CYP IAPT Embedding Change in Practice Dr Raphael Kelvin Consultant & Associate Lecturer Cambridgeshire & Peterborough NHS Foundation Trust & University of Cambridge Professional Advisor for CYP Mental Health Dept. of Health England Royal College of Psychiatrists CAP Institute 20 January 2012, London
Summary Importance Relevance Ambition
CYP IAPT Leadership Team Karen Turner, SRO, Deputy Director, DH Dr Sheila Shribman, NCD Children, DH Professor Peter Fonagy CYP IAPT Clinical Lead, Chair of the Training and Curriculum Group Kathryn Pugh, Project Manager Dr Raphael Kelvin, National Professional Advisor CYP MH Sarah Brennan/Young Minds, VIK User Participation Dr Miranda Wolpert, IAPT Informatics Lead, Chair Outcomes and Evaluation Group Duncan Law, Lead for the CO OP group, Outcomes Practice Group Dr Anne York, Chair Service Development Group Anne Spence, Colin Startup, Eleanor Keach, DH Policy Team leads Kevin Mullins, IAPT Central Team Manager Dr Margaret Murphy/Duncan Law; Co-Chairs of the Critical Friends Group
Summary The Core Of CYP IAPT www.iapt.nhs.uk/cyp-iapt/
CYP-IAPT model leading to more effective and efficient outcomes
CYP IAPT Impacts all Levels = QIPP Process Location Access Acceptability Administrative response Clinical process organization Structural elements of clinical governance OUTCOMES & SERVICES Workforce Content Clinical Practice Assessment Treatment Liaison Consultation Advise Teaching, R & D Teaching Training Research Development Commissioning Data Quality Clinical Outcomes PREMS/User Feedback PROMS Safety data Effectiveness Clinical & Cost effectiveness Quality Indicators Audit Performance Cost and activity
Workforce Skills Service Design Supervision Service Leadership & Management PROMS PREMS CROMS Clinical & Cost Effectiveness Dataflow User Therapist Within Session Data NHS Board Quality Board Commissioning Audit Evaluation Research National Networks
Why
Attributable Fractions for the Population The proportion of disorder that would be removed if the prior diagnosis were removed (AFPs) Adjusting for gender 26% for adult anxiety 23% for adult depression 24% for adult substance use disorder 32% for adult mania 46% for adult eating disorder 25% for adult schizophreniform disorder 41% for adult antisocial personality disorder. Removed or prevented not a great concept, but treatment could reduce the later burden of mental ill-health Conduct disorder & anxiety outcomes are broad and need attention Interventions exist Slide Courtesy of Prof P Jones
Cost Effectiveness of ADHD Treatment Fiscal Costs Estimates Effectively treated Age 5-7 Yrs Detected Referred Diagnosed Patient s Life Line Treated Effectively 500-1000 per yr 21,000 over 30 yrs Age 30-50 yrs Undetected Un-referred Personal and systemic costs: Long Term 5000-50,000 per yr Undetected, undiagnosed, untreated case pathway 150,000 1.5 million over 30 yrs Cost to the country per year of failing to detect 330 million to 4.04 billion
Value in Healthcare Condition or Group Specific Outcomes Patient Level Data is Necessary Full Cost of Care Cycle Not a Single Episode of Care Not Single Part of Care Pathway Outcomes/Quality Cost
This Represents Fundamental Shifts In Measures Inputs to Outputs Cross Sectional to Longitudinal Organisation Centred to Patient Centred Units of Care to Integration of Care
The Translation Gap Effective use of implementation science & practice 80% success Over 3 years (Fixsen et al., 2001) Letting it Happen No implementation team 14% success Over 17 years (Balas & Boren, 2000)
What CYP IAPT is NOT Not Adult IAPT Not standalone services Therapies in the first and second wave do not equal all necessary treatments in CAMHS
What CYP IAPT is A within service transformation Quality and outcomes focussed User informed Best evidence based
Best for Patients Fit for the Future Embedding Change Sustainability Patient Focussed
Commissioning Research & Development JSNA HWBB Delivery- Services Outcomes Quality Indicators Process Content Data
What have We done So Far?
