Peter Fonagy CYP IAPT Programme

Children)and)Young)People�s)Programme)

Professor)Peter)Fonagy)

Na8onal)Clinical)Lead,)CYP)IAPT)

Kathryn)Pugh)

Programme)Lead,)CYP)IAPT)

The)context)of)CYP)IAPT:)Costs)Mental illness during childhood and adolescence in the UK:

£11,030 to £59,130 annually per child

Lifetime cost of a 1-year cohort of children with Conduct Disorder: £5.2 billion

Including costs of various agencies

•  Health •  Social services •  Education •  Justice

Costs of adult crime with history of CD

• £60 billion in England and Wales

• £22.5billion attributable to CD

• £37.5 billion to subthreshold CD

Evidence-based practice has substantial clinical & cost benefits Little & Edovald, 2012; Suhrcke, Puillas & Selai, 2008

Only 6% of current spending on mental health goes to services aimed at children and young people Kennedy, 2010

How are we perceived?

VIDEO (YouTube link)

Reports)on)CAMHS!

“children)and)young)people)are)s8ll)oIen)receiving)

fragmented!and!inconsistent!support!…)support)is)s8ll)

some8mes)provided)too!late!in)a)crisis,)and)

informa2on)is)not!easy!to)come)by”))(2008)))

Reports)on)CAMHS!

“Urgent!ac2on!is)called)for)to)respond)to)the)mental)

health)needs)of)children)and)young)people.)Mental)

health)services)must!be!available!and!accessible,)

including)through)self7referral,)and)be)integrated)

with)other)services,)par8cularly)through)schools”)

Summary)of)the)issues)facing)CAMHS)

•  Significant)shortages!of!trained!professionals!!•  Current)level!of!CAMHS!staff!training!is!‘poor!and)

geUng)worse’)

•  Difficul2es!with!access!(very)few)services)offer)a)selfX

referral)route))

•  Poor!handling!of!transi2on!between)child)and)adult)services)

•  Inappropriate!provision!of!adult!services!to)young)people)

•  Data)that)could)and)should)be)used)for)performance)

management,)selfXcri8cal)professional)prac8ce)and)

commissioning)is)rarely!collected!

A!Step!Change—A!Transforma2on!

CAMHS

CYP - IAPT

The)CYP)IAPT)Programme)•  Using)rou2ne!outcomes!monitoring))

•  To)guide)therapist)and)supervisor)•  To)help!client!monitor!and)understand)how)

treatment)is)progressing)

•  Across)ALL!professions!•  Empowering)YP)to)take)control)of)their)care,)

establish)treatment)goals,)choose)treatment)

approaches)and)take)opportuni2es)to)improve)

their)own)health)

•  Improving)access)to!evidence7based!therapies!

•  Introducing)evidence7based!organiza2on!of)care)

What)Is)CYPXIAPT?))A)simple)evidence)based)implementa8on)of)EBP)

•  CYP)IAPT)was)conceived)as)a)centrally!ini2ated!modifica8on)of)CAMHS)in)the)direc2on!of!EBP!

•  It)is)achieving)remarkable)degree)of)cultural!change!in)

terms)of)the)acceptability)of)principles!of!EBP!

interpreted!broadly)through)a)modest)investment)in:)

•  service!change)•  training)service)leads!•  supervisors)and)therapists!

•  Learning!collabora2ves!made)up)of)universi2es)and)

local!area!partnerships!offer)mutual)support,)problemX

solving)and)learning)networks.))

Milestones

Three%task%groups%begin%work%(Educa6on%and%Curriculum,%Outcomes%and%

Evalua6on,%Service%Development)%

CYP%consulta6on%via%YoungMinds%

Milestones

C%Paul%Burstow,%Ministerfor%Care%Services%launches%first%year%

collabora6ves%C%First%draI%IAPT%Dataset%and%Rou6ne%Outcomes%Monitoring%

Measures%Launched%

Milestones

C%Applica6on%process%for%2012C2013%announced%

C%Accredita6on%steering%group%convened%

C%New%£%resources%announced%

Milestones

C%Key%Performance%Indicators%agreed%by%ERG%C%Process%to%develop%accredita6on%of%courses%and%individuals%for%CYP%IAPT%agreed%C%Former%Minister%for%Care%Services%announces%new%sites%C%34%%of%England%now%covered%C%YouTube%channel%launched%

Milestones

C%%25%new%CAMHS%partnerships%joined%the%programme%in%year%3%

covering%54%%of%the%0C19%%popula6on

Milestones

2,662%CAMHS%clinicians%will%be%using%outcome%monitoring%

across%42%sites%rising%to%3,950%in%a%further%12%months%

Milestones

Planned'recruitment'of'new'CAMHS'to'join'for'year'4'

CAMHS&partnerships&will&cover&60%&of&popula:on&0;19''

What)has)CYPXIAPT)delivered?)

•  A)na8onal)curriculum)for)four)therapies))

•  cogni2ve!behavioural!therapy!for)anxiety)and)depression)

•  parent!training!for)conduct)problems)

•  systemic!family!prac2ce!for)depression,)ea8ng)

disorder)and)conduct)problems)

•  interpersonal!psychotherapy!for)adolescent)depression)

!

