improving access and experience for people with …...improving access and experience for people...
TRANSCRIPT
Improving Access and Experience for
people with First Episode Psychosis
Third Improvement Community Event
@AQuA_NHS
#aquafep
Opening
• Housekeeping:
– Toilets
– Fire alarms
– Mobile phones
• AQuA faculty
• Twitter @AQuA_NHS
# AQuA_FEP
Delegates will:
• Have the opportunity to understand what data is available from NHS Benchmarking
• Receive an update on National guidance and measures
• Have updates from other early intervention teams regarding their progress in relation to the RTT
• Understand basic demand and capacity analysis
• Understand NICE guidance using employment support and family intervention
• Be provided with an AQ update and AQuA plans for 2016/17
Objectives
09:25 Julie Cullen Housekeeping and Opening
09:30 Zoe Page NHS Benchmarking EI data/ update
10:00 AQuA Demand & Capacity Tracker
10:30 BREAK
10:45 Team Leads Team presentations & table top discussions
12:00 LUNCH
12:45 Kate Hughes Understanding the IPS model
13:45 Paul French Training & development opportunities 2016
14:15 BREAK
14:30 Darren Flynn & Carl O’Loughlin
Helping people make informed decisions
15:40 AQuA & AQ Update on AQuA & AQ offer 2016/17
16:00 CLOSE
Agenda
EIP Service and Workforce Stocktake
Zoë Page, NHS Benchmarking Network
23rd March 2016
5
Background
6
- Introduction of Access and Waiting Time target for First Episode Psychosis
- Need to ensure workforce has manpower and skills to meet targets
- Some good evidence on EIP services already available
- Waiting times
- Caseloads
- Activity
- Discipline mix of staff
- But further data needed on AWT specifics
- Access to care coordinators
- Specific therapy skills e.g. CBTp and Family Therapy for delivery of NICE concordant package of care
Scope
7
- Work already underway with NHS London as part of regional preparedness programme
- Building on this, to undertake a national stocktake for England
- Provide data at team level to show variation internally within Trusts and geographically across England
- Use evidence of skills gaps to inform distribution of training & development funds
Findings 8
Service Overview
9
- Most teams have a lower age limit of 14 years (= 72%)
- In London this is typically 18 years
- Most teams have an upper age limit of 35 years (= 67%)
- A small number have a limit of 60 or 65 years
- Almost all teams provide support for 3 years (= 89%)
- Where an initial assessment period is used, this may be for 2 – 26 weeks (median 6 weeks)
Service Start Age
Referral Profile
Single Point of Access (8%)
Inpatient services (12%)
Transfer from another EIP team (2%)
CRHT (5%)
Another community team (20%)
Other (28%)
CAMHS (6%)
GP / Primary Care (18%)
Referrals from GP / Primary Care
EIT Appointment to Commencement of Medication (days)
Waiting Times
Caseload
Waiting Time for Care Coordination
Activity
Workforce Profile
London Midlands North South
Community Psychiatric Nurses (CPN) 41% 50% 43% 48%
Social Workers 4% 7% 7% 5%
Occupational Therapists (OT) 11% 6% 4% 11%
Clinical Psychologists 10% 7% 6% 5%
Psychiatry - Consultant 7% 5% 4% 4%
Psychiatry - Other 6% 3% 2% 2%
Support Workers / Outreach workers 5% 14% 18% 10%
Peer support workers 0% 1% 0% 2%
Mental Health Practitioners 1% 1% 7% 6%
Psychotherapists 0% 0% 0% 0%
Team Manager 7% 5% 6% 4%
Supernumerary Social Workers 6% 1% 3% 4%
CBTp
Family Therapy
Areas for Consideration 22
Areas for consideration
23
• What does ‘good’ look like?
• Caseloads per care coordinator
• Levels of access to CBTp / Family Therapy
• Pathways into care
• FEP patients outside EIP pathways
• Patients on other community team caseloads
• Patients in CAMHS services
• Also require access to care coordinators and care package
Demand & Capacity
Reference:
“Process & Systems Thinking” Improvement Leaders Guides
Every system is
perfectly designed to get the
results it gets
Paul Batalden, M.D.
Demand Management
and Capacity Planning is…
Making sure that there is the capacity to meet patient needs at the RTT stage of the journey
– Effectively and appropriately reduce or manage demand
– Resolve capacity problems at the appropriate point in the system
– Deal with constraints.
Key point:
ALL work is a process and all
processes are messy…and; • Have evolved over time
• Are rarely systematic
• Are often designed “on the hoof” and include
steps that don’t add value.
• Sometimes need “work arounds”
• Are different for each team / process / person
• Many processes are designed “top down” and
therefore not effective.
Therefore; Flow is
Inhibited & RTT Delays Develop!
• Demand exceeds available capacity.
• Mismatch between variation in demand and
capacity at specific times.
• Patients do not flow through the system to
accommodate further referrals in to the system.
30
Staff
skills
illness holiday
motivation
training shifts
Patients
Kit
Process
rooms not
the same
supplies
I.T not
the same
age
sex
race education
motivation
disease unclear
guidelines
differ
complications
80% is
under
our control
GP Discharged!
Information
transcription
transport
applications
Sources Of Variation In
A Clinical System
Is our system balanced?
Do we understand our;
- capacity?
- demand?
- working practices?
