peter fonagy cyp iapt programme
TRANSCRIPT
Children)and)Young)People�s)Programme)
Professor)Peter)Fonagy)
Na8onal)Clinical)Lead,)CYP)IAPT)
Kathryn)Pugh)
Programme)Lead,)CYP)IAPT)
The)context)of)CYP)IAPT:)Costs)Mental illness during childhood and adolescence in the UK:
£11,030 to £59,130 annually per child
Lifetime cost of a 1-year cohort of children with Conduct Disorder: £5.2 billion
Including costs of various agencies
• Health • Social services • Education • Justice
Costs of adult crime with history of CD
• £60 billion in England and Wales
• £22.5billion attributable to CD
• £37.5 billion to subthreshold CD
Evidence-based practice has substantial clinical & cost benefits Little & Edovald, 2012; Suhrcke, Puillas & Selai, 2008
Only 6% of current spending on mental health goes to services aimed at children and young people Kennedy, 2010
Reports)on)CAMHS!
“children)and)young)people)are)s8ll)oIen)receiving)
fragmented!and!inconsistent!support!…)support)is)s8ll)
some8mes)provided)too!late!in)a)crisis,)and)
informa2on)is)not!easy!to)come)by”))(2008)))
Reports)on)CAMHS!
“Urgent!ac2on!is)called)for)to)respond)to)the)mental)
health)needs)of)children)and)young)people.)Mental)
health)services)must!be!available!and!accessible,)
including)through)self7referral,)and)be)integrated)
with)other)services,)par8cularly)through)schools”)
Summary)of)the)issues)facing)CAMHS)
• Significant)shortages!of!trained!professionals!!• Current)level!of!CAMHS!staff!training!is!‘poor!and)
geUng)worse’)
• Difficul2es!with!access!(very)few)services)offer)a)selfX
referral)route))
• Poor!handling!of!transi2on!between)child)and)adult)services)
• Inappropriate!provision!of!adult!services!to)young)people)
• Data)that)could)and)should)be)used)for)performance)
management,)selfXcri8cal)professional)prac8ce)and)
commissioning)is)rarely!collected!
A!Step!Change—A!Transforma2on!
CAMHS
CYP - IAPT
The)CYP)IAPT)Programme)• Using)rou2ne!outcomes!monitoring))
• To)guide)therapist)and)supervisor)• To)help!client!monitor!and)understand)how)
treatment)is)progressing)
• Across)ALL!professions!• Empowering)YP)to)take)control)of)their)care,)
establish)treatment)goals,)choose)treatment)
approaches)and)take)opportuni2es)to)improve)
their)own)health)
• Improving)access)to!evidence7based!therapies!
• Introducing)evidence7based!organiza2on!of)care)
What)Is)CYPXIAPT?))A)simple)evidence)based)implementa8on)of)EBP)
• CYP)IAPT)was)conceived)as)a)centrally!ini2ated!modifica8on)of)CAMHS)in)the)direc2on!of!EBP!
• It)is)achieving)remarkable)degree)of)cultural!change!in)
terms)of)the)acceptability)of)principles!of!EBP!
interpreted!broadly)through)a)modest)investment)in:)
• service!change)• training)service)leads!• supervisors)and)therapists!
• Learning!collabora2ves!made)up)of)universi2es)and)
local!area!partnerships!offer)mutual)support,)problemX
solving)and)learning)networks.))
Milestones
Three%task%groups%begin%work%(Educa6on%and%Curriculum,%Outcomes%and%
Evalua6on,%Service%Development)%
CYP%consulta6on%via%YoungMinds%
Milestones
C%Paul%Burstow,%Ministerfor%Care%Services%launches%first%year%
collabora6ves%C%First%draI%IAPT%Dataset%and%Rou6ne%Outcomes%Monitoring%
Measures%Launched%
Milestones
C%Applica6on%process%for%2012C2013%announced%
C%Accredita6on%steering%group%convened%
C%New%£%resources%announced%
Milestones
C%Key%Performance%Indicators%agreed%by%ERG%C%Process%to%develop%accredita6on%of%courses%and%individuals%for%CYP%IAPT%agreed%C%Former%Minister%for%Care%Services%announces%new%sites%C%34%%of%England%now%covered%C%YouTube%channel%launched%
Milestones
C%%25%new%CAMHS%partnerships%joined%the%programme%in%year%3%
covering%54%%of%the%0C19%%popula6on
Milestones
2,662%CAMHS%clinicians%will%be%using%outcome%monitoring%
across%42%sites%rising%to%3,950%in%a%further%12%months%
Milestones
Planned'recruitment'of'new'CAMHS'to'join'for'year'4'
CAMHS&partnerships&will&cover&60%&of&popula:on&0;19''
What)has)CYPXIAPT)delivered?)
• A)na8onal)curriculum)for)four)therapies))
• cogni2ve!behavioural!therapy!for)anxiety)and)depression)
• parent!training!for)conduct)problems)
• systemic!family!prac2ce!for)depression,)ea8ng)
disorder)and)conduct)problems)
• interpersonal!psychotherapy!for)adolescent)depression)
!