The)effec8veness)of)Interpersonal)Therapy)(IPT))for)depression)

Rossello)&)Bernal,)1999)

n=71)

56%)

48%)

61%)

11%)

24%)

34%)

17%) 18%)

IPT) CBT) Wai8ng)List)

Adolescents!with!MDD!

Pre) Post) 3Xmonth)FXU)

0)

5)

10)

15)

20)

25)

Pre) Post) FollowXup)

Childhood!Depression!Inventory!

IPT) CBT) WL)

IPT NNT: 4 CBT NNT: 8

The)effec8veness)of)Family)Therapy)for)conduct)disorders)

Cur8s,)et)al)2009)

NICE Guidelines in 2009 and 2013 have identified Family Based Treatments as the most promising intervention for reducing adolescent antisocial and offending behaviour

0)

10)

20)

30)

40)

50)

60)

70)

80)

Pretreatment) Poshreatment)

0)

0.5)

1)

1.5)

2)

2.5)

3)

3.5)

Pretreatment)Poshreatment)

What)has)CYPXIAPT)delivered?)

•  A)na8onal)curriculum)for)four)therapies))

•  cogni2ve!behavioural!therapy!for)anxiety)and)depression)

•  parent!training!for)conduct)problems)

•  systemic!family!therapy!for)depression,)ea8ng)

disorder)and)conduct)problems)

•  interpersonal!psychotherapy!for)adolescent)depression)

•  A)curriculum)for)supervisors!!

•  A)curriculum)for)managers)undertaking)service)

development)and)transforma8on)

•  Supported)the)development)of)a)CYP)MH)e7pladorm.!

What is evidence-based practice in child mental health?

EBP$ Researcher$

Clinician$

Client$

Not$$‘delivered$unto’$clients$

via$field$workers$$from$researchers$$

on$high$

What)is)evidenceXbased)prac8ce)in)child)mental)health?))

EBP)

Researcher)Clinician)

Client)

A)fundamentally)par8cipatory)and)coXproduced)(coXconstructed))

enterprise)in)which)client,)researcher)and)clinician)are)all)fully)engaged)

EvidenceXBased)Prac8ce)

Fonagy)&)colls.)(in)press))What%works%for%whom?%A%cri1cal%review%of%treatment%for%children%and%adolescents.%Second)Edi8on.))

EBP)ScienceXinformed)

Organised)around)client)inten8ons)

Culturally)sensi8ve)

Con8nual)measurement)

of)effec8veness)

Acknowledges)impact)in)

children)and)families)

Takes)into)account)the)larger)social)context)

Enhancing)the)skills)of)

prac88oners,)

supervisors)&)service)

managers)in)EBP)

Three)major)components)of)the)CYP)IAPT)transforma8on)

Appropriately)

skilled))

CAMHS)

workforce))

1.)Closing)the)skills)gap)in)CAMHS)

Performance)Evalua8on)!  Assessment)of)video)recorded)therapy)

sessions)

!  Reports)of)individual)treatments)showing)

capacity)to)make)theory7prac2ce!links)and)

integrate!outcomes!informa2on)into)prac8ce)

!  Reports)on)feedback)from)supervisors,)young)

people)and/or)parents))

!  Summary)report)of)therapist�s!clinical!outcomes)over)the)training)period)

Three%major%components%of%the%CYP%IAPT%transforma6on%

2. Shift to collaborative practice

Client

Patient-reported outcomes

Clinical decision- making

Practitioner

Redressing!the!balance!of!exper2se!

Empowering)young)people)

Par8cipate))

in)service)design)

Par8cipate)in)training)of))

prac88oners)&)managers)

Understand)and)

modify)treatment)

progress)via)PROMs)

Empowering)young)people)enables)them)to….)

1.)Take)control)of)

their)care)

2.)Establish)

treatment)goals)

3.)Choose)the)treatment)

that’s)best)for)them)

Empowering)young)people)enables)them)to….)

4.)Improve)their))

own)health)

Three)major)components)of)the)CYP)IAPT)transforma8on)

3.)Transforma8on)of)par8cipa8ng)CAMHS)services)

Research)

evidence)

Pa8ent)

preferences))

&)values)

Clinician)

observa8ons)

BETTER)

CARE)

Adop8on)and)implementa8on)of)new)treatments)

Aarons,)Glisson,)Green,)et)al.,)2012)

More)than)a)technical)process,)a)social)process)

EBP)Organiza8onal)Social)Context)

Prac88oner)AUtudes)&)Behaviour)

To obtain the desired outcomes, many things must be in place

MetaXanalysis)of)EBP)vs.)Usual)Care))

0)

0.05)

0.1)

0.15)

0.2)

0.25)

0.3)

0.35)

0.4)

0.45)

Youth) Parent) Other)

Effect Size

F(3,228)=4.18, p<0.007)

Weisz et al., (2013) Do Evidence-Based Youth Psychotherapies Outperform Usual Clinical Care? A Multilevel Meta-Analysis. Archives of General Psychiatry

Measurement!for!a!purpose:!

