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TRANSCRIPT
IAPT
Performance
Workshop
Els Drewek Head of Intensive Support)
NHS England (els.drewek @nhs.net)
May 2015
1
This set of slides is provided in support of
the interactive workshop on IAPT
Performance and will cover the following
areas:
• Referrals and Access
• Recovery and Reliable Improvement
• Waiting Standards
All data provided is HSCIC published data either Q3
or January 2015 which was the first month of the
new monthly HSCIC reports
2
Referrals and Access
3
9%
10%
12% 12%
15%
10%
9%
14%
15%
12%
8%
11% 11%
16%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
NHSEastern
CheshireCCG
NHS SouthCheshire
CCG
NHS ValeRoyal CCG
NHSWarrington
CCG
NHS WestCheshire
CCG
NHS WirralCCG
NHSHaltonCCG
NHSKnowsley
CCG
NHS SouthSeftonCCG
NHSSouthport
andFormby
CCG
NHS StHelensCCG
NHSLiverpool
CCG
Access Rate
Access Linear (National 25th percentile) Linear (National 75th percentile)
Cheshire,W&W Merseyside
Cheshire and Merseyside
Cheshire and Merseyside
Source HSCIC January 2015 IAPT data.
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
NHS EasternCheshire
CCG
NHS SouthCheshire
CCG
NHS ValeRoyal CCG
NHSWarrington
CCG
NHS WestCheshire
CCG
NHS WirralCCG
NHS HaltonCCG
NHSKnowsley
CCG
NHS SouthSefton CCG
NHSSouthport
and FormbyCCG
NHS StHelens CCG
NHSLiverpool
CCG
Referral and Attrition Rates
Referrals closed without entering treatment as percentage of the prevalence (Attrition)
Referrals that enter first treatment (the access KPI)
Referrals required to achieve 15% access rate if the attrition rate remains the same
Achieving 15% access rate with current attrition rates will require more than 35% of prevalence to be referred
Chesire,W&W Merseyside
Cheshire and Merseyside Older People referrals percentage in prevalence vs percentage of referrals to IAPT
12%
4% 4%
8% 8%
6% 6% 6% 7%
10%
4% 5%
1%
8% 6%
2%
4%
6%
3% 4%
5%
5%
8%
3%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
NHSEastern
CheshireCCG
NHS SouthCheshire
CCG
NHS ValeRoyal CCG
NHSWarrington
CCG
NHS WestCheshire
CCG
NHS WirralCCG
NHS HaltonCCG
NHSKnowsley
CCG
NHS SouthSefton CCG
NHSSouthport
andFormby
CCG
NHS StHelensCCG
NHSLiverpool
CCG
Gap between the proportion of adults aged 65 or over who are referred to IAPT and who are estimated to have common mental healthproblems
Proportion of referred adults patients who are aged 65 or over
Chesire,W&W
Merseyside
Achieving and Sustaining Access Rates
Summary Are referral rates sufficient to deliver 3.75% access rates each quarter taking into account known attrition rates?
– Nationally 35% of patients referred do not enter treatment.
– There is good evidence that long waiting lists suppress referrals.
Is there a clear longer term strategy (CCG / HWBB / PHE) for primary care psychological therapies but with immediate priorities and a marketing plan that addresses:
– Simplified access and self referral routes
– Truly primary care led and not medically led
– Values the benefit Step 2 therapy can make to wellbeing of the population (mainly mild to moderate anxiety and depression) including specialisation of PWPs
– Links with physical health
– Early intervention
– Maximising older people access and BME Access
Cheshire and Merseyside Referral Indicators
Source HSCIC January 2015 IAPT data. National Attrition rate 36%, National Self Referral Rate 44%
Cheshire and Merseyside
Source HSCIC January 2015 IAPT data.
England
0%
10%
20%
30%
40%
50%
60%
70%
0% 10% 20% 30% 40% 50% 60% 70% 80%
Self
Refe
rrals
Attrition Rate
Self Referrals vs. Attrition
Recovery and Reliable
Improvement
10
Cheshire and Merseyside
Source HSCIC January 2015 IAPT data.