Measuring Demand and Capacity
in Early Intervention
Demand
No. of referrals
from all sources
in time period e.g.
weekly
• GP
• Self-referral
• SPOA
• CMHT
• Other
Capacity
Consider what
makes up your
capacity:
• Staff
• Skills
• Rooms
• Equipment
• Caseload
Focus upon your
current constraint
and measure your
capacity from this
context
Activity
Treatment
Provision
Discharges
Removals
other than
treatment
Capacity and Demand Model Consider a simple model
• Service users referred EI following normal distribution.
• First come first seen basis.
• Users need to be seen same time periods as referred.
Distribution of Referrals
0 20 40 60 80 100 120 140 160 180 200 220 240
Number of Referrals
Distribution of Referrals
Referral Activity Mu 65th 85th
μ = 120, σ = 25
Using the mean Plan for capacity of 120
0
50
100
150
200
250
300
Nu
mb
er
of
Serv
ice
Use
rs
Backlog Backlog Treats New Treats Capacity Demand
Using the 65th Percentile Plan for capacity of 130
0
20
40
60
80
100
120
140
160
180
200
Nu
mb
er
of
Serv
ice
Use
rs
Backlog Backlog Treats New Treats Capacity Demand
Using the 85th Percentile Plan for capacity of 146
0
20
40
60
80
100
120
140
160
180
Nu
mb
er
of
Serv
ice
Use
rs
Backlog Backlog Treats New Treats Capacity Demand
Performance
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pe
rce
nta
ge S
ee
n in
Pe
rio
d
μ 65th 85th
To Consider
• Models rely on useful data
• Determining referral numbers
• Models need revisiting
• Iterative process
Resolving Demand Issues
• Reducing variation in demand
• Address the entire patient process
• Which systems do or don’t work?
Look for patterns:
o Referral protocols and thesholds
o Daily/weekly/monthly/seasonl
o Who receives requests?
Resolving Capacity Problems
Increase capacity at the point where it will create the greatest outcome
– Ensure that the constraint has no idle time
– Put an inspection or checking stage in front of the bottleneck
– If the constraint is the expert skill, they should only be doing work for which their expertise is needed
– Provide extra support at the bottleneck
– Pool referrals to distribute the work and standardise the queue
Other useful
issues to explore
Does the pathway make sense?
• Wide open front door – experts at the
front. Avoids failure demand
• Is it a push or pull process
• Mapping of your pathway & interfaces /
Remove steps that don’t add value
• Reduce duplication
First Episode Psychosis
• Engaging with service users for improvement
• Sustainability
Rosy Borwell Julia Wood
Engaging with Service Users for Improvement
Aims
• To inform service development from the service user perspective
• To help the team promote awareness within the local community
• To provide a forum for service users to meet with other service users
• To help the team develop resources that will be useful for future service users
• To help in the delivery of staff training • To help further inform the organisation regarding
service user involvement
Types of engagement
Information giving
Information gathering
Consultation Involvement Partnership
To meet the aims Cumbria decided to focus on involvement
Focus group • Engagement: Service users identified through staff • Place of meeting:
– Where people live – Fixed or travelling venue – Where other activities are already taking place (e.g. football groups)
• Length of meeting: It is proposed that the initial meeting lasts for 2 hours with a good break in the middle so people can get to know each other
• Group size: Initially the plan would be to see how many people attend
• Chairing: Initially a member of staff would chair the meeting but it could evolve into a service user group which feeds back to the team
Learning from this planning: don’t be too descriptive – go with the flow!
Incentives to be involved
• Recognition, such as through a certificate or letter
• Character references
• Include in CV
Sustainability
The Sustainability Model
• Developed with and for the NHS using a co-production approach – contributors include:
– front line teams – improvement experts – senior administrative and clinical staff – people with specific expertise in the
subject area from academia and other industries
• Use by individuals or teams – self assessment
• Use at different points in time: – Setting up the improvement – in the
planning stage – Pilot testing phase – Following implementation – Beyond
Diagnostic tool that is used to predict the likelihood of sustainability of an improvement project
Cumbria’s approach
Thank you
Rosy Borwell Early Intervention in Psychosis Practitioner Cumbria Partnership NHS Foundation Trust
Tel: 01900 705262 [email protected]
Julia Wood
AQuA Affiliate Tel: 07412 653552
Children and Families
Sarah
Wright EIS RTT and Quality
Standard Improvement Lead
Lancashire Care Trust’s journey to implement NICE QS 80
Background
• Large Geographical area – 1.6M population
• 3 local authorities
• Service caseload of 780 against target of 720
• Average care co-ordinator caseload high teens
• Approx. 275 accepted into service from 468 referrals assessed.
Background
• Workforce profile
• 50 wte Team leaders / care co-ordinators
• 9 wte Support Time and Recovery Workers
• 7.4 wte Psychologist /CBT therapists
• 4.6 wte Consultant Psychiatrists
Journey to NICE Concordant care
• Management and clinical issues
• Culture of EIS & service user focus
• Referral to treatment
• Standards vs personalisation
• The EIS pathway in LCFT
Management and clinical issues
• Partnership and collaboration to consider best approach
• Focus on formulation and clear clinical decision making
• Engagement with team to understand current best practice
Culture of EIS & service user focus
• We were already very proud of LCFT EIS
• Maintaining the culture of tailored support to meet individual need
• Empowering the team whilst meeting minimum standards
• Always maintaining focus on those who access the service not on “performance targets”
Referral to Treatment
• First focus in our journey
• Process focused on efficiency - LEAN
• Outcomes marvellous and found to be very motivating area for team involved
• Issues with open pathways
Referral to treatment
Standards vs Personalisation
• The approach used for the RTT would not work for the other areas
• When is the right time to offer an intervention?
