Shared learning database

Leeds and York Partnership NHS Foundation Trust
Published date:
January 2013

Leeds and York Partnership NHS Foundation Trust (LYPFT) has developed a number of Integrated Care Pathways (ICPs) based on NICE and other clinical guidelines, existing procedures, protocols and pathways and local good practice. LYPFT agreed the ICP actions should be incorporated into the existing CPA care plan so that recommended actions can be linked directly with the service user's goals and translated into a personalised plan for their care. In addition to being offered core interventions tailored to their needs, service users will be offered interventions recommended for their specific mental health symptoms or diagnosis based on the Mental Health Clusters (the Psychosis Clusters in this example).

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 CG82 has now been replaced by CG178.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.

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

To develop an evidence-based Psychosis pathway which will:
- Provide good, evidence-based quality care to service users
- Reduce inconsistencies in practice
- Promote recovery and achieve better outcomes for service users
- Provide a means of tracking variance i.e. comparing planned interventions with what was actually delivered, and the reasons for variation.

Reasons for implementing your project

LYPFT implemented a Trustwide audit in 2010 which measured current practice against the key priorities outlined in NICE CG82 Schizophrenia. Low adherence figures for some of the key priorities meant LYPFT had to change its previous compliance declaration to 'working towards compliance'. The key priorities concerned were:
- Offer CBT to all people with schizophrenia (22%)
- Offer Family Interventions to all families of people with schizophrenia who live with or are in close contact with the service user (19%)

Reasons cited for the low adherence included data quality issues, confusion between 'offered' and 'received', and lack of awareness of NICE CG82 (Schizophrenia) and availability of resources to provide these interventions.

Action plans were implemented to address these areas of low adherence. LYPFT is undertaking a Transformation Programme to provide better, simpler and more efficient services. The development of ICPs is a key element of this programme.

How did you implement the project

A Psychosis Authoring Group was set up to develop the first draft of an evidence-based Psychosis ICP. The composition of the group included Consultant Psychiatrists, Nurses, Occupational Therapists, Social Workers and Pharmacists from Community, Assertive Outreach and Early Intervention Services. The main task of the group was to build a psychosis pathway which was relevant across all services, which built on the core pathway elements (interventions for all service users) and described interventions for service users in Clusters 11 - 17.

Members were allocated tasks and actions in accordance to their role and membership of the group to enable them to contribute their specific expertise in developing the Psychosis Pathway.

NICE guidance, literature search findings and service user engagement events informed content. Barriers to the development of the pathway included:
- NICE provide recommendations and guidance, not hard and fast rules
- Maintenance of clinical credibility and autonomy
- Potential to prevent provision of individualised care to address service user need
- Service and workforce reconfiguration prior to completion of the ICPs
- Practicalities of wider consultation
Methods to overcome these barriers included:
- Reiteration of how LYPFT implement NICE guidance in agreement with commissioners. Use of variance tracking to identify interventions which will be analysed with service user outcomes to monitor effectiveness of recommended interventions
- Identification of 'skills required' rather than 'roles', and ensuring a mix of roles in each small task group
- Incorporating the ICP actions in the CPA care plan (service user identified goals) and including service user views/wishes in the variance tracking
- Acknowledgement of the unintended consequences of the implementation of the Transformation Programme and consideration of engagement with this element of the Transformation Programme
- Development and agreement of Terms of Reference for the authoring team (including roles and responsibilities in relation to wider consultation)

Key findings

A re-audit of the recommendations of NICE CG82 Schizophrenia is currently in progress to assess the effectiveness of the 2010 audit action plans and whether performance has improved. (Initial data analysis indicates a 20% increase in adherence with the key priorities identified).

As the Psychosis ICP is currently in draft and being circulated for consultation, there are perceived benefits as well as actual benefits at this stage:
- educational aspect. Has raised awareness of NICE CG82
- consultation and development. Knowledge sharing, ownership, engagement and support.
- identifying resource required to deliver recommended interventions.
Future benefits:
- workforce planning. Having the right people in the right place, delivering the right interventions at the right time.
- variance tracking.
- outcome measures. CLOMs, PROMs and PREMs

Key learning points

Key areas and issues to consider:
- Timescales - matching the organisational timescales against effective development and implementation. Keeping a close eye on timescales and providing a good rationale and alternative action plan when these slip.
- Engagement of wide variety of stakeholders. Creative use of consultation and engagement eg individual, group, staffnet, feedback mechanisms. Promote 'done with' rather than 'done to'.
- Change management. LYPFT had two major Trustwide changes happening at the same time with the emerging properties of increasing strain on staff leading to the unintended consequences of higher rates of sickness.
- Implementation. The initial phase of the Transformation Programme had a 'go live' date when all staff were expected to use the new holistic assessment without sufficient consultation and testing. This next phase is an 'Implementation phase' to allow for further consultation, testing on live service users, useability within the electronic system and effectiveness (are outcomes achieved).
- Future monitoring and reviewing. Consideration of resource required, how to embed new or updated guidance, and consideration of who is responsible for monitoring, reviewing and updating.

Contact details

Cheryl Armstrong
Care Pathways & Clinical Guidelines Lead
Leeds and York Partnership NHS Foundation Trust

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