Slide presentations from "Improving care for people with psychosis in North West London", an event hosted by Imperial College Health Partners on 10th February, 2015.

1. 10th February, 2015
Improving Care for People with
Psychosis in North West London
Phase 2 Launch event
#nwlmentalhealth

2. Dr Geraldine Strathdee
National Clinical Director for Mental Health, NHS England
Setting the national context
#nwlmentalhealth

3. Psychosis care in England :dawn of
a new era
• Major new thinking and scientific discovery
• The 5 year Forward View
• New access standards to evidence based treatments
• We have the information to commission & plan for local areas
• We have the best quality standards in the world
• We have ‘what good looks like; services we can emulate
• We have new learning on how to fast track implementation
• We know how to develop leaders
• Lets get going ……
3

4. England is not alone: this is an international movement
4

5. The British Psychological
Society’s summary of what
we know about the
psychology of psychosis,
and how services need to
change as a result
Downloadable free from
www.understandingpsychosis.net

6. THE CONVERGENCE OF VIEWS ON PSYCHOSIS
• Childhood adversity
• Cultural communities lived
experience & discrimination
• Urbanicity
• Social isolation and alienation
• Intrusive life events
• Institutionalisation
• Cannabis & Kat
• PET studies show that excess striatal
dopamine appears to be a reflection of
risk factors - it is a mechanism, not a
cause
• Molecular genetics demonstrates a
continuum of vulnerability with much
overlap between disorders
High impact factors The gene & brain findings

7. New explanations for how the brain, biology and Social adversity interact in
the causes and impacts in psychosis
child abuse adverse life events sensitise the dopamine system & cause excessive salience
But if the cycle can be broken there should be recovery.
Howes & Murray. Schizophrenia: An integrated socio developmental cognitive model Lancet Dec 2013
Belinda Lennox, EIP lead, Oxford
• Smaller amygdala volumes found for children exposed to different forms of ELS.
• Smaller hippocampal volumes in children who were physically abused or from low
socioeconomic status households.
• Smaller amygdala and hippocampal volumes were associated with greater cumulative
stress exposure and behavioral problems. Hippocampal volumes partially mediated the
relationship between ELS and greater behavioral problems.

8. The most frequent complaint about
mental health professionals was that
they were too pessimistic about the
likely outcome
Schizophrenia Commission, 2014

9. • 65% had no psychotic symptoms at 10 years
• 46% had had none for >2 years (40% of those diagnosed as having Schizophrenia)
Of these who had no symptoms 56% had received medication
in previous two years
AESOP Study -387 patients followed-up ten years
after a first presentation with psychosis
Morgan et al. Psychol Med 2014;44:407–419

10. No-one can tell for sure what has
caused a particular person’s
problems. The only way is to sit down
with them and try and work it out.
The opportunity to talk things through
in this way is vital, but surprisingly rare.
Psychological therapy is very helpful for many people.
NICE recommends that it should be offered to everyone
with a diagnosis of psychosis or schizophrenia.
However currently most people are unable to access it.
Services need to change radically. We also need to invest
much more in prevention by attending to inequality and
child maltreatment. Concentrating resources only on
treating existing problems is like mopping the floor while the
tap is still running.

11. 11
5 Year Forward view Lifespan mental health
Being Born well Best early years Living and working well Growing older well Dying well
Building positive
mental health in
individuals and
communities
through raising
political & public
awareness and
reduced stigma
Prevention of
mental ill
health
through
addressing the
fundamental
causes
Improving
access to
timely, effective
services for the 16
mental health
conditions
maximizing the
potential of the digital
revolution
Transformation
of services to deliver
value, better outcomes,
quality & personalized
Right Care
Building a
sustainable
future
Of
Leaders,
intelligence & and
improvement
programmes
2015-2020

12. The 15/16 Access & Waiting Time Standards
12
By April 2016:
• 75% of people referred to the Improved Access to Psychological Therapies
programme will be treated within 6 weeks of referral, and 95% will be
treated within 18 weeks of referral.
• More than 50% of people experiencing a first episode of psychosis will be
treated with a NICE approved care package within two weeks of referral.
And there will be:
• £30m targeted investment on effective models of liaison psychiatry in a
greater number of acute hospitals. Availability of liaison psychiatry will
inform CQC inspection and therefore contribute to ratings.

