Patient flow and sampling strategy University of Sheffield 39
How did we define relapse? 1. Both PHQ-9 and GAD-7 at last session below cut-off 2. At least one measure above cut-off at review session 3. This measure also had to be a reliable deterioration University of Sheffield 40
Demographics Characteristics Full treatment Primary study cohort sample N = 5921 N = 2899 Demographics Mean age (SD; range) 41.19 (15.44; 16-92) 42.05 (15.87; 17-92) Females (%) 65.7% 65.1% Unemployed (%) 21.8% 12.5% Baseline clinical characteristics PHQ-9 mean (SD) 14.72 (6.17) 12.74 (6.15) GAD-7 mean (SD) 13.70 (4.98) 12.29 (5.15) WSAS mean (SD) 18.63 (9.50) 16.00 (9.06) Prescribed pharmacotherapy (%) 60.2% 55.4% Primary diagnosis Affective disorder 23.6% 22.6% Mixed anxiety and depression 40.0% 36.6% Generalized anxiety disorder 16.2% 19.0% Other 20.2% 21.8% Comorbid LTC 28.4% 27.0% University of Sheffield 41
The relapse rates 6-month replase rate of 41.8% 43% at HIT and 39.8% at LIT; a non significant difference HIT more likely to be prescribed meds, and significantly higher baseline and post treatment measures University of Sheffield 42
Categorical regression with optimal scaling: elastic net (regularized) coefficients N = 432 (training sample) Dependent variable = relapse status after acute-phase treatment F(16) = 2.94, p < .001, R Square = .11 Variables B SE Gender (reference = male) .000 .014 Age (decade groups) .097 .070 Unemployed pre-treatment .000 .012 Unemployed post-treatment .033 .043 ADM pre-treatment .000 .016 ADM post-treatment .000 .015 Minority ethnic group (reference = white British) .000 .005 LTC .020 .037 IMD (decile groups) .000 .027 Number of treatment sessions .145 .093 PHQ-9 pre-treatment .011 .036 GAD-7 pre-treatment .000 .023 WSAS pre-treatment .081 .070 PHQ-9 post-treatment .051 .037 GAD-7 post-treatment .000 .031 WSAS post-treatment .002 .048 HIT (ref = LIT) .000 .014 Follow-up period (weeks since last treatment session) .073 .065 University of Sheffield 43
ROC curve analysis: predictive accuracy of a machine learning (ML) model across training and test samples University of Sheffield 44
So? The rate is larger then the meta analysed average Its remarkably similar to the only IAPT relapse data published (41.7%; Ali et al, 2017) Residual symptoms again predicting relapse University of Sheffield 45
Study three So we know what predicts relapse, but can we do a more fine grained analysis of these residual symptoms? The usefulness of network theory and analysis University of Sheffield 46
A symptom network of four depression symptoms University of Sheffield 47
A network of comorbid anxiety and depression University of Sheffield 48
Phases in the development of anxiety or depression University of Sheffield 49
Connectivity over time University of Sheffield 50
Quick reminder! Item Symptom PHQ9_Q1 Low interest or pleasure PHQ9_Q2 Feeling down, hopeless PHQ9_Q3 Trouble sleeping PHQ9_Q4 Tired or little energy PHQ9_Q5 Poor appetite/overeating PHQ9_Q6 Guilt PHQ9_Q7 Trouble concentrating PHQ9_Q8 Moving slowly/restless PHQ9_Q9 Suicidal thoughts GAD7_Q1 Nervous, anxious or on edge GAD7_Q2 Uncontrollable worry GAD7_Q3 Worry about different things GAD7_Q4 Trouble relaxing GAD7_Q5 Restless GAD7_Q6 Irritable GAD7_Q7 Afraid something awful might happen University of Sheffield 51
Demographic information of relapse and remission samples. Relapse Sample Remission Sample N 93 774 Male 40% 32% Mean Age (SD) 47 (17.2) 44 (16.2) White British 99% 99% Unemployed 17% 11% Treated by CBT 77% 66% Treated by PWP 23% 35% University of Sheffield 52
Network of first session PHQ-9 and GAD-7 symptoms for a) the relapse sample and b) the remission sample. University of Sheffield 53
Network of PHQ-9 and GAD-7 symptoms at the final treatment session for a) the relapse sample and b) the remission sample. University of Sheffield 54
What the important residual symptoms Concentration difficulties (a symptom of depression) highly central in relapse network Trouble relaxing was highly central in the remission sample University of Sheffield 55
So what do we know? Relapse a common problem Residual symptoms appear important – and also being make unemployed during treatment and a comorbid LTC Granularity – the role of concentration difficulties in relapse We need to better support people – the role of low intensity relapse prevention support that is not overly burdensome or costly for the service; Wellcome grant application. University of Sheffield 56
I need to go! Reflections, questions or comments University of Sheffield 57
Yorkshire and the Humber IAPT Providers Network Time for a break? 15 minutes only please! www.england.nhs.uk