The)effec8veness)of)Interpersonal)Therapy)(IPT))for)depression)
Rossello)&)Bernal,)1999)
n=71)
56%)
48%)
61%)
11%)
24%)
34%)
17%) 18%)
IPT) CBT) Wai8ng)List)
Adolescents!with!MDD!
Pre) Post) 3Xmonth)FXU)
0)
5)
10)
15)
20)
25)
Pre) Post) FollowXup)
Childhood!Depression!Inventory!
IPT) CBT) WL)
IPT NNT: 4 CBT NNT: 8
The)effec8veness)of)Family)Therapy)for)conduct)disorders)
Cur8s,)et)al)2009)
NICE Guidelines in 2009 and 2013 have identified Family Based Treatments as the most promising intervention for reducing adolescent antisocial and offending behaviour
0)
10)
20)
30)
40)
50)
60)
70)
80)
Pretreatment) Poshreatment)
0)
0.5)
1)
1.5)
2)
2.5)
3)
3.5)
Pretreatment)Poshreatment)
What)has)CYPXIAPT)delivered?)
• A)na8onal)curriculum)for)four)therapies))
• cogni2ve!behavioural!therapy!for)anxiety)and)depression)
• parent!training!for)conduct)problems)
• systemic!family!therapy!for)depression,)ea8ng)
disorder)and)conduct)problems)
• interpersonal!psychotherapy!for)adolescent)depression)
• A)curriculum)for)supervisors!!
• A)curriculum)for)managers)undertaking)service)
development)and)transforma8on)
• Supported)the)development)of)a)CYP)MH)e7pladorm.!
What is evidence-based practice in child mental health?
EBP$ Researcher$
Clinician$
Client$
Not$$‘delivered$unto’$clients$
via$field$workers$$from$researchers$$
on$high$
What)is)evidenceXbased)prac8ce)in)child)mental)health?))
EBP)
Researcher)Clinician)
Client)
A)fundamentally)par8cipatory)and)coXproduced)(coXconstructed))
enterprise)in)which)client,)researcher)and)clinician)are)all)fully)engaged)
EvidenceXBased)Prac8ce)
Fonagy)&)colls.)(in)press))What%works%for%whom?%A%cri1cal%review%of%treatment%for%children%and%adolescents.%Second)Edi8on.))
EBP)ScienceXinformed)
Organised)around)client)inten8ons)
Culturally)sensi8ve)
Con8nual)measurement)
of)effec8veness)
Acknowledges)impact)in)
children)and)families)
Takes)into)account)the)larger)social)context)
Enhancing)the)skills)of)
prac88oners,)
supervisors)&)service)
managers)in)EBP)
Three)major)components)of)the)CYP)IAPT)transforma8on)
Appropriately)
skilled))
CAMHS)
workforce))
1.)Closing)the)skills)gap)in)CAMHS)
Performance)Evalua8on)! Assessment)of)video)recorded)therapy)
sessions)
! Reports)of)individual)treatments)showing)
capacity)to)make)theory7prac2ce!links)and)
integrate!outcomes!informa2on)into)prac8ce)
! Reports)on)feedback)from)supervisors,)young)
people)and/or)parents))
! Summary)report)of)therapist�s!clinical!outcomes)over)the)training)period)
Three%major%components%of%the%CYP%IAPT%transforma6on%
2. Shift to collaborative practice
Client
Patient-reported outcomes
Clinical decision- making
Practitioner
Redressing!the!balance!of!exper2se!
Empowering)young)people)
Par8cipate))
in)service)design)
Par8cipate)in)training)of))
prac88oners)&)managers)
Understand)and)
modify)treatment)
progress)via)PROMs)
Empowering)young)people)enables)them)to….)
1.)Take)control)of)
their)care)
2.)Establish)
treatment)goals)
3.)Choose)the)treatment)
that’s)best)for)them)
Empowering)young)people)enables)them)to….)
4.)Improve)their))
own)health)
Three)major)components)of)the)CYP)IAPT)transforma8on)
3.)Transforma8on)of)par8cipa8ng)CAMHS)services)
Research)
evidence)
Pa8ent)
preferences))
&)values)
Clinician)
observa8ons)
BETTER)
CARE)
Adop8on)and)implementa8on)of)new)treatments)
Aarons,)Glisson,)Green,)et)al.,)2012)
More)than)a)technical)process,)a)social)process)
EBP)Organiza8onal)Social)Context)
Prac88oner)AUtudes)&)Behaviour)
To obtain the desired outcomes, many things must be in place
MetaXanalysis)of)EBP)vs.)Usual)Care))
0)
0.05)
0.1)
0.15)
0.2)
0.25)
0.3)
0.35)
0.4)
0.45)
Youth) Parent) Other)
Effect Size
F(3,228)=4.18, p<0.007)
Weisz et al., (2013) Do Evidence-Based Youth Psychotherapies Outperform Usual Clinical Care? A Multilevel Meta-Analysis. Archives of General Psychiatry
Measurement!for!a!purpose:!
