take up from Big White Wall Sickness/ absence or staff turnover reduces access target delivery Increasing referrals is a joint responsibility and the target is agreed and tracked with mitigations agreed with CCG Expected to be similar but with some increase from last year CNWL, BWW and Carers Staff will provide additional hours to bridge the gap Referrals exceed capacity of staff Balance of referrals does not reflect step 2 and 3 split workforce proposed New referral pathways will be opened up in stages and monitored with GP referrals prioritised and new referrers kept informed of availability and waiting times monitored and managed Additional financial incentives for the delivery of the IAPT Waiting Time Standards Staff turnover could enable workforce balance to be adjusted to reflect referrals. If more step 3 referrals are received workshop step 2 interventions as a first stage will be increased to maintain delivery. Quality Premium Penalty of 180,000 if targets not achieved 1-3 Low risk 4-6 Moderate risk 8-12 High risk Extreme risk Currently the whole range of therapies are not available; increased funding will allow for the relevant staff training to take place 8

31 Managing the Risks to IAPT Access, Delivery and Recovery Rates Risk Description Likelihood Impact Total Mitigation NICE compliant therapeutic interventions not available to Harrow patients Support made available from Voluntary Service support organisations/bacp/cnwl Harrow Carers unable to deliver 1% IAPT compliance interventions Increasing referrals and support from CCG, CNWL, BWW and other VSOs to ensure delivery Agreement with CNWL to meet the 14% Additional Investment of 750k has been provided to CNWL to meet the target 1-3 Low risk 4-6 Moderate risk 8-12 High risk Extreme risk 9

32 Monitoring arrangements Activity reporting Contract monitoring Strategy planning HSCIC Monthly reports (2 months in arrears) Regional assurance NHS England CNWL Informatics Data validation Clinical Teams CNWL activity Big White Wall activity Integrated Performance Reports CNWL Contract Lead and associate CCGs CNWL Contract Team Central contract monitoring Finance Information Group Performance Exec Group Clinical Quality Group IAPT sub-group (Provisional data and qualitative feedback) Local assurance CCG Governing Body CNWL Board Oversight Group (Alternate months) CNWL Borough Director CNWL Clinical Director CCG/CNWL Executives (including COOs) IAPT Steering Group Fortnightly workstream Weekly steering group Pilot evaluation: Big White Wall & community venues Referrals GP-referral Self-referral Page 10