• Focus on clinical decision making and culture empowering clinicians
EIS pathway
SCREEN CAPTURE VIDEO
SHOWING LCFT PATHWAY
Continuous Improvement
• Supporting the team to take ownership
• Lean governance procedures
• The pathway being responsive and updated when new resources or information are available
• “Emperor`s new clothes”
Conclusion
The RTT and intervention standards pose different challenges to implement
In LCFT we have worked collaboratively to develop a pathway as a guide for our team
We hope this model will allow ownership and continuous improvement to be fostered
Table top discussions Focus Area
Organisation(s) Lead Project Focus
5BP Gill Pye
Cumbria Partnership Rosy Borwell Service user engagement/ Sustainability
GMW – Trafford Denise McArthur Service user engagement/Patient tracking
GMW – Bolton Kate Vogl Use of referral meetings
Pennine Care - Tameside Julia Wood
Lancashire Care Sarah Wright Sharepoint Hub/
AQuA Bernie O’Hare & Andy Wilson
RTT Electronic Trackers
Introduction to IPS and issues for consideration – North West EIP Services
Kate Hughes Recovery Programme Manager TEWV 23rd March 2016
• Offer supported employment programmes to people who wish to find or return to work.
• Consider other occupational or educational activities,
including pre-vocational training, for people who are unable to work or unsuccessful in finding employment
• Mental health services should work in partnership with local stakeholders to support access or retention to employment, education, volunteering opportunities
• Routinely record the daytime activities in their care plans, including occupational outcomes -
Take a moment or two to consider some of your biggest achievements in
life, consider some moments when you have felt like you were thriving
Employment Education
Volunteering Money
Friends met through work
Family – any link to work or education
A safe place to live
Highest unemployment rate of any disabled group – x2 likely to loose employment
(Burchardt 2003)
13% of people using specialist mental health
services are in employment (NHS Information Centre,
2012)
47% people using mental health services were not offered help with finding or keeping work but would have liked help (CQC Community MH
Survey 2015)
First Episode psychosis occurs at a pivotal stage of vocational and career development
Inadequate support in this area at this pivotal time has the potential to derail an individuals career prospects long term
Research consistantly shows a significant deterioration in employment rates 1 year post onset of psychosis (Birchwood et al.,1999, Singh, et al.,
2000Barnes et al., 2000, Garety & Riggs, 2001)
presence of symptoms have not been identified as a predictor
Having a job in the past 5 years has an influence
Wanting a job (Motivation) and self belief are the biggest predictors of positive outcomes
Having access to the right evidence based support
Who makes this judgement? - SDM
Pre-vocational training (train then place)
Work preparation courses
Sheltered Employment
Volunteering for long periods with no plan into employment
Place then train
Find a job then train
Supported Employment
Individual Placement and Support (IPS)
Focus on competitive employment as a primary goal
Eligibility based on the individual’s choice
Rapid job search, minimal pre-vocational training
Integrated into the work of the clinical team
Attention to client preferences
Develop relationships with employers based on client
preferences
Availability of time unlimited support
Benefits counselling should be provided to support transition
(Bond, 2008)
Primary goal is participation in mainstream education
Primary entry criteria is interest and motivation
Individualised assistance to access courses meeting
preferences in a variety of institutions
Rapid search, enrolment and commencement
Communication between MH service / education provider/
student support service
Ongoing support for education and employment goals
Benefits advice
Rinaldi et al (2010) First episode psychosis and employment: A review . International Review of Psychiatry 22, 2, 148-162.
Manualised Evidence based intervention
Fidelity correlates with outcomes achieved
IPS Fidelity Scale
The Fidelity Scale is the translation of the 8 principles into 25 items. Each rated on 1-5
Exemplary Score 115-125
Good Fidelity 100-114
Fair Fidelity 74-99
Not supported employment 73 and below
Staffing
Organisational Infrastructures
• Integration with CMHT through team assignment
• Integration with CMHT through frequent contact
• Collaboration between employment specialists and JC+/WP
• Vocational unit
• Role of employment supervisor
• Zero exclusion criteria
• Mental Health Trust focus on competitive employment
• Executive Team support
Number on caseload
Employment Services Staff
Vocational Generalists
Services
Work incentives planning
Disclosure
Ongoing, work-based vocational assessment
Rapid search for competitive job
Individualised job search
Job development – Frequent employer contact
Job development – Quality of employer contacts
Diversity of job types
Diversity of employers
Competitive jobs
Individualised follow-along supports
Time-unlimited follow-along supports
Community-based services
Assertive engagement and outreach by integrated team
Achieving integration between Health, Social Care and Welfare System – Practically and Financially
Funding
Reduced public sector funding
Combining funding streams
Securing long term funding / resource
Disbanding of Employment services
Securing infrastructure and strategic support and buy
in
Finding the right employment specialists
A vicious cycle of low expectations
Societal stigma – reasonable adjustments
Sustainability of implementation – it takes time
Balancing ongoing supports with need to deliver targets
While many believe many more individuals can work, 2/3 did not believe those on their caseload could gain open employment
Clinicians saw the importance of this as part of their role but did do not feel skilled and had limited confidence in current vocational support (Marwaha et al,
2008)
Early research suggests clinician training in motivational Interviewing to address ambivalence about employment
can improve IPS outcomes. (Rinaldi et al 2014)
Re-evaluate your baseline position
Consider how close or far away you are from being able to offer IPS or other supported employment within your local areas
Are there partner agencies with which you can work? How easy would this be?
