Dr John Hague East of England IAPT Clinical Lead GP Ipswich National chair IAPT LTC

1. Dr John Hague East of England IAPT Clinical Lead GP Ipswich National chair IAPT LTC/MUS SiG

2. First a thank you To Alan Cohen and Michael Parsonage Who helped with the work underlying this presentation And to Deborah Colvin and Colleagues for all the hard work in NHS London

3. The IAPT Programme 10th October 2007 - World Mental Health Day New funding over three years: �33m in 2008 �103m in 2009 �173m in 2010 To deliver Treatment for 900,000 people 3,600 new therapists Half the PCTs in England Delivering the very highest quality care (to RCT standard) is a guiding principle PCT�s monitored to ensure extra investment is real, not disguised cuts, and produces real change in patients

4. IAPT and economic downturn Additional �13 million to target �credit crunch stress� Faster rollout of IAPT in every area Employment support workers in every service Dedicated NHS direct Helpline Support More online info via NHS Choices Primary Care training to pick up signs of distress Investing in wellbeing

6. Characteristics of an IAPT service A team to manage people with common mental health problems Low intensity therapists High intensity therapists GP champion/lead Employment advisors Counsellors Others as needed The reason why the ration of high:low therapists is biased towards high intensity - is because it takes longer for them to see a patient - so that more of them are needed. All the calculations suggest that the low intensity workers will see more people, but by definition they are less disabled. The message that needs to be got over is that Both groups of therapists are equally important - they treat different groups of problems Interventions other than �just� CBT are delivered And that GPwSI are an essential part of the team approachThe reason why the ration of high:low therapists is biased towards high intensity - is because it takes longer for them to see a patient - so that more of them are needed. All the calculations suggest that the low intensity workers will see more people, but by definition they are less disabled. The message that needs to be got over is that Both groups of therapists are equally important - they treat different groups of problems Interventions other than �just� CBT are delivered And that GPwSI are an essential part of the team approach

7. Characteristics of an IAPT service Commissioner led MH Trusts are not necessarily the only provider No reason this cannot be PBC Commissioned against outcomes National Minimum Data Set for psychological therapies Outcome questionnaires to be delivered at particular times in the care pathway Shared database principles between service providers No data = no national money... MDS: Minimum Data set - the questionnaires make up the MDS Each site uses the same principles and definitions of treatment and recovery, patient satisfaction etc, so that comparisons can be made both within IAPT centres, and between IAPT centresMDS: Minimum Data set - the questionnaires make up the MDS Each site uses the same principles and definitions of treatment and recovery, patient satisfaction etc, so that comparisons can be made both within IAPT centres, and between IAPT centres

8. So What's IAPT got to do with LTC�s? The WRONG patients

9. So What's IAPT got to do with LTC�s? Have been having the wrong tests

10. So What's IAPT got to do with LTC�s? From the wrong Doctor Dr Justin Case

11. So What's IAPT got to do with LTC�s? In the wrong place

12. So What's IAPT got to do with LTC�s? Giving them the wrong diagnosis

13. So What's IAPT got to do with LTC�s? So they get the wrong treatment

14. Too Many Silos For too long care has been compartmentalised into physical and mental Often people are unwilling to look outside their silo We need to break down the silo walls and deliver TRULY holistic care

15. Too Many Silos mean... Patients don�t get better Or as better as is possible So they go back to the wrong Doctor In the wrong silo To get some more wrong tests��. I�m sure you all get the idea?

16. Waste between the silos The Economic Downturn is going to adversely impact NHS funding in the future We need to rapidly plan for prudence And spend money wisely

17. Barsky�s paper Somatization increases medical utilisation and costs independant of psychiatric and medical co-morbidity. Arch Gen Psych vol 62 Aug 2005, pp 903-910, Barsky et al

18. Barsky�s paper Average cost of medical care $2734 IF the patient also has somatisation, cost increases to $5678 This extra is 16% of the total cost of medical care Not related to age or differences in medical co-morbidity Those who somatise use twice as much PHYSICAL OPD and IP beds But not more psychiatric care

19. Who does �Barsky� apply to? People just with psychiatric disorder, with or without co-morbidity, cost less in total, or no more Cost is added with somatisation And even more if somatisation is combined with psychiatric disorder

20. Who does �Barsky� apply to? The somatisation population contains all the excess cost of physical healthcare 18% had panic disorder (also associated with more cost) 58% of somatisers also depressed or anxious Eg diabetes and COPD So this cost includes the �LTC dividend� Remember that treatments are available, and work, for anxiety, somatization, and depression And this provides an opening for therapy

21. Why? 69% of people with depression present in primary care with somatic symptoms (Simon et al) Around HALF of those seen in outpatients have �medically unexplained symptoms� Non personal primary care Hypochondriasis False illness beliefs Safety behaviour by Doctors Stigma Lack of training of those delivering physical care in the biopsychosocial model Lack of training of those commissioning physical care in the biopsychosocial model

22. Now lets do an English Barsky Barsky estimated 16% total extra cost Total NHS 08/09 spend is �92.6 billion 16-75 age group is 57.25% of population So this age group costs 53 billion Excess cost therefore is �8.5 billion (figures rounded) Thanks to Michael Parsonage

23. So? �Lack of training of those commissioning physical care in the biopsychosocial model� .....Except, potentially, PBC Because GP�s bread and butter is biopsychosocial care So PBC is ideally placed to sort all this out

24. A serious point This is not about �fobbing off� people with a psychiatric diagnosis This is about identifying and treating diagnosable conditions that present with physical symptoms (eg panic disorder presenting as chest pain) Or are co-morbid with physical symptoms (depression in heart disease, with 3 x the deaths of the non-depressed) While also detecting and treating physical disease to a high standard (people with panic disorder get heart disease too, and deserve to get both treated) Why should it be acceptable to miss a diagnosis? Or not treat a condition, just because it is a mental health condition?