Guiding!treatment!to!beher!outcomes!
Weisz)et)al.)(2012).)Tes8ng)standard)and)modular)designs)for)psychotherapy)trea8ng)depression,)anxiety,)and)conduct)problems)in)
youth:)a)randomized)effec8veness)trial.)Archives%of%General%Psychiatry,%69(3),)274X282.)
0)
0.5)
1)
1.5)
2)
2.5)
3)
Usual)Care) Standard)Condi8on) Modular)
Number)of)diagnoses)Pre))
Number)of)diagnoses)Post))
Manualized therapy without Match
Usual care Therapy delivered on basis of Match
15% 33%
TAU EBP EBP+Outcomes Monitoring
Service)improvements)linked)to)EBP)
• Reducing!varia2on!in!referral!rates!through)
• Improved)triage)and)
treatment)alloca8on)
• Improved)reahendance)
rates)
• Reduced)length)of)unnecessary)treatment)
• Reduced)inpa8ent)care)
Service)improvements)linked)to)EBP)
• Reducing!varia2on!in!referral!rates!
• Adop2ng!best!prac2ce!• Pathway)management)
• Opera8onal)management)
• Improved)pa8ent)flow)
through)the)system)
Service)improvements)linked)to)EBP)
• Reducing!varia2on!in!referral!rates!
• Adop2ng!best!prac2ce!• Increase!staff!produc2ve!2me!
through)rigorous)redesign)of)
methods)and)skill)mix)
Service)improvements)linked)to)EBP)
• Reducing!varia2on!in!referral!rates!
• Adop2ng!best!prac2ce!• Increase!staff!produc2ve!2me!!
• Create!flow!and!eliminate!
waste!from)poorly)designed)
systems)and)the)consequences)
of)demand)generated)by)
failures)and)errors)
Service)improvements)linked)to)EBP)
• Reducing!varia2on!in!referral!rates!
• Adop2ng!best!prac2ce!• Increase!staff!produc2ve!2me!!
• Create!flow!and!eliminate!
waste!!
• Reduce!complexity!X)a)
significant)driver)of)costs)&)
errors)based)on)inefficient)
clientXtoXclinician)feedback)
Annual)es8mated)savings)associated)with)service)transforma8on)and)EBP)
Am
ount
pot
entia
lly s
aved!
2011-12!0 2012-13!
10
20
30
40 £34,085
Based on assumption of £3,000 as the average cost of a CAMHS case 80% of cases seen fall into the category where benefits from outcomes monitoring and 63% where improvement associated with NICE prescribed treatment is relevant
£27,000
£12,875
2013-14! 2014-15!
£3,430
• Participation embedded in the service and organisation
• Involving commissioners
" Embedding outcomes monitoring in the teams
" CYP IAPT principles embedded in the overall strategic model for CAMHS service delivery with partner agencies
" Self referral growing in year 1 and 2 sites
" Improving supervision structures within teams
Strategies)for)sustaining)change))
Sustainability of CYP-IAPT: Today Governance Structure: feedback and learning
Quarterly report
Sites%
Collabora6ves%
FEEDBACK%
Sustainability of CYP-IAPT: Today Governance Structure: feedback and learning
Quarterly report
Data analysis by CAMHS Outcome Research Collaborative and Nexus
Lessons learned will be placed on the web
Monthly%Reports%
NHS IQ Cabinet Office
NHS England
Mechanism!to!facilitate!knowledge!transfer!!HEIs)to)
partnerships)to)commissioners)across)NHS)
Network!to!support!those!in!leadership!posi2ons)
Curricula!!&!case!
management!approaches!for)par8cular)disorders)
“Best!value!system!
templates”)–)shared)with)all)consor8a)as)a)model)of)
improvement)
Knowledge)Management)to)Ensure)Sustainability))
Sustainability)of)CYPXIAPT:)The)Future)
When)the)central)team)is)no)longer)present…)
Staff)turnover) Modifica8on)
of)programme)
requirements)
Changes)in)
funding)streams)
Development)of)a)na8onal)system)of)quality)assurance)
• Training)
• Performance)
• Service)characteris8cs)
Management)Training)
• Organisa8onal)culture)
• Climate)
Sustainability+of+CYP1IAPT:+The+Future+
Development+of+a+Na?onal+System+of+Accredita)on,
CYP)IAPT)X)The)Future)
• Programme)needs)to)demonstrate)effec2veness)and)Key)Performance)Indicators)))
• MindEd!eXportal)allows)CYP)IAPT)curricula)to)be)placed)on)web,)available)to)all)prac88oners)
• Outcome!monitoring!needs)to)be)built)into)all)clinical)curricula!!
• Developing)a)workstream)to)support!commissioners!!
• Accredita2on)will)support)long)term)embedding)of)CYP)IAPT)ideals)))
THANK&YOU&
&Thanks&to&everyone&
&THIS&HAS&BEEN&A&TRULY&COLLABORATIVE&
EXPERIENCE&