North Staffordshire Primary Care Psychological Therapies Service IAPT

1. North Staffordshire Primary Care Psychological Therapies Service (IAPT) Maximizing the role of the Psychological Wellbeing Practitioner Dr Mark Kenwright, Clinical Lead Sharon Heeks, PWP Manager Relieving distress, transforming lives

2. The Majority of IAPT patients will be treated at Low Intensity An IAPT site employing 40 workers 24 HI Therapists � treat 1728 patients (29%) 16 PWPs � treat 4208 patients (71%) Learning from Year 1 sites (32 PCTs) 38% Low Intensity only, 17% Both LI & HI, 28% High Intensity only, 8% �Other�

3. Aims of Workshop Explore some of the challenges to implementing the PWP Role Examine some of the learning from sites that have attempted to implement LI treatment in a stepped care model Provide some examples of successful PWP practices based on learning Provide some evidence of outcomes so far

4. Background to LI Treatment Models Anxiety and Depression often Chronic Treatment models developed following chronic disease management � Collaborative Care �A Multifaceted intervention involving 3 distinct professionals collaborating in Primary Care� Fletcher (2008)

5. Primary Care Practitioner (GP) Case Manager (PWP) Mental Health Specialist (HI Therapist) Content of collaborative care varies across RCTs

6. Bower et al (2006) Reviewed 34 RCTs of Collaborative Care for depression 3 variables appeared linked to better outcomes � Systematic Identification of Patients Case Managers with professional MH Training Specialist Supervision

7. Low Intensity Treatment � Challenges for HI Clinicians LI treatment is a different mindset Less evidence and guidance Therapists feel threatened by �Giving away specialist knowledge� Assumptions � �Watered down version of CBT� (Observer, 15th March 2009) LI Treatment = �Guided Self-Help�

8. LI Treatment Varies Across Services (and even �Within Services�) � Degree of �Prescription� Suitability Criteria Method of assessment / Triage Content of treatment Number of Support sessions Telephone vs Face-to-Face

9. �Good Practice� Lessons Learnt � Pathfinder & Year 1 Sites Clear, Specific, written clinical protocols for PWPs to follow Intensive in-house clinical skills training on engagement, assessment & treatment sessions (marked role-play and clinical sessions) In-house supervisor training & experience of Low-Intensity Work (demonstrations)

10. Engagement with Low Intensity Treatment � Managing Client Expectations 5 PCMHWs offered LI Treatment to 134 suitable patients � informed by GP they had been referred for face-to-face CBT Expectation Effect - only 61 (46%) accepted LI Treatment 7 PCMHWs offered LI Treatment as the main treatment of choice in Primary Care � 66% accepted

11. Educate Referrers and PWPs to explain LI Treatment Visit GP Practices � Focus presentation solely on role of PWP & LI treatment Engage GP Lead to advise and champion the service Provide clear, written guidance leaflets in GP Practices �Your Guide to Choosing Psychological Therapies� North Staffordshire Use scripts to train PWPs to engage clients

12. First Telephone call to patients � offering an assessment

13. Assessment � Triage? Psychological Wellbeing Practitioners are well trained to conduct patient-centred assessments It is, therefore, unnecessary for patients to be �triaged� through a lengthy and comprehensive mental health assessment by a highly qualified high-intensity therapist before they are allocated to a PWP - To do so would misuse precious HI resource - To do so would irritate patients

14. Assessment Offer choice of face-to-face vs telephone 90% of N.Staffs clients choose face-to-face PWPs trained to deliver same person-centred assessment as HI therapists Engages clients � demonstrates competence of PWP, develops rapport, trust & therapeutic relationship

15. Patients Views of the initial face-to-face interview (Simpson et al, 2008) �Its nice to see who you are going to speak to on the phone, so that you can put a face to them� �It was nice being able to put a face to the voice, I felt comfortable knowing I�d met her� �I came away from my first session feeling eased, like a weight off my shoulders� �He made me believe that I would get over this...kind of boosted my confidence...�

16. North Staffs Referral & Assessment Protocol Referral reviewed by HI therapist for suitability If suitable but risk/complexities indicated � Telephone �screened� by PWP first � brief structured interview If referral appears suitable & no risk/complexities indicated - straight to detailed person-centred assessment by PWP (no �screening�) Discussed in supervision post-assessment to validate patient allocation and choice of treatment

17. Assessment Structure of Initial Assessment Interview Differs across services Further in-service training � - Observation of HI Therapists - Role-play, recording and marking of assessments - Routine use of ICD10 to aid provisional diagnosis (particularly anxiety disorders)

18. Script to aid delivery of person-centred treatment rationale (including explanation of a problem-specific CBT model) Explanation of NICE guidelines and choice of recommended treatments

19. Treatment - Examples of Interventions Offered Signposting Information Prescription Medication Management Behavioural Activation Problem-Solving Sleep-Hygiene Advice on Exposure (as part of guided self-help)

20. Guided Self-Help Packages Depression � �Overcoming Depression and Low Mood� (Dr Chris Williams) or �Living Life to the Full� CCBT program GAD / Mild OCD � �Overcoming Anxiety� (Dr Chris Williams) Panic/Agoraphobia � �Overcoming Panic� (North Staffs Wellbeing Service)

21. Pathfinder � Out of 164 clients treated at Low Intensity 56 (34%) did not use any part of a Self-Help Package

22. 138 Referrals for depression (out of 312) 101 (73%) 37 suitable unsuitable 88 (64%) 13 Accepted SH Refused SH 26 13 49 On-line CCBT Standalone CCBT Workbook 19 7 8 5 41 8 Completed D.O Completed D.O Completed D.O