Yorkshire and the Humber IAPT Providers Network Provider Presentation: Barnsley IAPT Rick Stebbings, Tom Brown and Victoria Greensmith, Barnsley IAPT www.england.nhs.uk
BARNSLEY IAPT Rick Stebbings Tom Brown Victoria Greensmith
History of Barnsley IAPT • Formed in 2008 (2 nd Wave) • Commissioned to roll out to the World Class Commissioning practices • Work from 16+ • Barnsley College • Perinatal pathway
History cont.… • December 2016 – Significant increased referrals • Resulted in service failing waiting time targets • Long CBT waiting lists/ Not achieving 50% recovery rates • Commissioner and provider invited IST to review the service and review waiting lists. • Contract Performance Notice served 31/8/17 • Notice Tendering of service 21/12/17
Outcome of IST • IST identified a number of areas that contributed to the long waits, from admin processes due to having to input on two electronic systems, skill mix and therapy drift. • In collaboration with the IST a method of managing the CBT waiting list was formulated…..
The Process • Identify Problem • Validate list (already done by complete review of CBT waiting list) • Understanding Demand and Capacity • Review/Design Pathway • Agree communication strategy • Implement
Problem Identified • 615 clients awaiting 1-1 therapy • 80 awaiting Group therapy • Counselling and PWP waiting lists weren’t an issue so not included
Validate List • We had already completed a complete review of the waiting list 3 months prior to the IST visit, whereby all clients had been offered a 1-1 appointment to review their current needs and if needed to remain on the waiting list. • It was agreed this had validated the list.
Understand Demand and Capacity • Problem – following the IST report, service immediately issued a Contract Performance Notice. This meant there was a specific time schedule to report outcomes back to the CCG. Therefore there was limited time to start the project. • No time for full demand and capacity • We identified which staff would work on each pathway, and this capacity matched the predicted demand
Review/Design of Pathway • During the process it was important to have CBT staff supporting the process • Regular meetings to discuss the methods and seek ideas from staff. • Reinforced the importance of being successful
Review/Design Pathway • Split waiting list in 2 - Interim Pathway - New Business as Usual Pathway • Cut off date identified • Interim – any referral pre-dating 1 August 2017 • Business as Usual – any referral from 1 August 2017 • Interim – no OCD (no 12 session protocol identified) • Interim waiting list – 467 • New Business as Usual waiting list – 148
Review/Design Pathway cont … • Interim Pathway identified : • 3 x protocols identified that covered the problems for clients on the Interim Pathway: • Behavioural Activation – Depression • Trans-diagnostic (Barlow Model) – Anxiety • CPT – Trauma • All protocols were set up for 12 week programmes • Treatment Packs copied for staff
Review/Design Pathway cont … • Staff were asked to count missed sessions in the total offered. • Support from CCG around impact on recovery • This enabled us to predict the numbers of sessions required with how many clients we had on the list, and give us an end date for the interim pathway. • It was also agreed with the CCG that clients would be discharged back to the care of their GP at the end of the 12 session protocol whether they hit recovery or not, which could also impact on recovery figures.
Review/Design Pathway cont … • Business as Usual pathway Identified: • 2 face to face formulation sessions • Reduce 1-1 waiting list by increasing numbers into groups • Following the Formulation sessions the clients were to be placed at the top of the 1-1 treatment list, to ensure work completed in the formulation sessions was not lost/wasted, or allocated to a therapy group.
Communications Strategy • Time restraints meant that there was no time to complete a service user focus group • Service sent letter to the CCG explaining the strategy, so this could be communicated to all GP’s • Client’s were informed of their treatment package at their initial appointment and contracts were agreed with clients.
Implementation • The process was commenced November 2017 • Staff split- Interim pathway and Business as Usual pathway ran alongside each other • A perfect world would start with all therapists having a clear diary on the first day • The world isn’t perfect, staff had on -going clients, so pick up for the Interim was staggered
Implementation Issues • Cancellations • Inequality and complaints • Ethical • Impact on Leadership Team’s time.