What is realistic and where do you need to start – strategic, service, team level?
Use your money and time wisely
Training staff alone will not be sufficient to deliver IPS if you do not have infrastructures
Do you need some help and consideration to consider and guide this??
Why was a young lady disengaging from her EIP community support plan Was it because she was becoming increasingly depressed?
On having the case transferred to me I asked the question and this is what she said
‘ I have nothing to get out of bed for. All these visits seem pointless. I might have liked going to the gym as a hobby but I find it difficult to motivate myself to do that when I all I really want to do is return to University. Nobody is looking at that…. So yes I am feeling depressed…’is this what my life will be?
Our next 3 sessions:
A trip to the job centre, benefits advise
A trip to a pub where a part time job was advertised.
Links were made with University tutors and a planned return within 3 months was put in place
As I visited an young 18 year old in our 5 day crisis support programme, my heart nearly sank when they said they had an interview for casual Christmas work the next day. In a paternalistic manner, I advised them that this may not be the best idea. They had had a 9 month admission, our perception was that they were heading for another major crisis and there were concerns regarding risks. I'm pleased to say they ignored my well intended advice and secured the job. Needless to say they didn’t actually need the 7 day programme, nor an admission. This was a springboard for future education and work and our support in t his area was a mechanism for much better working relationships. This was a pivotal stepping stone in eventually completing an apprenteship and a longer term job
With no discussion and in the midst of ongoing psychosis a supporting letter from the psychiatrist landed on Helen’s door step. It was in relation to a benefits claim. Embedded in this letter was one, probably well meaning, sentence that proved to have a devastating impact which served to perpetuate the distress.
…..this lady is very unlikely to ever work again………
As an educated lady who had always valued work she reported the devastating effects this had on her self belief, hope for the future and identity beyond that of a patient
Helen is currently rebuilding her belief in her future potential and now sees employment as a potential for the future
Was advocating for clients request for a fit note to return to work 5 days after a discharge from a section 3 and a lengthy hospital admission a sensible move? They had good self awareness and a supportive employer Would it exacerbate their current symptoms? Risky compared to what?? The crisis the year before consisted of a similar inpatient admission and presentation, followed by discharge with a sick note to give them time to recover…… They took a serious overdose, were readmitted for 3 months and given ECT treatment So we went with the plan within a broader plan of support….and guess what…...no readmission…..no ECT…..and their life picked up relatively quickly.
Don’t people have the right to take risks and to be supported to do so
Being CONNECTED to others or something
Having HOPE for a better future
Maintaining or developing an IDENTITY beyond that of
an illness or a patient
Having MEANING in life or finding meaning in
distressing experiences
Feeling empowered and given CHOICE
Effectively supporting employment, education and
volunteering could be central to this process
While some of the work in this area requires infrastructures, funding / resource allocation and time
there are other things that are important
We should never underestimate our power as clinicians to influence an individuals self belief, motivation and
recovery
attitudes, beliefs, language, active listening and validation are massively important.
While research and training tells us a great deal, working in partnership with individuals with lived experience will
also help us get it right!!
It requires a strengths based approach
Psychosocial Intervention Training at the University of
Manchester
Advanced Practice Interventions in Mental Health
Content
• Provide a brief history of psychosocial intervention training at Manchester
• Highlight some of the strengths of the existing programme
• Consider drivers for change
• Consult with delegates regarding their views of the proposed changes to the Psychosis pathway
What are psychosocial interventions (PSI)? • Evidence based interventions developed for working
with people who have psychosis and their friends and families
• Includes Family Intervention (FI) and Cognitive Behavioural Therapy (CBPp) both are recommended by NICE (2014) to be offered to all people with psychosis or schizophrenia
• Research shows a range of enhanced clinical outcomes such as reduced relapse rates, reductions in symptoms and distress
History of PSI training at Manchester • 1993 - 1998 - Thorn Nurse Diploma
• 1998 – 2006 – COPE BSc(Hons) and Masters in PSI
• 2006 -present – Advanced Practice Interventions in Mental Health (APIMH) PGCert/Diploma/Masters in PSI for Psychosis
Strengths of the programme
• Strong adherence to the evidence base for PSI
• Taught by experienced clinicians, academics and researchers
• Groups are multi-disciplinary and reflect the staff that normally work in mental health services
• As well as academic outcomes clinical skills outcomes for FI and CBTp are assessed
Current programme - APIMH
• One year PG Cert / two year PG Diploma and three years Masters
• Years one and two have a combination of clinically focused skills based units and research methods units
• Year two also includes a leadership unit
• Year three is a literature based dissertation that can focus on service development
NICE quality standards for Psychosis plus APIMH response
1. Adults with a first episode of psychosis start treatment in early intervention in psychosis services within 2 weeks of referral.
