Shared learning database

South West London and St George's Mental Health NHS Trust
Published date:
August 2009

This describes the service and clinical operation of a service for Obsessive Compulsive and Body Dysmorphic Disorders throughout the severity spectrum. The service covers an adult population of approximately 1 million but by using NICE guidance optimises the effectiveness of interventions at all levels. The service has fewer than 5 WTE staff employed to meet these aims.

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 Comprehensive Service for Obsessive-Compulsive Disorder (OCD) and Body Dysmorphic Disorder (BDD) is designed to provide optimal treatment for patients throughout the stepped care levels of severity. This has been achieved by closely adhering to the NICE guidance and by operationalising this to determine the most cost-efficient way of delivering appropriate high quality interventions for all patients. OCD/BDD are common conditions which effect 1-3% of the adult population. Although the vast majority of patients improve with effective treatment, this has often either not been available, not been correctly understood and implemented by health care and mental health care professionals or has not resulted in improvements and has lead to a small but significant group of patients becoming chronically and severely unwell. The social implications of this are costly in terms of quality of life as well as cost to services. For example, in a sample of severely ill patients with OCD treated by our service who had an average age of 38 years, 87% were single and almost 70% were unemployed. In addition these individuals had histories of severe problems for an average of 18 years and had mostly had many years of ineffective treatment and healthcare intervention. Approximately 40% of inpatients are incontinent of urine and or faeces at the time of admission due to severe OCD problems. The Comprehensive Service for OCD/BDD aimed to alter the outlook for OCD/BDD patients in the South West London boroughs of Kingston, Merton, Richmond, Sutton and Wandsworth. The total adult population across these 5 boroughs is approximately 1 million and thus approximately 10,000 individuals would be expected to suffer from OCD/BDD. Resources were limited to 4.5 whole time equivalent therapists and 1 day a week Consultant Psychiatrist and thus the stepped-care model of care proposed by NICE was adhered to with varying intervention from the specialist service at each level of severity. The objectives are to ensure that patients throughout the OCD/BDD symptom severity profile receive optimal evidenced based treatment. The objectives were: o To ensure that patients with the most profound and severe OCD/BDD problems are recognized and treated directly by the Specialist Team o To offer help, support, supervision and joint working to mental health professionals in Community Mental Health Teams and Psychological Therapies in Primary Care Teams to improve treatment for the moderately ill OCD/BDD patients. o To increase awareness of evidenced based treatments for OCD/BDD in general practitioners and to increase public awareness and understanding of OCD/BDD and thus to increase number of patients treated at an early date

Reasons for implementing your project

Differing levels of intervention were introduced dependent of severity of OCD/BDD symptoms. o Level 1/2 Public and GP Awareness. o Production and distribution to GPs/Surgeries and Community groups of information leaflets on OCD/BDD and treatment o Talks at Academic meetings o Talks at local schools o Talks at various local Asian support groups o Development of website giving information for GPs and with downloadable brochures and other material o Production of brochures describing services o Production of leaflet about prescribing o Level 3/4 Psychotherapy in Primary Care and Community Mental Health Teams o Provision of training courses for mental health specialists demonstrating appropriate treatment o Direct clinical supervision groups for mental health care workers in primary care and also supervision groups from members of community mental health Teams o Joint assessment and working with other mental health care workers o Advice re medication and therapy o Level 5 o These patients have already failed to respond to appropriate medication and previous trials of psychological treatment and are treated by our specialists in the OCD/BDD service. The treatment generally takes the form of intensive home-based therapy with prescription of optimal medication. o Level 6 ( this service is offered in our Trust as a National Referral Unit for OCD/BDD funded by the National Commissioning Group) o This unit takes patients from throughout the British Isles and consists of 28 inpatients and 60 Community patients per annum. Strict requirements are necessary to ensure these services are offered equitably across the British Isles o These patients have already failed 3 separate trials of medication and 2 trials of psychological treatment (including home-based therapy) and in addition have profound OCD/BDD as measured by assessment tools.

How did you implement the project

1. To ensure best practice care for all patients with OCD/BDD in the local area. 2. To increase number of patients with OCD/BDD treated by the Service. 3. To demonstrate that these treatments were effective in terms of symptom reduction and quality of life. 4. To ensure that optimal services were available irrespective of ethnic and social origins of patients.

Key findings

This covered 3 main areas: o Monitoring percentage of time spent engaged in each Level of activity o Monitoring patient throughput at different Levels of activity o Recorded clinical outcome in terms of reduction in clinical symptoms Time Audit Since the introduction of the model in April 2006, the aim has been to increase productivity and to work intensively with the more severely ill patients while still offering input and advice as described above for the less severe patients. Full details of this are given in Appendix 1. Overall this shows that in 2007/08 the allocation of total available hours was divided as: o Level 1/2 1.5% of available time o Level 3 2 % o Level 4 4 % o Level 5 25 % o Level 6 50% o Assessment 10% o Travel to Patient's homes; o Training. 7.5% Clinical Throughput o Since April 2006 the number of patients at Level 5 treated every year have increased from 57 to 116 This represents a 203% increase o Since April 2007 (when current arrangements for inpatient unit were established) number of Level 6 patients treated as inpatients has increased from 21 to 32 and the number occupied bed days has increased from 1869 to 2941 This represents a 152% increase in treated patients and a 157% increase in occupied bed days Clinical Outcome Full details of patients' clinical characteristics are given in Appendix2. Level 5 patients improved with an average 32 % reduction in obsessions and compulsions (using the Yale Brown Obsessive-Compulsive scale which is an observer rated measure of incapacity caused by OCD/BDD. Level 6 patients improved with an average 31-45 % reduction in obsessions and compulsions (measured by observer rated and self-report measures) after an average 20 weeks in hospital Ethic origins of patients demonstrated that the number of referrals per Borough were at least as high as would be expected if there was equal access for all cultural groups.

Key learning points

Despite OCD/BDD being a very common condition, appropriate treatment is not always forthcoming o By targeting interventions for OCD/BDD based on the NICE stepped care model, many more patients can be treated appropriately o Minimal resource can still effectively interact to improve treatment at all Levels of the symptom-severity spectrum o Even the most severely ill patients can still make dramatic improvements with appropriate specialist treatment o Such targeted interventions using a stepped-care approach and minimal specialist resource may also be a useful model for other conditions in the areas of both mental and physical health

Contact details

Lynne M Drummond
Consultant Psychiatrist and Senior Lecturer
South West London and St George's Mental Health NHS Trust

Tertiary care
Is the example industry-sponsored in any way?