Guiding!treatment!to!beher!outcomes!

Weisz)et)al.)(2012).)Tes8ng)standard)and)modular)designs)for)psychotherapy)trea8ng)depression,)anxiety,)and)conduct)problems)in)

youth:)a)randomized)effec8veness)trial.)Archives%of%General%Psychiatry,%69(3),)274X282.)

0)

0.5)

1)

1.5)

2)

2.5)

3)

Usual)Care) Standard)Condi8on) Modular)

Number)of)diagnoses)Pre))

Number)of)diagnoses)Post))

Manualized therapy without Match

Usual care Therapy delivered on basis of Match

15% 33%

TAU EBP EBP+Outcomes Monitoring

Service)improvements)linked)to)EBP)

•  Reducing!varia2on!in!referral!rates!through)

•  Improved)triage)and)

treatment)alloca8on)

•  Improved)reahendance)

rates)

•  Reduced)length)of)unnecessary)treatment)

•  Reduced)inpa8ent)care)

Service)improvements)linked)to)EBP)

•  Reducing!varia2on!in!referral!rates!

•  Adop2ng!best!prac2ce!•  Pathway)management)

• Opera8onal)management)

•  Improved)pa8ent)flow)

through)the)system)

Service)improvements)linked)to)EBP)

•  Reducing!varia2on!in!referral!rates!

•  Adop2ng!best!prac2ce!•  Increase!staff!produc2ve!2me!

through)rigorous)redesign)of)

methods)and)skill)mix)

Service)improvements)linked)to)EBP)

•  Reducing!varia2on!in!referral!rates!

•  Adop2ng!best!prac2ce!•  Increase!staff!produc2ve!2me!!

•  Create!flow!and!eliminate!

waste!from)poorly)designed)

systems)and)the)consequences)

of)demand)generated)by)

failures)and)errors)

Service)improvements)linked)to)EBP)

•  Reducing!varia2on!in!referral!rates!

•  Adop2ng!best!prac2ce!•  Increase!staff!produc2ve!2me!!

•  Create!flow!and!eliminate!

waste!!

•  Reduce!complexity!X)a)

significant)driver)of)costs)&)

errors)based)on)inefficient)

clientXtoXclinician)feedback)

Annual)es8mated)savings)associated)with)service)transforma8on)and)EBP)

Am

ount

pot

entia

lly s

aved!

2011-12!0 2012-13!

10

20

30

40 £34,085

Based on assumption of £3,000 as the average cost of a CAMHS case 80% of cases seen fall into the category where benefits from outcomes monitoring and 63% where improvement associated with NICE prescribed treatment is relevant

£27,000

£12,875

2013-14! 2014-15!

£3,430

•  Participation embedded in the service and organisation

•  Involving commissioners

"  Embedding outcomes monitoring in the teams

"  CYP IAPT principles embedded in the overall strategic model for CAMHS service delivery with partner agencies

"  Self referral growing in year 1 and 2 sites

"  Improving supervision structures within teams

Strategies)for)sustaining)change))

Sustainability of CYP-IAPT: Today Governance Structure: feedback and learning

Quarterly report

Sites%

Collabora6ves%

FEEDBACK%

Sustainability of CYP-IAPT: Today Governance Structure: feedback and learning

Quarterly report

Data analysis by CAMHS Outcome Research Collaborative and Nexus

Lessons learned will be placed on the web

Monthly%Reports%

NHS IQ Cabinet Office

NHS England

Mechanism!to!facilitate!knowledge!transfer!!HEIs)to)

partnerships)to)commissioners)across)NHS)

Network!to!support!those!in!leadership!posi2ons)

Curricula!!&!case!

management!approaches!for)par8cular)disorders)

“Best!value!system!

templates”)–)shared)with)all)consor8a)as)a)model)of)

improvement)

Knowledge)Management)to)Ensure)Sustainability))

Sustainability)of)CYPXIAPT:)The)Future)

When)the)central)team)is)no)longer)present…)

Staff)turnover) Modifica8on)

of)programme)

requirements)

Changes)in)

funding)streams)

Development)of)a)na8onal)system)of)quality)assurance)

•  Training)

•  Performance)

•  Service)characteris8cs)

Management)Training)

•  Organisa8onal)culture)

•  Climate)

Sustainability+of+CYP1IAPT:+The+Future+

Development+of+a+Na?onal+System+of+Accredita)on,

CYP)IAPT)X)The)Future)

•  Programme)needs)to)demonstrate)effec2veness)and)Key)Performance)Indicators)))

•  MindEd!eXportal)allows)CYP)IAPT)curricula)to)be)placed)on)web,)available)to)all)prac88oners)

•  Outcome!monitoring!needs)to)be)built)into)all)clinical)curricula!!

•  Developing)a)workstream)to)support!commissioners!!

•  Accredita2on)will)support)long)term)embedding)of)CYP)IAPT)ideals)))

How are we perceived?

VIDEO (YouTube link)

THANK&YOU&

&Thanks&to&everyone&

&THIS&HAS&BEEN&A&TRULY&COLLABORATIVE&

EXPERIENCE&