2. Adults with psychosis or schizophrenia are offered cognitive behavioural therapy for psychosis (CBTp).
3. Family members of adults with psychosis or schizophrenia are offered family intervention.
• Revise existing course unit which focus on Assessment and Screening for Psychosis
• Existing course unit on CBTp to be further developed
• Existing unit on FI matches adequately to IAPT standards
NICE quality standards for Psychosis plus AIPMH response
5. Adults with psychosis or schizophrenia have specific comprehensive physical health assessments.
6. Adults with psychosis or schizophrenia are offered combined healthy eating and physical activity programmes, and help to stop smoking.
7. Carers of adults with psychosis or schizophrenia are offered carer-focused education and support programmes.
• Recently developed physical health promotion and wellbeing unit for psychosis addresses QS 5 and 6
• Existing family intervention unit includes flexible models for working with carers
Drivers for change
• Access and waiting time standards for FEP
• IAPT for SMI and core competencies agenda
• NICE quality standards for Psychosis
• Need for more flexible models of education in HE
NICE Quality Standards for Psychosis
1. Referral to EIP and start treatment within 2 weeks
2. Offer CBT for Psychosis
3. Offer Family Interventions
4. Offer Clozapine (if not responded to other meds)
5. Provide Supported Employment Programmes
6. Assessment of Physical Health
7. Promoting Healthy Lifestyles (exercise, smoking cessation, diet)
8. Offer carer focused education and support
124
Semester one Semester two
30 credit level 7 unit (NICE concordant) Assessment and Screening for Psychosis
30 credit level 7 unit (NICE concordant) Family intervention for Psychosis
PG Cert year one
Also plan to offer all of the above as stand-alone CPD units
Proposed evolution of the programme
Proposed evolution of the programme
Semester one Semester two
15 credit level 7 unit Research Design
15 credit level 7 unit (NICE concordant) Family intervention for Psychosis
15 credit level 7 unit Physical Health promotion and well-being
15 credit unit level 7 Developing Practice Managing Change
PG Dip year two
Also plan to offer all of the above as stand-alone CPD units
5-Day Clinical Skills Training in FI for EIS • NHS England provided an additional £5 million to enable EIS
staff to prepare to deliver NICE Guidelines, to be delivered by March 2016
• University of Manchester became one of the educational providers
• Two 5-day courses were commissioned and delivered w/c 29th February & w/c 7th March
• Approximately 40 members of staff from EIS across North West England attended these courses
• The training was very well evaluated and equips members of staff attending to deliver FI to families and carers of EIS service users
• The contract includes ongoing supervision & support for EIS in implementing FI
Helping People Make
Informed Decisions Dr Darren Flynn
Senior Research Associate and Practitioner Health Psychologist Institute of Health and Society (Decision Making and Organisation of Care Group), Newcastle University
Carl O’Loughlin AQuA Affiliate
Overview
• Shared decision making (SDM) – overview of key principles and processes
• Barriers to SDM
• Enablers to SDM
• Model of SDM skills
• Co-produced theory-based SDM film
– 2 short film clips
• Questions
Who has experience of making major purchases?
buying a car, a house, a holiday, a PC?
• Imagine when you went to make a major
purchase the sales assistant said to you:
– “I have chosen this car, house, holiday, PC for
you as I think it is best for you”
• Would you have responded as follows?
– “OK thanks very much - happy to go with
whatever you choose for me as you know
best”
• If NO – what would you say / like to know?
Making a decision when there is more than one
reasonable option, including no active treatment / doing
nothing (where appropriate)
• Often no clear research evidence that one option is better
than the other(s)
• Reasonable (available) options have different balances of
likely:
• Benefits (pros)
• Adverse effects or risks (cons)
• that can have both short- and long-term consequences
• which individual patients are likely to value differentially
PREFERENCE-SENSITIVE DECISIONS
Ideal for Shared Decision Making!
Patients and their families are involved as:
• Active partners with clinicians
• Meeting of EXPERTS to elicit the
patient’s personal:
Preference(s) for choice of treatment(s) from the available options
Beliefs/attitudes (values) towards the trade-offs between the pros and
cons of the available options
Shared Decision Making (SDM)
Good SDM = QUALITY (informed, preference & values-based) DECISIONS
• know about the options available to them (informed)
• know what’s important to them (preferences and values-elicited)
• receive treatment consistent with their personal preferences & values
Goal of SDM is to facilitate delivery of high-quality care that
is both evidence-based and person-centred
New Horizons: A Shared Vision for Mental Health
Equity and Excellence: Liberating the NHS
“no decision about me without me”
No Health Without Mental Health: A Cross-Government Mental
Health Outcomes Strategy for People of All Ages.
The Health and Social Care Act 2012
legal duty for NHS England and CCGs to involve patients in their care
NICE Guidance for management of mental health diagnoses
NICE Quality Standards
Patient experience in adult NHS services: improving the experience
of care for people using adult NHS services
Service User Experience in Adult Mental Health (QS 3, 8, 9 and 11)
Recent Precedent in Law:
Montgomery v Lanarkshire Health Board, UK
Supreme Court,11th March 2015
• Previously, clinicians could judge how much information to
disclose to a patient
• Provided they explained the risks of a given treatment
• to the extent that it accorded with a responsible body of
medical opinion (the Bolam test)
• The law now generally requires that clinicians must take:
• ‘reasonable care to ensure that the patient is
aware of any material risks involved in any
recommended treatment, and of any
reasonable alternative or variant treatments.’