25. What about stakeholders? PBC is ideally placed to engage stakeholders, as primary care is close to patients Look at what NHS Bedfordshire, and Herts have achieved with stakeholder involvement Then there is NHS London.....(thanks to Deborah Colvin for the next slides)

26. Process and Stakeholder Engagement 26

27. Proposed MUS Care Pathway 27

28. So... These show how NHS London has made this everyone�s business And linked to all stakeholders Thus achieving balance of local issues with central advice

29. We have 2 choices Wave a shroud and say it�s a shame Form an economic argument

30. So We�re using the �Layard Method� Producing compelling economic arguments works Look at the speed and acceptance of IAPT Shroud waving just does not work as well

31. What have we done Produced a simple toolkit That will be distributed by DH and LMC�s And is available online http://www.iapt.nhs.uk/2009/03/practiced-based-commissioning-to-imporove-primary-care-mental-health-delivery/ That makes producing winning economic bids a matter of cutting and pasting Copies of the files are available on a CD � a few are here today

32. Here are some examples Either these will reduce utilisation Or streamline care to include work between the silos Often incorporating IAPT But also apply to LTC�s, primary care and PBC

33. Chest pain The evidence �38% of those referred for investigation of chest pain to cardiologists have panic disorder, of these 45% agreed to treatment for the panic disorder� Journal of Internal Medicine 1999; 245: 497�507 Panic disorder in chest pain patients referred for cardiological outpatient investigation. T. DAMMEN1, H. ARNESEN, �. EKEBERG, T. HUSEBYE & S. FRIIS From the Departments of Psychiatry, Cardiology,Acute Medicine, Ullev�l University Hospital, Oslo, Norway The evidence . �34% of those with angiographically normal coronary arteries have panic disorder� Am J Cardiol. 1989 Jun 1;63(18):1399-403Panic disorder in patients with chest pain and angiographically normal coronary arteries.Beitman BD, Mukerji V, Lamberti JW, Schmid L, DeRosear L, Kushner M, Flaker G, Basha I.Department of Psychiatry, University of Missouri-Columbia.

34. Chest pain The evidence �GAD-2 is an effective screen and GAD-7 and effective measure for anxiety disorders, including panic disorder Ann Intern Med. 2007;146:317-325. Anxiety Disorders in Primary Care: Prevalence, Impairment, Comorbidity, and Detection Kurt Kroenke, MD; Robert L. Spitzer, MD; Janet B.W. Williams, DSW; Patrick O. Monahan, PhD; and Bernd Lowe, MD, PhD � The proposal Change RACCP pathway to include screen using GAD-2 If score more than 3 do GAD-7 Refer those scoring > 8 to IAPT (independant of cardiac outcome) Half of those referred will recover....

35. Pain clinic The evidence 21.5% of general population have chronic pain 30-45% of those attending pain clinics have depression CBT is an effective treatment for chronic pain Eg in back pain surgery costs �7,830 Rehab costs �4,526 For the same benefit

36. Angina The evidence A CBT based self help plan has been shown to improve psychological, symptomatic and functional status of those with angina Avoiding 40% of revascularisations and half of emergency admissions Moore RKG et al 2007 Journal of pain and symptom management Vol 33 issue 3 pages 310 to 316

37. Diabetes 25% of those with diabetes are also depressed That is 2-3 times the prevelance in the general population They have Worse health outcomes More symptoms Worse self care Increased cost of 50 to 75% (Simon 2005) Or 2.5 � 4 x cost (Trong Lee)

38. COPD 51% have significantdepression or anxiety Upto 67% have panic disorder A pilot in Hillingdon showed potential saving of �3.00 per �1.00 spent on CBT Clearly this needs replication in an RCT

39. Rheumatoid Arthritis Increased prevelance of depression 5 year follow up of those given NICE approved therapies early in course of illness (Sharpe et al (2005) Significant reduction in healthcare usage Less admissions, injections, physio

40. Stroke 61% get post stroke depression Middle aged men 3x more likely to suffer stroke if they get depressed Effective treatment Enhances QOL Improves physical functioning Improves emotional functioning Improves social functioning

41. But don�t forget governance Who employs the therapists? Who supervises them? Links to IAPT Links to physical health and primary care Governance and proper commissioning joins the silos up�. Zealots like me need a completer finisher in their team!

42. The result is The RIGHT patients

43. But there is a solution Have been having the RIGHT tests

44. But there is a solution From the RIGHT Doctor

45. But there is a solution In the RIGHT place

46. But there is a solution Giving them the RIGHT diagnosis

47. But there is a solution So they get the RIGHT treatment Personal Holistic Includes self care

48. But there is a solution So they get better I�m sure you all get the idea?

49. Do we you have the courage to do it?

50. Do we have the money NOT to do it?

51. Thank you Dr John Hague john.hague@eoe.nhs.uk 07771 734572 Presentation available on www.eoe.nhs.uk/iapt