Peter Fonagy CYP IAPT Programme

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Peter Fonagy CYP IAPT Programme

  1. 1. Children)and)Young)People s) Programme) Professor)Peter)Fonagy) Na8onal)Clinical)Lead,)CYP)IAPT) Kathryn)Pugh) Programme)Lead,)CYP)IAPT)
  2. 2. 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 Costs of adult crime with history of CD • £60 billion in England and Wales • £22.5billion attributable to CD Including costs of various agencies •  •  •  •  Health Social services Education Justice • £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
  3. 3. How are we perceived? VIDEO (YouTube link)
  4. 4. 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)) )
  5. 5. 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”)
  6. 6. 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!
  7. 7. A!Step!Change—A!Transforma2on! CAMHS CYP - IAPT
  8. 8. 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)
  9. 9. 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.))
  10. 10. Milestones Three%task%groups%begin%work% (Educa6on%and%Curriculum,%Outcomes%and% Evalua6on,%Service%Development)% CYP%consulta6on%via%YoungMinds%
  11. 11. Milestones C%Paul%Burstow,%Ministerfor%Care% Services%launches%first%year% collabora6ves% C%First%draI%IAPT%Dataset%and% Rou6ne%Outcomes%Monitoring% Measures%Launched%
  12. 12. Milestones C%Applica6on%process%for% 2012C2013%announced% C%Accredita6on%steering%group% convened% C%New%£%resources%announced%
  13. 13. 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%
  14. 14. Milestones C%%25%new%CAMHS%partnerships% joined%the%programme%in%year%3% covering%54%%of%the%0C19%% popula6on
  15. 15. Milestones 2,662%CAMHS%clinicians%will%be% using%outcome%monitoring% across%42%sites%rising%to%3,950%in% a%further%12%months%
  16. 16. Milestones Planned'recruitment'of'new' CAMHS'to'join'for'year'4' CAMHS&partnerships&will&cover& 60%&of&popula:on&0;19''
  17. 17. 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) !
  18. 18. The)effec8veness)of)Interpersonal)Therapy)(IPT))for)depression) n=71) Childhood!Depression!Inventory! Adolescents!with!MDD! 61%) 56%) 20) 48%) 15) 34%) 17%) 11%) 25) 24%) 18%) 10) 5) 0) Pre) Post) IPT) IPT) Pre) CBT) Post) Wai8ng)List) 3Xmonth)FXU) IPT NNT: 4 CBT NNT: 8 CBT) FollowXup) WL) Rossello)&)Bernal,)1999)
  19. 19. The)effec8veness)of)Family)Therapy)for)conduct)disorders) NICE Guidelines in 2009 and 2013 have identified Family Based Treatments as the most promising intervention for reducing adolescent antisocial and offending behaviour 3.5) 80) 3) 70) 60) 2.5) 50) 2) 40) 1.5) 30) 1) 20) 0.5) 10) 0) 0) Pretreatment)Poshreatment) Pretreatment) Poshreatment) Cur8s,)et)al)2009)
  20. 20. 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.!
  21. 21. What is evidence-based practice in child mental health? EBP$ Researcher$ Clinician$ Client$ Not$$ ‘delivered$unto’$clients$ via$field$workers$$ from$researchers$$ on$high$
  22. 22. What)is)evidenceXbased)prac8ce)in)child)mental)health?)) Client) EBP) Clinician) Researcher) A)fundamentally)par8cipatory)and)coXproduced)(coXconstructed)) enterprise)in)which)client,)researcher)and)clinician)are)all)fully)engaged)
  23. 23. EvidenceXBased)Prac8ce) Culturally) sensi8ve) Con8nual) measurement) of) effec8veness) Acknowledges) impact)in) children)and) families) Organised) around)client) inten8ons) ScienceX informed) EBP) Takes)into) account)the) larger)social) context) Fonagy)&)colls.)(in)press))What%works%for%whom?%A%cri1cal%review%of%treatment%for%children%and%adolescents.%Second)Edi8on.) )
  24. 24. Three)major)components)of)the)CYP)IAPT)transforma8on) 1.)Closing)the)skills)gap)in)CAMHS) Enhancing)the)skills)of) prac88oners,) supervisors)&)service) managers)in)EBP) Appropriately) skilled)) CAMHS) workforce))
  25. 25. 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)
  26. 26. Three%major%components%of%the%CYP%IAPT%transforma6on% 2. Shift to collaborative practice Patient-reported outcomes Practitioner Client Clinical decisionmaking