• PDAs are the most common means of supporting SDM:
– provide evidence-based information about:
• available options
• outcome states - possible benefits, adverse effects and consequences of available options
• probability of possible benefits, adverse effects and consequences of available options
– risk communication – use of numerical / graphical techniques
– allow people to express and clarify their preferences
and values with regards to the available options
– provide a step-by-step way to make a decision
Benefits of SDM supported by patient decision aids:
• Improved knowledge
• Improved clarity about their personal preferences
• More realistic perception of outcomes
• Reduced decisional conflict
• Greater involvement in decision making
• Improved patient-clinician communication
• Increased satisfaction with healthcare
• Better adherence to medication and self-management /
lifestyle behaviour change
• Better outcomes in long-term care
• Cost-savings
O’Conner et al (2009; 2011, 2014); Joosten, 2008
Wider Benefits of SDM
• Implementing SDM in routine NHS care has potential for
significant reductions in healthcare costs:
– SDM/PDAs with patients eligible for hip and knee replacement
• surgery reduced surgery rates by 38%
• yielded cost savings of ~ 21% over a 6-month period
• SDM/SSM can impact upon current health inequalities
provided health literacy is taken into account
– patients in minority groups or with low health literacy have more to
gain from supported engagement
• SDM can facilitate the delivery of more equitable use of
healthcare interventions and resources
– planning service provision based on the population aggregate of
informed, values-based patient decisions
• In the great majority of mental health disorders
– there are real choices that are sensitive to service users’
preferences and values:
• varying individual preferences for information, involvement in
decisions and choice of therapeutic options
• different balances of benefits and risks/adverse effects and
consequences that individuals value differently
Most adults with mental health conditions, including those
with severe mental illness:
desire information on their condition
are capable and willing to be involved in decision-making
Adams et al 2007; Arora & Mchorney 2000; Bunn et al 1997; Charles et al 2006; Cortes et al 2009; Hamann et al 2005, 2006,
2007, 2008; Seale et al 2006
SDM in Mental Health
Supports personal agency (empowerment &
autonomy) of service users
• increasing knowledge and insight into their symptoms and
diagnosis
• providing a choice between options for treatment / care
enabling active involvement in decision-making in their
treatment and care
• better ‘active’ adherence to their treatment and self-
management/care plans
SDM in Mental Health
Supports development/strengthening and maintenance of a
positive therapeutic alliance
• active and equal responsibility of service users and
clinicians
• reducing disengagement with services
Supports living well with mental health symptoms
• Personal wellness strategies & activities (personal
medicine)
Can support “Parity of Esteem”
People actively involved in establishing priorities for their
lives
SDM is a therapeutic intervention Flynn et al (2015)
• Mental Health Acute Inpatient Service Users
Survey 2009
Only a third (34%) were “definitely” involved as
much as they wanted in decisions about their
care and treatment
Survey by the Patients Association in 2012
80% of primary care patients wanted greater
involvement in decision-making
Community Mental Health Survey 2012
Approximately a quarter (25%) of adults
prescribed new medications not informed about
potential side-effects
Barriers to SDM
• Clinicians, service users/their relatives may:
– be unaware of SDM
– be ambivalent about the therapeutic benefits of
SDM and its value for supporting recovery
– be unaware of all available options at preference-
sensitive decision points across clinical pathways
– have poor health / statistical literacy
– lack the skills and confidence for SDM • distrust their capability to engage in dialogue about
available options
Flynn et al (2016) in preparation
Barriers to development of a positive therapeutic
alliance - a critical prerequisite for good SDM
• Service users and their relatives may be unaware
of the diagnosis and diagnostic criteria
• Perceptions about capacity of service users
• Perceptions amongst clinicians that they are
'already doing SDM‘
• Preference of some clinicians to rely on intuition
regarding service users’ preferences for engaging
in SDM
• Lack of evidence-based and robustly evaluated
decision aids to support SDM about a range of
decisions
– with accessible information about options to enable
informed-values based decisions; e.g.
• What is CBT and how is it different from counselling?
• Lack of up-date information on charitable and
voluntary support services available locally
Flynn et al (2016) in preparation
• Discordant service user and clinician values:
– clinicians using SDM as a coercive device to ‘direct’
service users towards a specific option
– concerns about clinical 'appropriateness of service
users' choices'
• Service user confidentiality trumping value of
involving relatives in the SDM process
• There is limited time for SDM in clinical
consultations
Consequences of barriers to SDM
Lack of constructive engagement in SDM process,
undermining service users' experience
1: SDM is a fad – it will pass
2: In SDM, patients are left to make decisions alone
3: Not everyone wants SDM
4: Not everyone is good at SDM
5: SDM is not possible because patients are always
asking me what I would do
6: SDM takes too much time
7: We’re already doing SDM
8: SDM is easy! A tool will do
9: SDM is not compatible with clinical practice
guidelines
10: SDM is only about the doctors and their patients
11: SDM will cost money
12: SDM does not account for emotions
Enablers to SDM
• Evidence-based interventions for service users,
their relatives and clinicians
– awareness of SDM and its value for supporting recovery
– development of knowledge & skills (capability) for SDM
• co-produced SDM film
• Address the Elephant in the Room – Stigma
– Learning from MAGIC SDM programme
• Attitudes trump skills, which in turn trump tools
• Evidence-based interventions to tackle stigma
Flynn et al (2016) in preparation
Nurture a positive therapeutic alliance
• Inform and involve relatives in the SDM process
• Explore service users’ beliefs about the likely causes of their symptoms
– Explain the criteria for diagnosis
– Does the service user agree?
