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Type and Title of Submission


Title:

NICE Guidelines for Depression and Anxiety: Audit and Implementation in Southwark

Description:

This project was designed to identify whether patients with Anxiety and Depression in Southwark were being treated in accordance with the NICE Guideline recommendations; specifically with regards to stepped-care and the provision of evidence-based psychological treatments. In addition to this barriers to implementation were identified and recommendations to increase implementation were made. The follow-up project involves implementing the recommendations from the project to increase compliance with the NICE Guidelines.

Category:

Clinical

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG22 & CG23 - Anxiety & Depression

Category(s) that most closely reflects the nature of the submission:

Implementation policy
Audit tool

Is the submission industry-sponsored in any way?

No


Description of submission


Aim

The main aim of this project was to identify the extent to which the NICE Guidelines for Depression and for Anxiety were being implemented within the London Borough of Southwark, with regards to the recommendations for psychological treatment and a stepped care approach to management. The results of the project could then be used to develop a set of recommendations aimed at improving the implementation of the recommendations. There are a number of services in Southwark that provide treatment for patients with anxiety and depression but for the purposes of this project the main analysis was limited to a comparison of the primary care Community Clinical Psychology Service (CCPS) and the five secondary care Assessment and Brief Treatment (ABT) teams which form part of the community mental health teams. According to the NICE stepped care model the CCPS service should be offering treatment to patients who meet the criteria for Steps 2 & 3 of the Anxiety model and Step 3 of the depression model. The ABT teams should be offering treatment to patients who meet the criteria for Step 4 of both the anxiety and depression stepped care models.

Objectives

The main objectives of this project were: 1A) To determine whether evidence based psychological treatments were being offered to patients with depression and anxiety in Southwark. 1B) To examine whether steps 2, 3 & 4 of the stepped care approach to management were being followed. 2A) To investigate possible barriers to the implementation of the NICE Guidelines including knowledge of the Guidelines and clinical practice of GPs and team members. 2B) To explore patient satisfaction with the current services available. 3A) To develop and implement a set of recommendations that would increase compliance with the NICE Guideline recommendations. 3B) To conduct a second audit following implementation of the recommendations from the first to identify whether compliance with the guidelines has increased.

Context

To meet the objectives outlined above a number of studies were undertaken: 1) An audit was conducted to gather information on the types of patient referred to the CCPS and ABT services in Southwark and information was also gathered on the treatments and interventions that were offered to and received by these patients. The results of this audit provided the information needed to fulfil objectives 1A and 1B. 2) To meet objectives 2A and 2B surveys were conducted with staff from the ABT Teams, Southwark GPs and patients whose notes were used for the audit. The surveys with ABT staff and GPs were designed to identify any barriers to implementation of the NICE Guidelines, including knowledge of the guidelines and availability of relevant resources. The patient satisfaction survey results and the results from two focus groups were used to explore patient satisfaction with the services. 3) Objective 3A is currently ongoing (See monitoring and evaluation below for more details) and the second audit (objective 3B) will be conducted from February to August 2009.

Methods

1A) If the NICE recommendations for psychological treatment were fully implemented the majority of patients treated at CCPS and a high number of patients treated at the ABT teams should have been offered CBT. The results showed that 84% of the depressed patients and 93% of the anxious patients treated at CCPS were offered CBT. However at the ABT teams CBT was not routinely offered with only 13% of depressed patients and 23% of anxious patients being offered CBT. At the time of the audit the ABT teams were not fully staffed with psychologists, which may have affected this result. 1B) The NICE Guidelines for Depression and for Anxiety recommend a stepped-care model which outlines the type of patients that should be treated at each Step. The audit results showed that a stepped-care approach was being followed for some, but not all, patients in Southwark. Based on strict adherence to the NICE Guidelines for Depression 70% of patients treated at CCPS and 56% of patients treated at the ABT Teams were appropriate for the service. Similarly for anxiety, strict adherence to the Guidelines meant 81% of patients treated at CCPS and 52% of patients treated at the ABT Teams were appropriate for the service. 2A) The results from the ABT staff survey and GP survey indicated that both groups had a good knowledge of the referral and acceptance criteria for the ABT service. However the results also identified two main barriers to the implementation of the NICE guidelines: a lack of resources to provide recommended treatments and a lack of knowledge about the guidelines. 2B) The patient survey results showed that care pathways had a significant influence on patient satisfaction. Patients who had a direct referral to a service and were kept on for treatment had a significantly higher level of satisfaction than patients who had been assessed at a number of different services and were then assessed at the ABT or CCPS service before being referred on again for treatment.

Results and evaluation

Since the completion of the audit project in April 2008 a number of recommendations have been made and many of these are now in the process of being implemented. 1) Training on the NICE Guidelines for Depression has been provided for ABT Staff Members, Primary Care Mental Health Workers, Primary Care Counsellors and Primary Care Psychologists. Training on the NICE Guidelines for Anxiety has been arranged and will take place during September and October 2008. 2) An assessment manual is being developed with a view to creating a more standardised assessment process across the five ABT teams. 3) A report on the audit has been written and disseminated within the borough, a copy of which is provided in the supporting material. 4) A paper detailing the results from the depression part of the audit has been submitted for publication and a number of other papers are currently being written. 5) We are visiting a number of GP surgeries to present the findings from the audit to them and to give them some further information about the implementation of the NICE Guidelines for Depression and for Anxiety within Southwark. A repeat audit will be conducted in February 2009 when a number of the recommendations have been completed. The aim of this audit will be to identify whether implementation of the guidelines has increased.

Key learning points

What we learned: 1) Conducting the surveys in addition to the audit was very worthwhile as it provided us with information which could be used to understand why the NICE Guidelines were not being fully implemented. 2) We learned that the best method for getting a high rate of survey completions was to set up a meeting with the ABT Teams and GP surgeries and then use the meeting as time for them to complete the survey and return it to us. This method gave us an 86% completion rate on the ABT staff survey. Unfortunately we also learnt that it was difficult to arrange visits to some GP surgeries and so we also sent out an electronic version of the survey to all 274 GPs in Southwark, which received a very low response rate. 3) The data collection for the audit would be quicker and more straightforward if all staff were trained to enter their clinical notes onto the electronic system using a standardised format. 4) There needs to be an implementation period after the initial audit during which time the recommendations can be actioned. Otherwise, staff are less likely to feel supported and encouraged to use the Guidelines. 5) It took time and thought to analyse the results of the patient surveys. 6) Support from general management was very important in helping with the audit and implementation 7) The GP survey was less successful because of the low response rate by post. 8) That patients with depression and anxiety may also have other co-morbid problems such as personality disorder, which may affect treatment decisions.

View the supporting material

Contact Details

Name:Louisa Rhodes
Job Title:Research Worker
Organisation:Institute of Psychiatry, Kings College London
Address:Psychology Department (PO77) De Crespigny Park,
Town:London
County:London
Postcode:SE5 8AF
Phone:0207 848 0255
Email:louisa.rhodes@iop.kcl.ac.uk

 

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This page was last updated: 23 September 2008

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.