Administration • Administration of the preparation and implementation of the strategy was crucial. • In Barnsley we have 2 hubs of admin, screening and treatment. • The waiting list was split into the 2 pathways, and admin were given lists of the staff on each pathway.
Administration (cont …) • We telephoned clients whose appointments would be 1 week or less away to confirm agreement with their appointment. • We asked staff to plan diaries in order to give at least 2 weeks notice of an appointment, however this was not always possible. • We monitored progress of clients at 6 weeks and at discharge to check the protocols were effective.
Outcomes of Interim Pathway • August 2018 – ‘Interim’ pathway cleared leaving 378 on the new ‘Business as Usual’ pathway (reduced from 615). • Recovery figures were not negatively effected • Having staff engaged is key • Overall determination was required in order to engage everyone and keep the project on track, but ultimately the process was worth while
Business As Usual Outcomes • Clients engaged well with the two formulation sessions, however this led to some problems. In practice reduced the numbers going into groups. • Changed this pathway – 4 week Core CBT skill group sessions offered to everyone • Aim to reduce number of one to one sessions, increase numbers into groups and reduce numbers of group sessions
The Tender • Contract Performance Notice removed by CCG Feb 2018 • SWYPFT successful in retaining the contract - much reduced budget • Impact - staff were put at risk and relocated - 1 staff member made redundant - Emotional Well-being of the team - Increased pressures - Reduced staff numbers
Current Position • Now signed off by the IST • Just inputting on one system • New Website • Extended Working Hours
Current Position (cont …) • Achieving national targets • Bid submitted for expansion of LTC – start of that journey • Been a very difficult period but also have achieved a lot to be proud of
Future Challenges • Additional targets • Waiting times reduced to 4 and 16 weeks (CCG) • Aspirational moving to recovery 60% (CCG) • Clients offered face to face appointment for assessment within 2 days • PEQ at every session
Thank you Any Questions?
Yorkshire and the Humber IAPT Providers Network Yorkshire and the Humber PPN Paul Boyden, Yorkshire and the Humber PPN www.england.nhs.uk
The Yorkshire & Humber Psychological Professions Network Dr Paul Boyden Development Lead & Senior Clinical Psychologist Sheffield Health and Social Care NHS Foundation Trust P.Boyden@Sheffield.ac.uk
The context Expansion in psychological workforce in the past decade (e.g. IAPT, Physical health care, maternity) Increased diversity of roles within the psychological professions workforce (e.g. PWP as a workforce) Psychologically informed practice in some areas of health and social care Popularity of psychology at undergraduate level provides a good supply of entrants Integration into teams alongside mental/physical health services and social care
Background Lack of a joined up career path Lack of a shared identity Lack of a coherent voice in workforce planning No coordinated national voice
Opportunity The Five Year Forward View workforce expansion requirements Potential to expand existing roles Potential in new psychological roles Multi-professional voice of psychological professions can be stronger Service user and other stakeholder promotion of psychological approaches and workforce Collaboration with other practitioners with training in psychological approaches Need for psychologically informed practice across the whole of health and social care
Who are the other Stakeholders? Arms Length Bodies NHS PPN North funded (NW/NE) Services Experts by The The experience Public Members Professional PPN KSS Bodies Local Communities Universities Commissioners
What is the PPN? Free membership network for all psychological practitioners in NHS services / Universities and associated stakeholders Provides workshops / events linked to a strategic NHS agenda Communicates with members about news and relevant issues Supports workforce planning, development and commissioning
What it isn’t A professional body A network that represents any specific professional group above others A body that represents individual practitioners A body led entirely by the agenda/interests of its members A network representing mental health more broadly (e.g. nurses, OT, support workers)
Our mission We join together to inform both the strategic stakeholders and our members around key areas. We seek to enable our members to engage with each other and relevant partners in supporting collaboration and promotion of evidence based practice across the whole health service. We seek to influence policy, practice and organisations to ensure that psychological approaches are embedded within health and social care for all.
Animation https://youtu.be/osRe6fim7jM
Structure Workforce Board/Steering Group Terms of Reference Communications, Twitter, Newsletter + Blog Website Membership Stakeholder event – Spring 2018 Conference
Contact Us Yorkshire and Humber P.Boyden@sheffield.ac.uk www.nwppn.nhs.uk @YH_PPN
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