STEPPED CARE MODEL

Matt Broadway-Horner Programme lecturer in the mental health and social sciences faculty

Agenda

•Aims

•What is IAPT?

•The Programme in London

•Challenges, Opportunities and Discussion

Aims

•Greater understanding of the IAPT programme and what it is trying to achieve

•How the programme has been rolled out, specific challenges for London and further work to be done by 2014

•Where IAPT might sit in the new commissioning landscape

•How IAPT can fit in to wider primary care strategies including further engagement with primary care

•What IAPT can offer local authorities and Health and Wellbeing Boards?

What is IAPT?

•National programme - implement NICE recommended psychological therapies for anxiety and depression.

•First phase (2008-2010) - £400,000,000 to train 3600 new therapists to treat a total of 900,000 people

•Second phase (2011-2014) - £400,000,000 to train 2400 new therapists, treating 1,000,000 people a year(15% need).

•Outcome monitoring - sessional measures - key indicators access, recovery, moving off sick pay/ benefits

•Population approach - assessing need and developing services and a workforce with the relevant competencies to meet that need.

•Increase capacity - specific curricula developed for extensive training programme to train a new workforce - LI and HI staff•A ‘full’ service consists of around 40 clinicians for a population of 250,000.

‘It was the practical work that made me realise I can do the

things I feared and without doing them with the therapist I

don't think I’d have made nearly as much progress’

The IAPT Argument (Depression Report 2006)

• Mental Health service provision often focuses on psychosis which deserves attention but affects 1% of population at any one time.

• Many more people suffer from anxiety and depression (approx.15% at any one time - 6 million people in England).

• Economic cost is huge (lost output £17 billion pa, of which £9 billion is a direct cost to the Exchequer).

• Effective psychological treatments exist. NICE Guidance recommends CBT for depression and all anxiety disorders plus some other treatments for individual conditions (EMDR for PTSD, Interpersonal Psychotherapy, Couples therapy, Counseling & Brief Dynamic Therapy for some levels of depression).

• Less than 5% of people with anxiety disorders or depression receive an evidence based psychological treatment. Patients show a 2:1 preference for psychological therapies versus medication

• Increased provision largely pay’s for itself

Key Features of IAPT services

•Stepped care - least intrusive, most effective treatment is offered first

•Range of evidence-based interventions

•Easy access - self referrals

•Target under-represented groups –multi lingual, older people

•Links to employment support

•Integrated with primary care

•Integration with other parts of mental health system

The Stepped Care Model

IAPT delivers services at step 2 and 3 of this model

The Stepped Care Model

The IAPT Programme in London

The IAPT programme in London has been one of graduated rollout and focussed on areas of highest deprivation first - this means that most of inner London has good coverage - outer London generally has less capacity and is less well resourced. Despite having an IAPT service in every PCT only about 60% geographical/population coverage.

The IAPT Programme in London•Services vary hugely in size with a large number unable to meet the needs of the local populations due to limited capacity and investment. The ability to meet need ranges from 0.23% to 11.42% and London as a whole is meeting 6.5% need.

•London currently has a workforce of around 1000 psychological therapists with well over half of these being trained and funded directly by the programme. The majority of this workforce is concentrated in central London.

Challenges and Opportunities

•Developing role in LTCs•Increased risk of MH problems / impact on physical health outcomes•Link to developing LTC pathways •Training for staff - balance between specialist skills and generic skills

•Developing work with primary care teams•MUS – joint management•Collaborative care models – depression and LTCs/ MUS•Balance between close working with PC and efficient, centralised models•Balance between GP preference for more inclusive service and maximising recovery rates.

•Developing public health approach•Prevention/ mental health promotion•Targeting specific groups to improve access•Links with physical health programmes

•Links with social care/LAs•Impact of welfare reforms•Employment – best way of providing this support•Children’s centres/ housing

Challenges and Opportunities

•Make it local - integration with existing mental services

•Ensuring coherent services with multiple providers

•Who will be key players in decisions about commissioning IAPT services?

•CCGs•HWBs•Public Health•Commissioning Board

• Activity scheduling – Increasing pleasure and achievement

• Thought challenging – Identifying and challenging negative automatic thoughts

• Problem solving– Exploring and breaking down problems into manageable tasks

• Via 1:1, telephone, groups and computer• Computer Aided CBT

– Beating the Blues– Fear Fighter

CBT Interventions at Step 2

• Based on modified CBT framework• Same principles as many of the self-help books but

support and encouragement of trained worker• Oxford Cognitive Therapy Centre Self help manuals• Maximum of 6 sessions, each 40-50mins• Delivered in community settings; GP surgeries,

libraries and Children Centres

Step 2 Guided Self Help

• Step 2 – Depression and Anxiety group– Introduction to CBT Skills– Turkish Access– Assertiveness – Stress group– Turkish stress group– Post Natal Adjustment– Employment– Fear Fighter Group

• Step 3– Mindfulness CBT group– Social Anxiety group – Worry group– Trauma Recovery– Trauma Recovery Turkish

Speaking

Groups

You can find further information about the IAPT programme at:

www.iapt.nhs.uk