Shared learning database

Institute of Psychiatry
Published date:
September 2009

Audit, implementation work and re-audit. How we improved implementation of the NICE Guidelines for Depression and the Anxiety Disorders (GAD, OCD & BDD, PTSD) in the London Borough of Southwark.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The aim of this project was to: a) Monitor how well services in the London Borough of Southwark were implementing the NICE Guidelines for Depression and the different Anxiety Disorders (GAD, OCD & BDD, PTSD). b) Identify the problem areas and gaps in implementation of the Guidelines. c) Improve implementation, particularly the implementation of a stepped-care approach and d) Encourage services to more frequently offer evidence-based treatments, specifically, the provision of psychological therapies. 1a) Increase recording of patient information on the electronic patient note system. 1b) Improve recognition and recording of diagnosis to enable easier implementation of the NICE Guidelines for Depression and the different Anxiety Disorders (GAD, OCD & BDD, PTSD). 2) Improve gate-keeping in Southwark services to increase implementation of a stepped-care approach. 3) Increase the number of patients being offered the appropriate evidence-based treatments (in accordance with the NICE recommendations).

Reasons for implementing your project

An audit conducted from October 2007 to March 2008 showed that the NICE Guidelines for Depression and Anxiety were not being fully implemented within community services in the London Borough of Southwark. The audit included five secondary care Assessment and Brief Treatment (ABT) teams at Step 4 of the NICE Guidelines, and the Primary Care Psychology Service, a small psychology service operating at Step 3 of the NICE Guidelines. The main results from the audit were: a) 33% of patients had no marital status or ethnicity in their notes and 30% had no mention of risk, despite this being a Trust requirement. b) 20% of patients referred to the ABT teams were assessed as inappropriate for secondary care and referred back to their GP for primary care interventions. c) Based on a strict interpretation of the NICE Guidelines, 46% of patients treated at the ABT teams and 25% of patients treated at the psychology service were being treated at an inappropriate service for their needs. Some patients should have been treated lower down the stepped-care model and others should have been stepped-up for treatment in secondary care. d) Only 18% of patients treated by the ABT teams were offered CBT. 91% of patients treated at the psychology service were offered CBT. Investigation of these results indicated that there were a number of reasons for the gaps in implementation of the guidelines, including: 1) Variations in the assessment process across the teams. 2) Lack of knowledge of the NICE Guidelines for Depression and the Anxiety Disorders in both primary (GPs, CCPS staff) and secondary care services (ABT staff). 3) Limited resource availability in primary care, encouraging GPs to refer to secondary care to guarantee treatment. 4) Poor gate-keeping in secondary care. 5) Limited availability of psychological therapies in primary and secondary care, restricting provision of CBT.

How did you implement the project

The results from the original audit identified areas where implementation of the NICE Guidelines could be improved. To address this, three main implementation projects were carried out: a) Dissemination of the findings from the first audit. This took two forms: - writing a report and executive summary for circulation to service leads. - Presenting the results to a wide range of audiences including; GPs, ABT Staff, Psychologists and Counsellors. By raising awareness of the findings, staff were encouraged to start making changes in line with the Guidelines and project objectives. b) Training and Link-working Increasing knowledge of the Guidelines was an important stage of the implementation work and is important to all 3 objectives. ABT Staff, Counsellors, Psychologists and PCMHWs working in the same locality were invited to attend one of five training events on the NICE Guidelines for Depression and for the Anxiety Disorders. This encouraged collaboration between staff working on different steps in the stepped care model. GP surgeries were visited with a representative from the ABT teams and several short training sessions were provided on the NICE Guidelines. c) Assessment Manual A manual was developed for the ABT teams, to encourage staff to collect all the relevant information before making decisions about referrals. The manual covers all aspects of an 'initial' community mental health assessment and was developed through consultation with managers, service users and ABT staff. Following a three month pilot, the manual has now been issued and is in use at all five ABT teams. By encouraging staff to complete a thorough assessment, the manual has helped with all three project objectives.

Key findings

A second audit is underway using the same methodology as the first, but covering a new time period from February to October 2009. This will enable us to compare the findings from before and after the implementation work. Preliminary findings from the second audit show the following improvements in relation to the objectives: 1a) Better recording of information on the electronic patient notes system. There is no missing data for marital status or ethnicity, and risk is entered for 98% of patients compared to only 70% in the first audit. 1b) More diagnoses are being recorded and staff are identifying different severities of depression or different anxiety disorders. Training on the NICE Guidelines is likely to have encouraged staff to be more specific about a patient's difficulties because of the impact this has on the type of treatment they should be offered and the service they should be treated at. 3a) In terms of gate-keeping, only 9% of patients assessed at the ABT teams in the second audit were referred back to the GP for primary care treatment, compared to 20% during the first audit, indicating more suitable GP referrals. Training on the guidelines and the use of the assessment manual are likely to have contributed to this improvement. 3b) Collection of the interventions data is not yet complete but there has been a development in Southwark, which has increased provision of psychological therapies. Southwark received funding from the Department of Health to introduce the Improving Access to Psychological Therapies programme. This has significantly increased the availability of Guided Self-Help, CCBT, CBT therapy and mindfulness groups at steps 2 and 3 of the stepped care model. We expect the final results to show that more patients are receiving the appropriate treatments for their needs and are experiencing better outcomes as a result.

Key learning points

1)The first audit enabled us to identify how well the NICE Guidelines were being implemented in Southwark and helped us to pinpoint the gaps in implementation. This provided a valuable starting point for determining what changes were needed within the services. 2)Using surveys with ABT staff and GPs allowed us to put the results from the first audit into context and to tailor some of the implementation work to the needs of staff. In particular both surveys highlighted a lack of knowledge about the NICE Guidelines and so training sessions were provided. 3)Providing staff with training on the NICE Guidelines not only increased awareness of the recommendations but also provided them with a tool to use when deciding on the appropriateness of referrals to their service. Many of the ABT staff now refer to the NICE Guidelines in their letter back to the GP if they are rejecting a referral because the patient should be receiving treatment in primary care. 4)Dissemination of the findings was a key part of the implementation work because it provided staff with justification for the changes that were being introduced, giving them further incentive to support the developments. This was particularly important when introducing the assessment manual into the ABT teams as it did have the potential to increase their workload. 5)The assessment manual has been an important project for increasing equality of access to services. The manual not only encourages staff to complete a more thorough assessment but it also ensures that staff are using the same framework for the assessment. This will encourage fairer, more informed decisions about the treatments a patient should receive and the service that should be providing them.

Contact details

Louisa Rhodes
Research Worker
Institute of Psychiatry

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