  27. 27. Redressing!the!balance!of!exper2se!
  28. 28. Empowering)young)people) Understand)and) modify)treatment) progress)via)PROMs) Par8cipate)) in)service)design) Par8cipate)in)training)of)) prac88oners)&)managers)
  29. 29. Empowering)young)people)enables)them)to….) 2.)Establish) treatment)goals) 3.)Choose)the)treatment) that’s)best)for)them) 1.)Take)control)of) their)care)
  30. 30. Empowering)young)people)enables)them)to….) 4.)Improve)their)) own)health)
  31. 31. Three)major)components)of)the)CYP)IAPT)transforma8on) 3.)Transforma8on)of)par8cipa8ng)CAMHS)services) Pa8ent) preferences)) &)values) BETTER) Research) Clinician) evidence) observa8ons) CARE)
  32. 32. Adop8on)and)implementa8on)of)new)treatments) More)than)a)technical)process,)a)social)process) To obtain the desired outcomes, many things must be in place EBP) Organiza8onal) Social)Context) Prac88oner) AUtudes)&) Behaviour) Aarons,)Glisson,)Green,)et)al.,)2012)
  33. 33. MetaXanalysis)of)EBP)vs.)Usual)Care)) F(3,228)=4.18, p<0.007) 0.45) 0.4) 0.35) 0.3) Effect 0.25) Size 0.2) 0.15) 0.1) 0.05) 0) Youth) Parent) Other) Weisz et al., (2013) Do Evidence-Based Youth Psychotherapies Outperform Usual Clinical Care? A Multilevel Meta-Analysis. Archives of General Psychiatry
  34. 34. Measurement!for!a!purpose:! Guiding!treatment!to!beher!outcomes! 3) TAU EBP+Outcomes Monitoring EBP 2.5) Number)of)diagnoses)Pre)) Number)of)diagnoses)Post)) 2) 15% 33% 1.5) 1) 0.5) 0) Usual care Usual)Care) Manualized therapy Standard)Condi8on) without Match Therapy delivered on Modular) basis of Match 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.)
  35. 35. 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)
  36. 36. Service)improvements)linked)to)EBP) •  Reducing!varia2on!in!referral! rates! •  Adop2ng!best!prac2ce! •  Pathway)management) •  Opera8onal)management) •  Improved)pa8ent)flow) through)the)system)
  37. 37. 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)
  38. 38. 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)
  39. 39. 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)
  40. 40. Amount potentially saved ! Annual)es8mated)savings)associated)with) service)transforma8on)and)EBP) 40 £34,085 £27,000 30 20 10 0 £12,875 £3,430 2011-12 ! 2012-13 ! 2013-14 ! 2014-15 ! 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
  41. 41. Strategies)for)sustaining)change)) •  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
  42. 42. Sustainability of CYP-IAPT: Today Governance Structure: feedback and learning Quarterly report Sites% FEEDBACK% Collabora6ves%
  43. 43. Sustainability of CYP-IAPT: Today Governance Structure: feedback and learning Quarterly report Monthly% Reports% NHS England NHS IQ Cabinet Office Data analysis by CAMHS Outcome Research Collaborative and Nexus Lessons learned will be placed on the web
  44. 44. Knowledge)Management)to)Ensure)Sustainability)) “Best!value! Mechanism!to! Curricula!! system! facilitate! &!case! templates”)–) knowledge! Network!to! management! shared)with)all) transfer!! support!those! approaches! consor8a)as)a) HEIs)to) in!leadership! for)par8cular) model)of) partnerships)to) posi2ons) disorders) improvement) commissioners) across)NHS)
  45. 45. Sustainability)of)CYPXIAPT:)The)Future) When)the)central)team)is)no)longer)present…) Staff)turnover) Changes)in) funding)streams) Modifica8on) of)programme) requirements) Development)of)a)na8onal)system)of)quality)assurance) •  Training) •  Performance) •  Service)characteris8cs) Management)Training) •  Organisa8onal)culture) •  Climate)
  46. 46. Sustainability+of+CYP1IAPT:+The+Future+ Development+of+a+Na?onal+System+of+ Accredita)on,
  47. 47. 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)))
  48. 48. How are we perceived? VIDEO (YouTube link)
  49. 49. THANK&YOU& & Thanks&to&everyone& & THIS&HAS&BEEN&A&TRULY&COLLABORATIVE& EXPERIENCE&

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