www.england.nhs.uk
The National Expectations
for Improving Access to
Psychological Therapies West Midlands
Strategic Clinical Network
June 2015
Caroline Coxon
Intensive Support Manager - IAPT Mental Health Unit
NHS England ([email protected])
1
www.england.nhs.uk 2
NHS Mandate – 2015/16
3.9 ………..extending and ensuring more open access to the Improving Access to Psychological Therapies (IAPT) programme, in particular for children and young people, and for those out of work, and to continue planning for country wide service transformation of children and young people’s IAPT. NHS England will work with stakeholders to ensure implementation is at all times in line with the best available evidence. NHS England will maintain the commitments that at least 15% of adults with relevant disorders will have timely access to IAPT services, with a recovery rate of 50%. In addition, NHS England will ensure that by March 2016, 75% of people referred to the IAPT programme begin treatment within 6 weeks of referral, and 95% begin treatment within 18 weeks of referral.
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Adult IAPT What Next?
• Address Variation (Equity) – Access & Recovery
• Improve Choice – Provider & Treatment
• Introduce Waiting Time Standard
• Integrate provision with physical health care
pathways
• Improve access within mental health care
pathways
• Introduce an outcomes based currency and tariff
• Improve employment support
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Achieving and Sustaining Access
Rates? • Are your referral rates sufficient to deliver 3.75% access rates
each quarter?
• What are your attrition rates?
• Nationally - 35% of patients referred do not enter treatment.
• There is good evidence that long waiting lists suppress referrals.
• Do you have a clear longer term strategy for IAPT / primary care psychological therapies?
• With immediate priorities and a marketing plan including:
• Simplified access and self referral routes
• Truly primary care which is not medically led
• Links with physical health
• Early intervention
• A Step 2 service including the specialisation of PWPs
• Maximising older people access and BME Access
‘Recovery’ and ‘Reliable Improvement’
• The Key Performance Indicator (KPI) is 50% for
Recovery.
• Commissioners and the Providers need to understand
through sound audits or root cause analysis why the
recovery rate is not being reached so that the cause
can be addressed.
• Reliable Improvement is equally as important and is
being Nationally measured and monitored
• Commissioners and Providers need to understand
how their performance varies from the national
average on both.
Recommendations
9
– Monitor both Recovery and Reliable Improvement
together at all times.
– Make the link between presenting condition /
diagnosis, the range of NICE guidance for that
condition and the therapy offered
– Understand outcomes by:
• Step, Team, Modality and Therapist
– Therapist monitoring
– Offer choice of therapy by commissioning the full
range of NICE recommended modalities so that it
meets the needs of your population
Waiting Standards / Targets
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• 75% of patients to have received their first treatment
within 6 weeks from date of receipt of referral
• 95% of patients to have received their first treatment
within 18 weeks from date of receipt of referral
Measurement of the standard
• Guidance was published on 20 February 2015 to support
measurement of the new waiting time standard.
• The new national indicators will measure waiting times
from referral date to the start of a course of treatment –
i.e. for those people who have two or more treatment
sessions.
• Local areas will also be required to capture and monitor
waits from referral to first treatment appointment for all
people who enter the service and this should include
people who receive a single treatment session.
• Patient-initiated delays will not be taken into
consideration when calculating the IAPT indicator.
Tolerances have been built into the IAPT standard to
allow for such delays.
• A number of additional measures will be captured in
national reports to guard against the introduction of
perverse incentives into local commissioning
arrangements
12
Improving Access to IAPT – Waiting Times
Improving Waiting times for Psychological Therapies (IAPT) Guidelines
and FAQs, http://www.england.nhs.uk/2015/02/13/mh-standards/
www.england.nhs.uk
Operationalising Access
Standards
The focus should be on entry to a course of treatment in order to
ensure the standard doesn’t introduce a perverse incentive into
local commissioning arrangements that would affect current case
mix or encouraging providers to:
Increase the proportion of patients offered a single session of
assessment and advice, rather than a course of therapy
Reduce the average number of sessions that are given to those
people who have a course of therapy
Introduce artificial treatment starts where patients have an early
appointment but are then put on an ‘internal’ waiting list.
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Cont….
There is a need to monitor contextual indicators with time series analysis to set the historical context and determine variance; enabling quality assurance of service provision. These include:
Average number of sessions
Numbers completing treatment as a percentage of those who entered treatment;
Case mix variance, both in terms of provisional diagnosis and also severity of symptoms;
Waits between first and second appointment to visualise long waits ‘hidden’ from nationally reported waits.
Additional reports commissioned from the HSCIC by NHS England to be available by Q4 2014/15. Further Reports will be commissioned for 2015/16 and will be available from October 2015.
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Good Practice in Waiting List Management
• Written pathways are in place with:
• agreed waiting standards for assessment, first treatment and all subsequent treatments in line with National IAPT RTT rules.
• Clearly defined clock starts and clock stops
• Senior Clinical sign off that (1) pathways are sound and (2) that decisions on what is first treatment are accurate (*)
• Admin Processes are defined in a clear written Access Policy
• (*) Accountability for accurate recording and reporting is understood with delegated accountability from the Trust Board
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• Focus on numbers of patients waiting
• Target waiting lists understood that will consistently deliver the waiting time standards calculated for the service.
• All waits are understood and visible i.e. daily/weekly PTLs are in place
• Tackle hidden waits as well as waits to first appointment
• Plans are in place to address backlogs (numbers waiting in excess of the target waiting list) in line with 6w and 18w standards by the end of Q4 2015-16.
Cont..
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What’s on the Horizon?
• Payment By Results (PBR)
• Rewards good outcomes rather than just activity
• Is fair (MONITOR criteria):
• To Patients;
• To Providers;
• To Commissioners;
• To Tax Payers
• Minimises perverse incentives and opportunities
for gaming
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• Is efficient and stable
• Incentivises innovation, efficiency and
improvement
• Enables Parity with Physical Health Services
Cont..
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Overview of Currency Model - Outcomes
10 Outcomes incentivised and a percentage of the price paid
for meeting targets. The expectation is that the exact split will
be for local determination
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Monitor / NHS England’s Objectives for
Commissioners
20
By April 2015 all contracts to be underpinned by an
understanding of need, evidence-based responses to need and
expected outcomes
By April 2016 all contracts to include clear incentives for the
delivery of outcomes, outcome and quality driven payment models
will have been introduced in a limited number of areas AND have
robust data on cost, activity, quality and outcomes
By April 2017 a wholesale shift to outcome-focused contracting
As a minimum IAPT within block contracts this year should
specify the volume(s) to be delivered with appropriate levers
in place that will ensure delivery
Providers are advised to use 2014-15 to understand costs,
and establish sound performance monitoring (activity and
outcome) and should can expect shadowing of new
currency in 2015-16
Monitor has indicated it will mandate implementation of
IAPT currency in 2017. Providers should expect all IAPT
contracts to have been extracted from blocks and
commissioned along the lines indicated here.