Shared learning database
Type and Title of Submission
The Implementation of NICE Guidelines Relating to Psychological Interventions for People with SchizophreniaDescription:
As part of the development of a comprehensive Early Intervention Service, to increase access to evidence-based psychological therapy for people with psychosis and thereby improve outcomes.
Please note that this example was originally submitted to demonstrate implementation of CG82 Schizophrenia (update). CG82 has now been replaced by CG178. The example has been reviewed and continues to align with the new guidance.
ClinicalDoes the submission relate to the general implementation of all NICE guidance?
NoDoes the submission relate to the implementation of a specific piece of NICE guidance?
YesFull title of NICE guidance:
CG178 - Psychosis and Schizophrenia in adultsCategory(s) that most closely reflects the nature of the submission:
Is the submission industry-sponsored in any way?
Description of submission
As part of the development of a comprehensive Early Intervention Service, to increase access to evidence-based psychological therapy for people with psychosis and thereby improve outcomes.Objectives
1) Cognitive behavioural therapy is available as a treatment option to all clients. 2) Family Interventions are available to all families who are in close contact with the client. 3) Reduce levels of depression and positive psychotic symptoms. The Service was set up in relation to national guidance through the NHS plan and subsequently the Mental health Policy Implementation Guidance. These documents indicated the level of service provision required for Early Intervention services. The services within this plan were based on a specific population so we utilised their figures and calculated the number of staff required based on local numbers. Then through the audit we identified the current level of input and the sought extra funding for the shortfall from the PCTs. At the time, Early Intervention was the number one mental health priority for Dh and therefore PCTs and mental health trusts. EI still remains in the operating framework for the NHS, further emphasising its importance. We already had a significant level of expertise in this area so no further training was required but we do commit to a regular ongoing training program.Context
Prior to the set up of the Early Intervention Service, a more traditional psychiatric service was in place with psychological interventions sparse and periferal. A Healthcare Comission audit relating to NICE guidelines for schizophrenia was carried out in June 2008. The audit was carried out with a random sample of 100 service users from Bolton, Salford and Trafford Directorates who were under the care of Community Mental Health Teams, Assertive Outreach, Community Rehab and Early Intervention. The audit found that Family Interventions were appropriate for 57% of service users (service user lives with or is in close contact with a family member). However, Ø 4% of service users had been offered and undertaken at least one session of FI in the last 12 months. Ø 2% were offered FI but it was not undertaken Ø FI was not applicable for 6% of service users* Ø 45% of service users were not offered FI. *FI was not applicable if the individual was not able to to participate in an informed discussion, their carer/advocate was unavailable or if they refused to participate or allow discussion on family interventions with their family. The audit results for CBT are as follows: Ø 5% of service users were offered and had undertaken at least one session of CBT Ø 9% of service users were offered CBT but it had not been undertaken Ø CBT was not applicable for 7% of service users* Ø 79% of service users were not offered CBT *CBT was not applicable if the individual with schizophrenia is not able to participate in an informed discussion with the clinician responsible for treatment at the time and an advocate or carer is not available. This audit highlights the lack of structured psychological interventions that were taking place within certain services. One of the key aims of the Early Intervention Service was to develop meaningful engagement and provide evidence-based interventions during the early phase of illness.Methods
1. Cognitive behavioural therapy is available as a treatment option to all clients. The 2007/2008 Early Intervention Service Evaluation found that 68% of clients were offered CBT; 43% of clients had undertaken at least one session, 24% of clients had been offered CBT but had not yet undertaken a session. 98% of clients who accepted CBT had their first session within 3 months of referral. 2. Family Interventions are available to all families who are in close contact with the client. The 2007/2008 Early Intervention Service Evaluation found that 88% of clients had the presence or absence of a significant other (family member or partner) identified. Contact was made with 67% of families who were identified as being in close contact with the client within 4 weeks. 74% of families who were identified as being in close contact with a service user were offered a carer?s assessment. 73% of families who were identified as being in close contact with a service user were offered family intervention. 3. Reduce levels of depression and positive psychotic symptoms Data from the three teams were combined in order for a statistical analysis could be run for the Early Intervention Service as a whole. Baseline total BDI scores were compared with 6-month scores using a paired sample t-test. The t-test shows a significant difference between baseline and 6 month total BDI scores (p = .000) indicating a significant reduction in levels of depression across the three teams within 6 months of accessing the service. Baseline PANSS positive total scores were compared with 6 months scores using a paired sample t-test. The t-test shows a significant difference between baseline and 6 month PANSS positive total scores (p = .009) indicating a significant reduction in levels of positive psychotic symptoms across the three teams within 6 months of accessing the service.Results and evaluation
Data about psychological interventions was obtained from the Early Intervention Service Evaluation work reported in April 2007 and April 2008. Data was collected by dedicated Assistant Psychologists by looking at clients' electronic and written records and meeting with team leaders, care coordinators and psychologists working across Bolton, Salford and Trafford Early Intervention Teams. The results show that clients receiving a service from an Early Intervention Team are far more likely to receive psychological therapy than clients receiving a service from more traditional psychiatric services. Results also show that within users of Early Intervention Services, there was a significant reduction in levels of depression and positive psychotic symptoms within 6 months of accessing the service.Key learning points
It is important to differentiate which psychological interventions are being offered. There is a difference between offering structured one to one therapy and psychologically informed care coordination. Failure to adequately define what is being measured and reported may lead to inconsistent results from audit and service evaluation work. It is important to train all staff in the values of Early Intervention and incorporate these values into person specification when recruiting. Engagement is a major barrier in delivering psychological interventions to some clients. Strategies for engagement, reducing fear and stigma associated with mental health services and normalisation contribute to a greater proportion of clients being able to access psychological interventions. A clear supervision structure is necessary to ensure that psychologists and psychological therapists can work with other team members to enable them to deliver psychologically-informed interventions to clients. In the early stages of establishing an innovative service, it may be beneficial to have an Early Intervention-specific management structure. When Early Intervention Services in Bolton, Salford and Trafford were set up a Hub and Spoke model of service delivery was implemented. The Hub acted as an agent to bring together strands of service delivery, development, audit, training, clinical leadership and supervision across the three teams to ensure consistency with best practice guidelines, with the associate directors being responsible for the development and management of the service. A degree of management independence allows an innovative service to develop without becoming diluted by pressure from generic services. It is hoped that in the future innovative elements of Early Intervention Teams will become core to other services.
View the supporting material
|Job Title:||Assistant Clinical Psychologist|
|Organisation:||Greater Manchester West Mental Health NHS Foundation Trust|
|Address:||Prestwich Site, Bury New Road|
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This page was last updated: 27 March 2009