13. Psychosis care in England :dawn of a new era
• Increasing access to evidence based treatments (early) and
transforming our current system
• We have the information to commission & plan for local areas
• We have the best quality standards in the world
• We have ‘what good looks like; services we can emulate
• We have new learning on how to fast track implementation
• We know how to develop leaders
• We have services that are delivering excellent care, BUT the
variation is
13

14. What do the mental health NICE guidelines say
There are 7 core effective care interventions
1. Right information
2. Right Physical health care
3. Right Medication
4. Right Psychological therapies
5. Right Rehabilitation/ training for employment
6. Right Care plan addressing housing, healthcare, self management
7. Right crisis care
In the Right least restrictive setting by the Right trained, supervised team
1
Mental health : Is the problem that we have no evidence or value based guidance?
 Mental health has over 100 NICE Health Technology appraisals, NICE
guidelines, Public health related guidelines and Quality standards…..
 The problem is not lack of guidance
 The problem is that we have not focused on how we learn and disseminate from
those that can and have implemented
 We have not communicated this to our Boards
 The standard of Care has unacceptable major variation across England

15. The standards in your area
15

16. Have you ever been offered Cognitive Behavioural
Therapy (CBT)?
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
41
42
39
21
24
50
65
09
20
17
25
33
49
45
48
06
08
44
02
07
67
12
27
31
59
51
60
05
04
36
01
16
TNS
69
54
61
29
72
71
10
03
13
19
56
53
11
28
46
15
52
74
73
47
64
43
70
66
38
35
37
30
34
63
26
68
Source: Audit of practice
Yes No, but was available No, as CBT was not available Not known Yes, was taken up

17. Mental health system of care:
what can be done to build personalized, recovery orientated care & reduce suicide at every
level
High
secure
beds
Medium
secure beds
Low secure beds
Intensive rehabilitation
closed unit
for complex dual diagnosis
Open rehabilitation units
Locally authority Residential rehabilitation
Supported accommodation with care package
Own tenancy plus personalized budget
24/7 Assertive outreach/ community forensic team
multi agency teams
24/7 Assertive outreach /rehabilitation & recovery,
multiagency teams
24/7 Assertive outreach /rehabilitation &
recovery multi agency teams
Rehabilitation / recovery team:
multi agency
Rehabilitation / recovery team
CMHT/ Enhanced primary care SMI
with 3rd sector outreach
CMHT/ Enhanced primary care SMI
with 3rd sector outreach
Design Principle :It is vital to understand that in mental health our ‘technology’ and ‘care model design principle’ is that in
order to provide safe, NICE concordant , efficient services, we need proven effective care teams to link with beds
In mental health we are expert at using case managers to triage all admissions & work early on the discharge plans
The beds The teams

18. Another way to say communities are what
makes the world a place we want for
ourselves and our children work
18

19. The top 8 key implementation fast track
success techniques
1. Board to floor commitment
2. Clinical leadership by top medics and nurses
3. Proper sophisticated programme management
4. Feed back progress to each clinical team so they can own need to
improve
5. Commission and employ GPs to come on to wards to help immediate
actions but also to train and supervise MH staff ( mega fast improvement
and smoke free wards with this technique)
6. Use of templates for both primary and secondary care : like any QOF
activity …clinicians decision support tools
7. Work force training , preferably practice nurses and ward nurses and con
together
8. CQC & Monitor regulatory emphasis

20. Phoebe Robinson
Programme Manager, Imperial College Health Partners
Beverley
Expert by experience and Imperial College Health Partners steering group
(Phoebe and Beverley’s Prezi presentation is available online to view at
http://prezi.com/duh75qzcnolz/?utm_campaign=share&utm_medium=copy&rc=
ex0share)
(The next seven slides are the source data for the Prezi presentation delivered at
the event)
Improving the psychosis
pathway in North West
London – our journey
#nwlmentalhealth

21. We used a rigorous method to identify
psychosis patients in health system data
Identify by
ICD-10
Diagnostic
Codes
Identify by
MH PbR
Clusters
Identify by
Lived
Experience
(HONOS)
HES
MHMDS
Anonymised data
across 3 years
Apr 2011 - Mar 2013
Mental Health Care
Secondary and
Community
Physical Health Care
A&E, Inpatient
and Outpatient
Identify
users with
psychosis*
Raw data licensed by Janssen Healthcare Innovation from the Health
and Social Care Information Centre, 2013
21
*Approach validated by clinicians in multiple AHSNs

22. 22
Combining the 3 approaches gives us a
“user-by-user” count of those with psychosis
Source: MHMDS 2010-2013 (3 years)
Psychosis using defined criteria*
Other
mental
health
23,937
(29%)
3 years*
Unknown*
81,643
35,067
22,639
Psychosis
Source: ICHP user data contained in HES and MHMDS datasets licensed from
HSCIC, 2014
*These service users belong to ICHP Lower Super Output Areas but have no valid diagnostic,
cluster or HONOS codes; It is difficult to differentiate among errors, transient users or “not
yet classified” patients
2,520
(29%)
2,996
(38%)
Hillingdon
6,495
8,616
7,839
Hounslow
2,948
(45%)
4,314
(44%) 2,698
(38%)
Hammersmith
and Fulham
6,232
Harrow
7,1017,259
Central
London
2,678
(43%)
Brent
5,589
Ealing
9,873
3,492
(48%)
2,291
(41%)
West
London
CCGs: Latest recorded across 2010-11 to 2012-13

