Appendix 5(a)
“Making Psychological Care Everybody’s Business”
Proposals for the Development of Effective Approaches to Providing Psychological Care and Psychological Therapies across the Adult Network
Contents
- Introduction
- Background
- The Stepped Care Approach
- Proposal for the Provision of Psychological Therapies – “NICE Guidance Plus”
- Organisational and Management Arrangements
- Specialist Psychotherapies Service
- Eating Disorders Service
- Workforce Implications
- Next Steps
Appendices
- Types of Psychological Treatments as an Integral Component of Mental Health Care
- Proposed Range of Psychological Therapies/Treatments to be Provided
- Sample Job Descriptions
- Key Consideration Questions
- Introduction
1.1.This paper puts forward ambitious proposals for significant improvements in the
ways in which psychological care and psychological therapies are managed and provided across the Adult Network. A number of proposals are put forward for consideration and we welcome your views and responses.
1.2.In 2001 the formal consultation document for the establishment of a new Mental
Health Trust in Lancashire suggested that the proposed Care Trust would be a new type of mental health organisation, which would
“ Create a culture in which social, psychological and medical models of mental health and illness are equally valued”. (p 14)
1.3.The proposals have important implications for all staff, all services and all teams
and for the ways in which specialist staff in psychological services are organised, managed and professionally supported.
1.4.Overall, the aim is to meet the needs and aspirations of our service users to have
access, in a timely way, to a level of psychological care or psychological therapy, which meets their needs. The implementation of changes as a result of this consultation plus the effective outcome of active negotiation with commissioners will result in improvements for all service users.
1.5.Achieving this aim has important implications for the following:
- The development of psychological skills and competence across the whole workforce
- The need for staff (from any professional background) with psychological skills to have the opportunity to use and develop these competencies with appropriate supervision
- The responsibilities of Community Mental Health Teams, other services and their managers for the provision of effective psychological care and for waiting time and waiting list management
- The development of effective clinical and operational governance arrangements for the provision of psychological therapies within teams, localities and across the Network.
In the following sections, a number of key issues are highlighted and proposals are put forward for the way in which these challenges and opportunities can be addressed.
1.6.Broadly, the proposals in this consultation are organised into four major themes:
- Proposals regarding the model of service delivery for psychological care and psychological therapies
- Proposals about ensuring the range of therapies provided are evidence based and NICE compliant
- Proposals regarding the organisational and management arrangements to support the delivery of these agreed services
- Proposals regarding the workforce implications of the above.
2. Background
2.1.As part of professional training, all staff working within specialist mental health care should develop knowledge and skills in relation to psychological care and psychological treatment.
2.2.Broadly speaking it may be helpful to consider three types of activity in this area:
i) Type A: - Psychological treatment as an integral component of mental health care
ii) Type B: - Eclectic psychological therapy and counselling
iii) Type C: - Formal psychotherapies
(NHS psychotherapy services in England – a review of strategic planning – September 1996)
Appendix A provides more information about the above three types of activity.
2.3.Building on the above review the DoH document “Organising and Developing Psychological Therapies” (July 2004) indicated that “psychological therapies are part of essential health care…(but that)…in many mental health services psychological therapy provision is patchy, uncoordinated, idiosyncratic, potentially unsafe and not fully integrated into management systems” (p1). This report concluded that “psychological therapies have an important place amongst the range of treatments available as part of comprehensive, user centred mental health services. As the evidence base for the effectiveness of psychological therapies have grown, so has their popularity; they should no longer be regarded as optional components of mental health care” (p39)
2.4. In a recent review of waiting times and waiting lists for specialist psychological
therapies (April 07) across the Network three key issues were highlighted:
2.4.1.There are clear differences in the priority given by commissioners to the
development of specialist psychological services across Lancashire. This is both an historical legacy and a feature of more recent service developments. Across the Trust there are examples of new ‘policy guidance compliant’ services being developed with funding for medical and nursing staff, but not the required funding for specialist therapy provision.