Funding 8 million each year over the Four year CSR 2011-2015 Much interest across Government, Nationally and Internationally
What did we ask for? Selection by competition Commitment to the vision and to the reality of delivery Genuine appreciation of the partnership with our clients children, young people and parents Commitment to quality and collaboration at a national and a local level
What did our offer include? Training and backfill for staff Trainees Supervisors Managers/leaders Funding for service development, IT infrastructure, participation Creating change agents within CAMHS Funding for a further year for data capture across the service
Expressions of Interest Selection Over 30 HEIs or training providers got in touch with CYP IAPT 13 Bids Received 3 Collaboratives selected
The IAPT Learning Collaborative Lam &South Greenwich Herts Sussex UKCL Assure quality Organise training Deliver content (in partnership) Wandsworth Cambridge Westminster Haringey
The IAPT Learning Collaborative Ox and Bucks Wilts and BaNES Gloucs Reading Assure quality Organise training Deliver content (in partnership) Swindon Bournemouth, Dorset and Poole
The IAPT Learning Collaborative Manchester and Salford Barnsley Derby Salford Training Centre Assure quality Organise training Deliver content in partnership Pennine North Pennine South
Building a lasting collaborative: example New Partnership Salford New Partnership New Partnership Barnsley Derby New Partnership Salford Training Centre Assure quality Organise training Deliver content in partnership Manchester New Partnership Pennine North New Partnership Pennine South
The IAPT Learning Collaborative Partnership 1 NHS CAMHS VS Commissioners Partnership 3 NHS CAMHS VS Commissioners HEI Assure quality Organise training Deliver content (in partnership) Partnership 2 NHS CAMHS VS Commissioners
Building a Lasting Collaborative Partnership 4 NHS CAMHS VS Commissioners Peer Support Partnership 3 Mentorship NHS CAMHS VS Commissioners Mentorship Partnership 1 NHS CAMHS VS Commissioners HEI Assure quality Organise training Deliver content (in partnership) Partnership 6 NHS CAMHS VS Commissioners Peer Support Partnership 5 NHS CAMHS VS Commissioners Mentorship Partnership 2 NHS CAMHS VS Commissioners Peer Support
Utilisation of Data
Decision Support Data System Clinical practice tends to rest on belief rather than evidence We will start with capacity building, not accountability Cannot scare people into top performance Use data to guide patient care rather than for performance evaluation Public evaluation of policies to promote quality and public support
Evidence from Physical Medicine
30-Day Mortality Rate Following Bypass Peterson et al, 1998 7 Surgery in non-ny Hospital 30-day CABG Mortality 6 5 4 3 2 Outcome Reports Published Surgery in NY Hospital With Outcome Reports Published 19% decrease 33% decrease 1 1987 1998 1989 1990 1991 1992 Procedure Year NY State Cardiac Surgery Program: Publishes provider-specific outcome
A Glimpse at our Measures
1. Initial Assessment Before or at first meeting young person and/or parent complete SDQ (30 items) RCADS (47 items) Other measures and interview as as relevant practitioner : Which of 22 problems are relevant? Which of 13 contextual factors are relevant? How are they doing in school? Aims to -identify key problems - assess impact and severity - note other relevant factors With permission from Miranda Wolpert
2. Frequent Symptom review (each meeting/weekly) Towards the start of each session/weekly : young person and/or parent up to 12 key questions relevant to the problem. For example: Afraid of being on own at home Worries about being away from my parents. Worries in bed at night Afraid of being in crowded places Scared of sleeping on own Scared to stay away from home overnight. Trouble going to school because feels afraid With permission from Miranda Wolpert
3. Frequent Goal /key problem review (each meeting/weekly) Young person, parent review up to 3 key goals Rate 0-10 Before or at the start of each session/weekly : With permission from Miranda Wolpert
Conceptual framework: Shared decision making (Wolpert et al., in prep) 1. Young people and those working with them agree key problems and goals together 2. Those working with young people support them to understand the options available to them. 3. Young people and those working with them agree which options for help they will try. 4. Young people and those working with them review progress. 5. Young people and those working with them discuss options and make any changes if necessary. With permission from Miranda Wolpert
CYP-IAPT CO-OP CYP-IAPT Outcomes Oriented Practice Working Group to develop processes and the language to enable outcomes oriented practice Detailed practical suggestions to be used by clinicians across CAMHS modalities interventions and across the whole range of presenting problems Develop ways of using information about treatment progress to encourage better collaborative working through shared decision making, to support supervision practice
4. Frequent Feedback Towards end or after each session: 1 2 All present in session answer: Did you feel listened to? Did you understand what was said in the meeting? Did you talk about what you wanted to talk about? Did the meeting give you ideas for the future? practitioner Updates problems and contextual factors if relevant Notes if any key events Notes who present? Don t worry, it can be done with a quick tick box!! With permission from Miranda Wolpert
1 5. Full Review young person and/or parent complete SDQ (30 items) RCADS (47 items) Other measures and interview as relevant 2 At 6 month or 6 session review Practitioner reviews: Which of 22 problems are relevant Which of 13 contextual factors are relevant How are they doing in school? With permission from Miranda Wolpert
How many people will this reach? Year I (2011-2012) 120 professionals and 50 service leaders and supervisors Modernisation transformation will impact 50-60 localities around 1,000-1,200 staff Total population covered = 2.3 million (Ox and B = 717,822; UKCL = 912,988; Manchester = 695,400) Total England population under 19 = 12.4 million Percentage covered = 18.7%
Now our work really begins Three excellent collaboratives of committed colleagues to translate vision into reality Continued support and challenge from children and young people, and professionals Enormous interest at a national and international level We need to ensure quality at every level
The Heavy Lifting is Just Starting
Contacts NHS/University raphael.kelvin@cpft.nhs.uk Dept of Health raphael.kelvin@dh.gsi.gov.uk