23. This allows us to look for patterns in user
demographics…
23
0
500
1,000
1,500
2,000
2,500
3,000
3,500
20-
24
35-
39
25-
29
40-
44
15-
19
45-
49
30-
34
50-
54
60-
64
55-
59
90+85-
89
80-
84
75-
79
70-
74
65-
69
Service users in
NW London CCGs
Psychosis
Other mental health
*Age in 2012-13

24. … and identify areas with highest need
24
Top 25 GP practices
by number of
service users with
psychosis
(over 100 users
each)

25. We are able to build a picture of demand for
mental health care in our region…
25
Users with psychosis need 4 times as
many HCP contacts (healthcare
professional contacts) as users with
other mental health conditions
Users with psychosis need over 50%
more inpatient bed days per user
per year as users with other mental
health conditions
29%
72%
89%
100%
Inpatient Ward
bed days
994,729
Healthcare Professional
contacts
1,406,530
Service users 81,643
Other mental health
Psychosis
Unknown
67
23
39
6
Inpatient bed days
per user per year
HCP contacts
per user per year
Charts cover activity across 2 years;
they do not include all activity at Mental Health Trusts

26. … and measure the impact of our service
users on the rest of the health care system
26
8,966
Psychosis users needing
A&E (anytime in 3 years)
Psychosis users needing
Acute Trust Emergency admissions
(anytime in 3 years)
16,243
23,937Psychosis service users (3 years)
5
8,875
A&E attendances by
users with psychosis per year (3 yr avg)
28,447
Inpatient emergency admissions
by users with psychosis per year (3 yr avg)
47,692
Inpatient emergency bed days
by users with psychosis per year (3 yr avg)
Average length of stay per admission (days)
67% of Psychosis users visit
A&E and 37% get emergency
admissions to Acute Trusts
With unit cost assumptions of
£108 per A&E attendance and
£255 per Acute Trust bed day,
we estimate NW London
spends over
£3 million on A&E
attendances and nearly
£12 million on Acute Trust
beds (emergency only) for
psychosis patients

27. 27
Identifying psychosis users within MHMDS
ADD Based on ICD: Select all those with ICD-10 codes F20 to F29 in the Primary or
Secondary Diagnosis fields, using all relevant Events (PDIAG or SDIAG Events) in 2 years
ADD Based on Clustering: Select all those with Cluster values from 10 to 17 in the Cluster
field, using the highest PbR Cluster value across all relevant Events (MHCT Events) in 2
years
ADD Based on Honos: Select all those with a Honos Question 6 (hallucinations and
delusions) score between 1 and 4 in the “original” Honos questionnaire (working age
adults), using all relevant Events (HNS Events) in 2 yrs; Also select those with these scores
for Honos CA (children/adolescents) Question 7 or Honos 65+ (elderly) Question 6.
REMOVE For those selected based on ICD-10 alone (and not by any other method):
Remove those with ICD-10 codes F21, F23-24, F26-29 (leaving only F20, F22 and F25)
REMOVE For those selected based on PbR Cluster alone (and not by any other method):
Remove PbR Cluster 15 (severe psychotic depression)
REMOVE For those selected based on Honos Q6 score alone (and not by any other
method): Find the ICD-10 codes and remove those with ICD-10 codes F31 (bipolar
disorders) /F60 (personality disorders)
… with a similar approach for 2010-11 data (without Clusters)
REVISED Selection criteria using Events in 2011-12/2012-13 data…

28. Professor David Kingdon
Professor of Mental Health Care Delivery, University of
Southampton
Taking the pathway forwards
#nwlmentalhealth

29. Moving forward with
pathways
David Kingdon (dgk@soton.ac.uk)
Professor of Mental Health Care Delivery

30. Preventative
strategies
Collaborative
assessment of
needs
Effective
intervention
Intelligent
guidance
Responsive
funding
Psychosis &
complex trauma
(‘BPD’)
programmes
Systematic
regular &
responsive to
service user
‘What’ & ‘when’
condition-based
care pathways
Outcome-focused
reliable and
relevant
information
Effective
interventions &
community care
rewarded
Integration of
psychosis (EIP) &
complex trauma
initiatives
HoNOS,
WEMWBS
DIALOG F&F
Specific scales
Imperial &
Wessex Pathways
& intervention
coding
National Mental
Health Intelligence
Network (incl.
MDLDS+)
Individual and
stratified
personal
budgets