2.4.2.Psychological services have also differed in the ways in which their staff have been deployed to provide services. In some areas staff are embedded as members of multi-disciplinary teams, in others, staff are likely to be based in a department of psychological services.
2.4.3.There are also clear differences in the extent to which providing psychological
care and psychological therapy are seen as either the business of the whole team or the work of a specific group of staff. Generally speaking, waiting times and waiting lists are shorter where providing psychological interventions are seen as central to the work of the whole team and are provided as part of a tiered approach.
2.5.Nationally, mental health has become one of the three clinical priorities for the
NHS (along with cancer and heart disease). National policies have emerged over the past decade, notably the 1998 White Paper ‘Modernising Mental Health Services’ and the National Service Framework for Mental Health (NSF) (DoH 1999).
2.6.The underlying ethos of the National Service Framework (NSF) for newly
developing services is to maximise service user choice and involvement. Providers must strive to ensure that the services they deliver are:
- User centred, meeting individual needs
- Recovery focused
- Socially inclusive, assisting with problems such as accommodation, finance etc.
2.7.At a local level the Lancashire Mental Health and Social Care Partnership
Board produced ‘A Comprehensive Mental Health and Social Care Strategy for Adults of Working and Older Age residing in Lancashire’ (2004) and a subsequent consultation document ‘Working Together to Improve Mental Health” (2006). These documents set out a comprehensive mental health delivery programme for the whole of Lancashire.
2.8.A new, integrated LCT and LCC (Lancashire County Council) adult mental
health management structure has now been completed and a number of professional lead posts were identified as part of the Network leadership team.
2.9.In relation to primary care mental health services there are different
commissioning arrangements and service delivery models in place across the Trust, and this is likely to remain true in the near future. LCT’s involvement in this area is likely to be determined by the commissioning intentions of PCTs. However we intend to compete to develop primary care mental health services:
a)In collaboration with commissioners
b) By competing for tendered services
c)Through working closely with other agencies and partners to secure LCT involvement in the provision of PCMH services.
2.10.With the development of the Improving Access to Psychological Therapies
(IAPT) programme the place of psychological therapies becomes central to the provision of high quality primary care focused mental health delivery. Such services should be ageless, and link with a range of social care components aimed at providing holistic approaches to people’s mental distress. The component psychological therapy skills will need to focus on the delivery and evaluation of high volume, low intensity interventions including brief CBT, and solution focused therapy as well as larger scale psychoeducational groups. There will also be a foreseeable need for high quality supervision of practice from skilled psychological practitioners, whether as a direct part of the PCMHT, or co-opted in via SLAs.
2.11.CMHTs have been a core element of mental health services in Lancashire for
over fifteen years. However each team has developed different ways of delivering a service to their local population. It is proposed that through the Service Transformation Programme the functions of CMHTs are systematically reviewed and that new operational models are explored. The following ideas are under consideration:
1.Separate Primary Care resources from the CMHT and create separate PCMHTs
2.Develop New Ways of Working within PCMHTS and CMHTs
3.Clarify the responsibilities of the CMHT to manage Psychological Therapy referrals and interventions as a core element of the team
4.Create core functions within the CMHT (see figure one below). For example:
- Develop an assessment and treatment team made up of all members of the current multi-disciplinary CMHT. This team would include skilled Psychological Therapists.
- Develop a complex treatments team made up of multi-disciplinary workers with advanced skills who would treat service users with highly complex and variable mental health problems.
- Develop a long-term conditions team - a group of multi-disciplinary workers who would treat, care for and support service users with severe mental health issues. This team would also treat and support carers. The team’s emphasis would be on treatment, recovery and social inclusion. It is likely that this team would be made up of Psychiatrists, Social Workers, CMHNs and Support, Time and Recovery Workers.
5. Describe and create capacity models in PCMHTs and CMHTs based on treatment modes (NICE Guidance) and diagnosis (e.g. the number of service users with depression requiring an agreed number of therapy sessions; the number of service users with family / relationship issues requiring family group therapy).