• Inform service users about the preference-sensitive decision points and choices across clinical pathways
• Availability of ‘private practice’ options for psychological therapies and counselling
Flynn et al (2016) in preparation
Fill The ‘Black Hole’ of Support
• Interim period after initial and subsequent
consultations
– Critical period for preparing service users/relatives for SDM
• Decision navigators to prepare patients/relatives for SDM:
– Peer support workers (experts by experience)
– Quality decision aids / options grids and information on
local support services (NHS and non-NHS)
– Provision of advice and guidance on health and lifestyle
behaviour change
Flynn et al (2016) in preparation
Implementation of SDM:
patient pull or clinician push?
• Capturing the hearts and minds
(attitudes/beliefs) of patients and clinicians
about SDM is a critical prerequisite for wide-
spread acceptability / implementation
• SDM is a complex intervention
– Complex range of skills and ‘confidence’
needed for ‘good’ SDM
– Pressing need for evidence and theory-based
multi-faceted SDM interventions
• Flynn, 2012; Flynn et al 2015
Model of SDM Skills
Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A,
Kinnersley P, Cording E, Tomson D, Dodd C, Rollnick S,
Edwards A, Barry M. Shared Decision Making: A Model for
Clinical Practice. J Gen Intern Med. 2012; 27(10): 1361–1367.
open access paper:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445676/
For use with clinicians, service users/families, and external facilitators
1. Theory- and evidence-based tools for clinicians, service users and
families, including facilitators / decision navigators:
• Knowledge of key principles and processes of SDM
• Value of SDM for patient outcomes
• Demonstrating (modelling) the range of skills for good SDM
2. Evidence- and theory-based training/CPD to develop/augment:
– Willingness attitudes/intentions to engage in SDM
– Capability knowledge / skills / confidence
– Behaviour engagement in a good SDM interaction Flynn (2012); Flynn et al 2016 (in p
Ideally co-designed/produced with clinicians and patients:
• reflect their perspectives, priorities and lived experiences
• sensitive to the specific context of decision making
Congruent with the principles of SDM!
@SDMinDepression
Introduction and
selected narration by
Frank Bruno MBE
Access the film and co-designed
materials at:
http://sdmdepression.ncl.ac.uk
Experts by experience engaged in a co-production process
– appear in the film as actors and narrators
– led on development of the storyboard, script & editing process,
including marketing material and dissemination activity
• co-production process example of good practice (HQIP)
Film informed by Bandura’s Social Cognitive
Theory
Encoding: embedding key messages in memory
through use of graphics/images
Modelling of skills for ‘good’ SDM via simulated
primary care consultations to support learning by
observation (vicarious learning) and confidence
(self-efficacy) for SDM
Uses mild/moderate depression as an exemplar • not designed to be representative of clinical practice but to
• capture ‘hearts and minds’
• demonstrate skills for SDM
More detail about the processes of
patient and public ‘involvement’ is
warranted, in particular ‘how exactly’ as
opposed to simply ‘the what’
Staley K. Exploring Impact: Public Involvement in the NHS. Public Health and Social
Care Research, Eastleigh: INVOLVE, 2009
Based on discussions within the film production
team, we identified key processes for ‘good’ co-
production
1.Identify an appropriate cadre of experts by
experience
2.Shared understanding of topic and its value
3.Relinquish control over the budget
• Reduces the power imbalance
4.Breaking down barriers – create an
atmosphere of trust to facilitate sharing of
personal experiences Flynn et al (2016) in preparation
5. Engagement and inclusive exercises, discussions
and feedback mechanisms
6. Skills auditing and development
» Recognising everyone has useful skills and
interests
» Ensure all have an agreed role(s) and are happy
with them
7. Co-produced and delivered piloting of outputs
8. Support with skills development in project
management
» Professional researchers learning to let go!
• Role of technical consultant, facilitating access to
resources and building confidence of team members
Flynn et al (2016) in preparation
• Clips from SDM film
• 1 clip focused on choice/option talk (initial
consultation)
• 1 clip focused on preference/decision talk
(follow-up consultation)
Part of an interactive role play exercise within a
CPD workshop that is currently being evaluated for
use with mental health clinicians, peer support
workers and service users
Conclusions • SDM is a complex ‘therapeutic’ intervention in mental
healthcare
• Pressing need for multi-faceted SDM interventions in
mental healthcare
– raise awareness of SDM and its value for supporting
recovery
– capture ‘hearts and minds’ of clinicians and service users
(attitudes trump both skills and tools)
– enhance capability and willingness of clinicians, service
users and their relatives to engage in SDM
• evidence- and theory-based skills training for SDM
• co-production as a key improvement strategy
• Implementation strategy to embed SDM across clinical
pathways
Final Thoughts Richards T, Montori VM, Godlee F, Lapsley P, Paul D. Let the
patient revolution begin. BMJ, 2013; 346
But partnering with patients must be seen as far more than the latest route to healthcare efficiency. It’s about a fundamental shift in the power structure in healthcare and a renewed focus on the core mission of health systems. We need to accept that expertise in health and illness lies outside as much as inside medical circles and that working alongside patients, their families, local communities, civil society organisations, and experts in other sectors is essential to improving health. Revolution requires joint participation in the design and implementation of new policies, systems, and services, as well as in clinical decision making.
SDM as an approach to
service and quality
improvement!