-10%
0%
10%
20%
30%
40%
50%
60%
70%
80% Recovery and Reliable Improvement
Recovery Reliable Improvement
Cheshire and Merseyside
Source HSCIC January 2015 IAPT data.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90% Completion Rates
National Diagnosis Analysis – Q2
Problem Descriptor Finished course of
treatment
Not at Caseness Recovered Recovery Rate
(%)
F10 - Mental and behavioural disorders due to use of alcohol 75 15 15 25.0
F50 - Eating disorders 215 30 70 38.6
F33 - Recurrent depressive disorder 4,350 230 1,635 39.7
F43 - Reaction to severe stress, and adjustment disorders 3,560 300 1,370 42.1
F99 - Mental disorder, not otherwise specified 4,855 800 1,730 42.6
F31 - Bipolar affective disorder 110 15 40 43.3
Other ICD10 code 1,745 170 700 44.3
Z63 - Oth probs related to prim sup grp, inc family circumstances 870 125 335 45.0
F32 - Depressive episode 18,780 1,350 7,865 45.1
F40 - Phobic anxiety disorders 3,590 605 1,375 46.1
F42 - Obsessive-compulsive disorder 2,000 185 870 48.0
F41 - Other anxiety disorders 36,025 3,170 16,060 48.9
F45 - Somatoform disorders 830 95 405 55.2
Invalid Code 220 45 100 58.7
No code provided 37,475 4,530 13,795 41.9
13
Ordered by recovery rate, with the lowest recovery rate first.
Based on quarterly supplementary analysis and displayed at 3 digit ICD10 code
level in line with v1.5 reporting Data source: Improving Access to Psychological Therapies (Adult IAPT) Dataset
HSCIC Data Quality and Provisional
Diagnosis
14
Few providers are giving a valid Anxiety disorder specific measure that is relevant to the diagnosis. In these
cases GAD7 will be used instead of an ADSM.
Provisional Diagnosis (now Problem Descriptor) recording has shown improvement and is now at 60%
Recording of therapy type is still lower than in version 1, but has increased from 59% to 70% validity. This
rise in validity is responsible for the variation between version 1 and version 1.5 entering treatment figures in
the October Final activity data.
New data quality measures have been introduced with version 1.5 of the dataset.
>= 80 70 - 79 60 - 69 50 - 59 40 - 49 < 40
Oct13 Nov13 Dec13 Jan14 Feb14 Mar14 Apr14 May14 Jun14 Jul14 Aug14 Sep14 Oct14
75 75 76 77 77 77 77 77 77 69 71 71 7210 9 9 9
75 77 80 82 81 79 83 80 84 98 98 98 98
91 94 95 96 96 97 97 97 97 96 95 96 96
93 93 92 93 93 93 92 92 93 94 94 93 93
93 93 93 92
97 96 98 99
93 93 92 93 93 93 92 92 93 93 94 93 93
51 52 52 52 53 53 53 53 53 50 52 58 60
80 79 79 87 87 86 86 85 85 59 66 68 70Therapy Types (1-4)
Provisional Diagnosis
Patient Health Questionnaire (PHQ9) Score
Organisation Code of Commissioner
NHS Number
Generalised Anxiety Disorder (GAD7) Score
General Medical Practice Code
Appointment Type
Anxiety Disorder Specific Measures
Validity by Data Item (Valid %): October 2013 to October 2014 Final
NATIONAL
Data source: Improving Access to Psychological Therapies (Adult IAPT) Dataset
Recovery and Reliable Improvement
Summary • For 2015-16 the KPI is the 50% Recovery. However, Recovery and Reliable
Improvement are equally important as they measure different things and services need to understand how their performance varies from the national average on both.
• Commissioners and the providers need to understand through sound audits or root cause analysis why the recovery rate is not being reached so that the cause can be addressed.
• On reliable improvement, if a service is below average it equally needs to be understood through audits why high numbers of patients do not show reliable change/improvement.
• Recommendations –
– Monitor both together at all times.