31. Pre-psychosis Early psychosis Persistent psychosis Recovery
Acute care pathway
EIP pathway Assertive outreach pathway
Community mental health pathway
Collette’s journey
Social
services
care
Early
intervention:
care
coordination &
medication
Safety &
rehabilitation:
hospital
medication&
DBT
Independence:
support, reduced
medication &
CBTP
Recovery-
self-
manageme
nt

32. 'More than 80% of patients with their
first episode of psychosis will recover
…. less than 20% will never have
another episode.
Quoted by Marco M Picchioni, Clinical Lecturer in
psychiatry and Robin M Murray, Professor of Psychiatry (2004)
Robinson D, Woerner MG, Alvir JMJ, Bilder R, Goldman R, Geisler S, et al.
Predictors of relapse following response from a first episode of schizophrenia
or schizoaffective disorder. Arch Gen Psychiatry 1999;56:241-7.

34. Stroke Pathway

35. http://fingertips.phe.org.uk/profile-group/mental-health

36. We can also benchmark general outcomes
and care standards against peer CCGs
Sources: Commissioning for Value Datapack, NHS Rightcare, Nov 2014
Figures show
performance on a
few key indicators,
when compared to
10 “similar” CCGs

37. 37
Basic Data
Incidence and prevalence of people with psychotic disorder
Number of people in services with diagnosis of psychosis with co-existing substance
misuse &/or complex trauma (BPD) (from diagnostic coding & HONOS/MCHT)
Access to interventions
Timeliness – to CBT, FI, ISP
Duration of untreated psychosis
Delayed discharge
Early access to services
Timeliness
EIP referrals/predicted incidence
No and % who access Acute Care Team
(CRHT compared to admissions)
Length of stay with ACT
MHA detention rates
A&E attendances
Section 136 assessments
Contact with Criminal Justice System
Emergency admissions to hospital
Physical health
% patients who have a health
passport at 6 month review
Admissions to general hospital
Physical health checks (QOF) &
intervention (CQC) (MHLDDS)
Outcomes
Change in symptoms: HoNOS, DIALOG +/- DRAKE, PHQ9, GAD7, Mania scale
Changes in Hope Agency and Opportunity (PROM): Accommodation & Employment
Carer and family support
Recovery & relapse rates at 6 months, 1 & 2 years
Self-harm/ suicide /premature mortality

38. 38

39. Psychosis Pathways
– can efficiently address service user need
– support staff implementing evidence-based
interventions through local ownership
– provide incentives for prevention and least
restrictive care
– produce persistently positive outcomes and
recovery

40. Dr Bill Tiplady - Acute Services Lead Psychologist, Central And North West
London NHS Foundation Trust
Professor Thomas Barnes - Professor of Clinical Psychiatry, Imperial College
Professor David Kingdon - Professor of Mental Health Care Delivery, University of
Southampton
Beverley – Expert by experience, Imperial College Health Partners steering group
Phoebe Robinson – Programme Manager, Imperial College Health Partners
Panel discussion: North West
London pathway development
#nwlmentalhealth

41. Panel 1 – Developing the Psychosis Pathway
1. How can we continue to iterate and develop the pathway and make it a living
document?
2. Are there any parts of the pathway that are more or less developed and why?
3. What are the key ways in which ICHP can use this pathway to support
improved outcomes for people with psychosis?
4. What have been the key learnings from the project process?
#nwlmentalhealth

42. Steve Shrubb
Chief Executive, West London Mental Health NHS Trust
Collaborating across North
West London and beyond
#nwlmentalhealth

43. Steve Shrubb - Chief Executive, West London Mental Health NHS
Trust
Dr Shanaya Rathod – Mental Health Clinical Lead, Wessex AHSN
Dr Geraldine Strathdee – National Clinical Director for Mental
Health, NHS England
Phoebe Robinson – Head of Project Development and
Performance, Imperial College Health Partners
Panel discussion:
Collaboration across North
West London and beyond
#nwlmentalhealth

44. Panel 2 – Collaborating to embed and spread
our work
1. What have been the main benefits of working together the Imperial College
Health Partners to deliver this work?
2. How can we look to spread this innovative work more widely?
3. What can AHSNs learn from this mental health project that could be used to
drive change in other parts of their work programme?
#nwlmentalhealth

45. Lunch
#nwlmentalhealth

46. Session 1: What does a shared journey to delivery of the North
West London psychosis pathway look like? (Dawson Room)
Session 2: Collaborative working across AHSNs on Mental Health
(Seacole Room)
Session 3: Early intervention in psychosis – next steps for North
West London (Wild and Hindle Rooms)
Workshops
#nwlmentalhealth

47. Close
#nwlmentalhealth