AQ Psychosis Developments
Proposed Timeline
• Event 23rd
March
• Update on trust
working
• Have asked for a
few slides to
inform on this
23rd March 2016
AQuA Psychosis
Event
AQ / AQuA
Work stream
AQuA work stream – widens to
cover all Access and Waiting
Time standards
July 2016
Proposed Webex
(1st Quarter Data)
October 2016
Proposed Collab
(6 months data)
AQ work stream - EIP
Fe
ed
in
to
Quality of Data
Quality of Care
Progression of the MHSDS
Reporting through Advancing Quality
What will AQ report?
• Initially looking at data quality as trusts
adapt to the demands of the national
dataset and associated standards
• Which data elements…?
Data Elements: Those elements that will contribute to the RTT
calculations:
Referral Request Received Date
Primary Reason for Referral
Referral to Treatment Period Start Date
Referral to Treatment Period End Date
Care Professional or Service Team Type
Data Elements:
Those elements that will contribute to future
reporting;
Attended or Did Not Attend
Coded Findings e.g Smoking status
Psychosis First Treatment Start Date
Assessments e.g. HONOS scores
How will AQ Report?
Very much in the spirit of AQ;
• Benchmarking North West
• Routine standardised reporting
• Utilising data to generate discussion and
service improvement locally through
collaborative events
DATA
Reports
Source data from
national publically
available reports,
pulled together to
report on the North
West position and
individual trust results.
OR Data from
commissioner extracts
from HSCIC via the
North West DSCRO.
First Episode of Psychosis Programme:
Update 2016-17
AQuA’s Programme Aims & Objective
Programme Aims
To improve access and experience of people with First Episode Psychosis
referred to secondary mental health services.
Programme Objectives
To set out an optimal service pathway for people experiencing a first episode of psychosis including what constitutes a NICE approved care package.
To share definitions/understanding of the start and finish point for access times
To process map existing Early Intervention pathways To share best practice To use quality improvement approaches to improve access and
experience working at team level within organisations
What have we done?
• All North West based Early Intervention (EI) teams
invited to participate. (Nine teams actively involved).
• Three improvement collaborative events. (April 15-Mar16).
• In absence of definitive guidance, the programme attempted to establish best understanding of the National Target.
• Teams supported in the use of quality improvement methodology and measurement for improvement .
• All teams supported with on-site coaching.
What Improvement Measures have we used?
• Access times (to treatment)for people
experiencing a first episode of psychosis
• Service User Experience
• DNA rates
Example of PDSAs
• Pathway mapping and redesign
• Evidence base for EDIT
• Initial Assessment
• Working with CAMHs
• Using the electronic patient tracker
• DNAs
• Introducing ARMs
• Redesigning workforce
• Increasing user engagement
• Meeting NICE standards
Ongoing Risks & Issues
1. Lack of National Guidance re RTT. (Available from March 2016).
2. Data collection at team level and availability of useful data as evidence of continuous measurement.
3. Staff time to work on improvements and attend events
183
Next Year (or April 2016)
184
Breakthrough Series Collaborative
10 Crisis Teams recruited (4hr Response time) and 10 Early Intervention teams (14 working day RTT).
The AQuA BTS Collaborative will provide;
• Three learning events and a final event (50 delegates per event)
• Separate monthly virtual learning sessions for crisis teams and EI teams
• Two on site visits to each clinical team between learning events to support implementation
• Continuous measurement
• Instruction in the theory and practice of improvement. (Learning sessions).
Improvement Methods
• Breakthrough Series collaborative
• Site Visits
• Sharing of Best Practice
• Model for improvement / small cycles of change.
• Measurement for improvement
• Demand & capacity
• Capability building
• Lived experience
• Approach to Spread & Sustainability
How the AQ FEP measurement will support Quality
Improvement • Trusts submit Psychosis data into Mental Health Services Data
Set (MHSDS)
• AQ will report and benchmark the data for the NW (and drive to improve the quality of the data) awaiting confirmation re availability
• This data will be used as a part of continuous measurement in the breakthrough series collaborative to track progress against the RTT
• The run charts will provide each team with a visual display of the data.
Next Steps
• Advertise offer to MH member organisations
• Apply via Project Charter
– Exec sponsor
– Project Lead & team
– Confirmation that teams will
• Attendance at learning events
• On line learning sessions
• On site support / coaching
• Share best practice and engage with continuous
188
Contact Details
189
190
AQuA’s Breakthrough Series Collaborative
6 – 12 months
Recruit Members:
Formal Governance
Agreements
Expert
Meeting LS1 LS2 LS3
Sustaining
Improvement
Dissemination (Publications, etc.)
Enlist
Participants
(20 teams)
Prework
Framework
and local
plans
AP1 AP2 AP3*
Spread
A P
D S
A P
D S
A P
D S
Ongoing Supports
• Email / AQuA Portal / Calls • Monthly webinars
• Team reports • Site visits
• Measurement for Improvement • Sponsor
*AP3: continue reporting data as needed to document
success
LS = Learning Session AP = Action Period
Apr16 May16 Jun16 Sept16 Dec16 Celebration: Mar17
Delegates will:
• Have the opportunity to understand what data is available from NHS Benchmarking
• Receive an update on National guidance and measures
• Have updates from other early intervention teams regarding their progress in relation to the RTT
• Understand basic demand and capacity analysis
• Understand NICE guidance using employment support and family intervention
• Be provided with an AQ update and AQuA plans for 2016/17
Objectives