– Make the link between presenting condition/diagnosis during treatment, NICE guidance for that condition and therapy offered
– Understand outcomes by Step, by Team, by modality, by therapist
– Offer choice of therapy by commissioning the full range of NICE Recommended modalities so that it meets the needs of your population
Cheshire and Merseyside
Commissioner Recovery Rate Reliable Improvement Completion Rate
England 45.1% 61.7% 51.8%
Eastern Cheshire 56.5% 63.3% 79.0%
Halton 51.3% 68.8% 37.2%
Knowsley 40.9% 60.9% 60.5%
Liverpool 33.7% 60.0% 63.7%
South Cheshire 66.7% 62.5% 53.3%
South Sefton 41.5% 62.8% 67.2%
Southport and Formby 42.9% 60.0% 68.2%
St Helens 43.8% 57.9% 39.6%
Vale Royal 53.3% 70.6% 65.4%
Warrington 42.4% 50.0% 62.3%
West Cheshire 50.0% 57.4% 66.7%
Wirral 46.2% 61.4% 45.6%
Source HSCIC January 2015 IAPT data.
Waiting Standards
17
Cheshire and Merseyside Average Waits to first treatment
Source HSCIC January 2015 IAPT data.
2.8
5.4
0
2
4
6
8
10
12
14
16
NHSEastern
CheshireCCG
NHS SouthCheshire
CCG
NHS ValeRoyal CCG
NHSWarrington
CCG
NHS WestCheshire
CCG
NHS WirralCCG
NHS HaltonCCG
NHSKnowsley
CCG
NHS SouthSefton CCG
NHSSouthport
andFormby
CCG
NHS StHelensCCG
NHSLiverpool
CCG
Waiting list Backlog 1st quintile (<3.2 weeks) Waiting list Backlog 2nd quintile (3.2 weeks - 4.84 weeks) Waiting list Backlog 3rd quintile (4.84 weeks - 7.4 weeks)
Waiting list Backlog 4th quintile (7.4 weeks - 11.8 weeks) Waiting list Backlog 5th quintile (>11.8 weeks) Linear (National 25th percentile)
Linear (National 75th percentile)
Chesire,W&W Merseyside
Numbers Waiting and Clearance times
Source HSCIC January 2015 IAPT data.
• From a operational management perspective, the
numbers of patients that are waiting are as important, if
not more important than the waiting times achieved.
• Clearance times in weeks suggests the scale of the
backlog to be cleared, irrespective of the actual numbers
and the size of the service. It is the number of weeks it
would take to clear the waiting list if no new referrals
arrived
• The service needs to understand the sustainable
position, i.e. the number of patients that can sensibly be
waiting to deliver a particular waiting standard
Cheshire and Merseyside
Source HSCIC January 2015 IAPT data.
0
2
4
6
8
10
12
14
16
18
20
Wee
ks to
Cle
ar
Clearance Times
Cheshire and Merseyside – Comparison between the
national waiting standard (2 or more sessions measured at
discharge ) and current waits achieved (all first treatments)
Commissioner 6W All 18W All 6W KPI 18W KPI Clearance
England 76.5% 96.8% 77.5% 95.3% 6.4
Eastern Cheshire 5.3% 63.2% 6.7% 70.0% 16.2
Halton 2.3% 69.8% 12.5% 62.5% 17.6
Knowsley 7.9% 76.3% 26.1% 87.0% 10.8
Liverpool 95.5% 100.0% 97.0% 99.0% 3.4
South Cheshire 73.3% 96.7% 75.0% 93.8% 5.3
South Sefton 92.2% 100.0% 97.7% 100.0% 7.3
Southport and Formby 95.5% 100.0% 100.0% 100.0% 4.8
St Helens 25.0% 68.8% 21.1% 78.9% 7.4
Vale Royal 88.5% 100.0% 82.4% 94.1% 3.5
Warrington 39.3% 100.0% 65.8% 100.0% 7.0
West Cheshire 43.2% 98.8% 72.2% 98.1% 11.5
Wirral 64.0% 99.2% 78.9% 98.2% 5.4
Source HSCIC January 2015 IAPT data.
Cheshire and Merseyside clearance times
vs waiting experience
Source HSCIC January 2015 IAPT data.
England
0
2
4
6
8
10
12
14
16
18
20
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Weeks t
o C
lear
Wait
ing
Lis
t
6W Performance (All Patients Treated in January)
Clearance Time vs. Waiting Time
What is First Treatment ?
FAQs from: Improving Access to Psychological Therapies (IAPT) Waiting Times Guidance and FAQ’s February 2015. http://www.england.nhs.uk/2015/02/13/mh-standards/
12. Question: What is meant by the terms ‘assessment appointment’ and an ‘assessment with treatment appointment’?
Answer: An ‘assessment’ appointment is when the service makes initial contact with the patient (face-to-face, telephone or email) in order to assess the patient’s condition and whether they are suitable for treatment. This is sometime carried out by a triage or single point of access service. An ‘assessment with treatment’ appointment is when the initial contact is extended by the healthcare profession to include an IAPT compliant treatment.
13. Question: How is first treatment defined?
Answer: The decision on what is treatment is a local decision that should to be clearly laid out in written, local pathways and have senior clinical sign off in the organisation. Such protocols should also clarify when an appointment should not be recorded as treatment. The final decision on whether a particular appointment is the start of treatment should not be a blanket decision but be made by the healthcare professional undertaking the appointment in the knowledge of those pathways. It is important to ensure the ‘Appointment purpose’ field is completed on clinical systems as this is a mandatory field.
Long waits not visible in national reports
• The following slide gives an indication of hidden waits.
• It is the wait from first to second appointment.
– Nrs of patient who had a 2nd appointment during January 2015 who waited over 28 days and over 90 days since their 1st appointment
– Scale of the problem: The above figures as a percentage of the number of patients discharged in the period who had two more appointments.
– (not adjusted for patient choice delays)
• It is acknowledged that this is not the full extent of hidden waits in the system.
Cheshire and Merseyside Commissioner 28+ 1st–2nd 90+ 1st–2nd
Completed
Treats 28+ Ratio 90+ Ratio
England 22,830 3,783 39,790 57.4% 9.5%
Eastern Cheshire 25 * 150 16.7% *
Halton 25 * 80 31.3% *
Knowsley 130 15 115 113.0% 13.0%
Liverpool 475 75 500 95.0% 15.0%
South Cheshire 110 25 80 137.5% 31.3%
South Sefton 235 * 215 109.3% *
Southport and Formby 145 * 150 96.7% *
St Helens 10 * 95 10.5% *
Vale Royal 80 * 85 94.1% *
Warrington 120 * 190 63.2% *
West Cheshire 270 60 270 100.0% 22.2%
Wirral 180 105 285 63.2% 36.8%
Source HSCIC January 2015 IAPT data.
IAPT Waiting Standards Recommendations
Source HSCIC January 2015 IAPT data.
• CCG and providers have established written pathways from referral to
discharge that contain waiting standards for assessment, first
appointment and subsequent appointments, (including step-up) that
are in line with the 6 wk and 18 wk standard and acceptable to
patients and referring clinicians.
• There is a good understanding of the requirements for sustainable
delivery and the run rate to deliver the 3.75% each quarter separate
from any discussion on clearing backlogs.
• Providers establish PTL Management that weekly/daily visualise and
manage all long waits and/or unequal waits by locality, therapy types
or for particular therapists, whether this is for first treatment, for
second treatment or subsequent treatments including step up.
• Delivery of the agreed waiting standards, and numbers of patients
waiting at every point are monitored in contract meetings against
expected numbers.
27
Example PTL Reports. The number of patients waiting on a particular date
by weeks waited – Develop by Site, by Therapy Type, dated and undated,
0-1
Weeks
1-2 Weeks 2-3 Weeks 3-4 Weeks 4-5 Weeks 5-6 Weeks 6-12
Weeks
12-18
Weeks
18+
Weeks
Dated 5 20 74 60 40 22 10 9 5
Undated 94 83 15 8 2 7
IAPT Intensive Support Team [email protected]
07810030100