Figure 1 provides a diagrammatic illustration of how a CMHT could function.
FIGURE 1
Locality CMHT Model
2.12.Service users would be able to access assessment and treatment by means of
agreed care pathways focusing on achieving and meeting NICE guidance. For example, a service user with a psychosis (in the long term conditions team) would be able to access CBT for depression treatment and management from the complex treatment team. Staff would also be able to work into the three teams to provide sessional time for specific therapies and interventions, for example when supervision was required by a CMHN or SW who was delivering family therapy for a service user with Bi-Polar Disorder symptoms.
2.13.The crossover of skills and capacity would be limited to delivering treatment as
part of an assessed package of care. Mostly staff would remain dedicated to focusing on providing treatment within their own intra-CMH team.
2.14.This model would allow the CMHT to focus its resources more efficiently on
delivering effective, evidence based treatment and care. It would help the team to organise its work more efficiently and be able to describe service and resource shortfalls.
2.15.In terms of workforce development, greater clarity would emerge about the level
and type of training which the Trust would support, in regards specific agreed psychological therapies which would be required to meet demands, and identified.
2.16.In relation to inpatient services, a number of recent publications, including the
MH “NSF–5 years on” have indicated the need to improve access to psychological therapies as part of the care package provided to service users receiving in-patient care. There are a number of appropriate models available, although currently there is a dearth of provision across LCT (with some exceptions). The two current models are; provision of assessment and therapy from a Clinical Psychologist who provides sessional input or, via Nurse Practice Development staff who are ward based and aim to provide direct assessment/therapy, as well as upskilling all ward staff members in a range of skills to enable a more psychologically informed regime of care to be developed.
2.17.Views are therefore sought on how to improve the provision of
psychological therapies within inpatient settings.
2.18.Within LCT it is recognised that change is an ongoing part of service
development and this can result in services being restructured. Changes to the delivery of psychological care will impact on a range of staff and this will result in roles and duties having to change. Changes to posts will be managed in accordance with the Trust’s policy on The Management of Organisational Change (HR 025).
2.19.It is also important to note that the proposals outlined in this paper will need to
take place within the existing total resources for psychological services.
2.20.Finally, whilst the emphasis in this paper is the provision of psychological
therapies and treatments, it is also recognised that a coherent psychological contribution to specialist mental health care is about more than one to one or group assessment and therapy. In some parts if the Trust good use is already being made of psychological skills in consultation, training, supervision, service audit, evaluation and research. It is recognised that all these areas of activity need to flourish and be supported within new professional and management arrangements.
3. The Stepped Care Approach
3.1.It is proposed that a stepped care approach to the delivery of psychological therapies and treatments is adopted across all primary and secondary care mental health teams.
3.2.This approach aims to initially provide a range of minimal/brief interventions
combined with monitoring to determine whether the patient needs to be moved either to the next/more intensive step, or to a less intensive service provision. The stepped care approach contrasts with a more traditional approach where large numbers of service users are referred to specialist services, which then either become overloaded, or inefficiently provide interventions not wholly suited to the person’s needs.
3.3.The adoption of a stepped care approach, allied to the broader context of new
ways of working, would respond to the needs of service users and their journey through clearly defined steps following a single point of access. Figure 2 below provides a diagrammatic representation of the stepped care approach.
FIGURE 2
Example of an Overview of the Stepped Care Approach
3.4.It is recognised that this approach is already in place in some parts of the Network and allows for high quality psychological care and psychological therapy to be provided by appropriately skilled staff across a range of disciples working in the context of clear supervision arrangements.
3.5.Views are sought on the proposal to implement a stepped care approach across all primary and secondary mental health teams.
- Proposal for the Provision of Psychological Therapies – “NICE Guidance Plus”
4.1.The Trust is aware of its responsibility to provide a range of NICE guidance
compliant services which include the provision of an identified range of psychological therapies.
4.2.It is therefore proposed that teams and services will be audited to indicate
whether they are guidance compliant in all areas, including the provision of psychological therapies.
4.3.It is also recognised that there are a range of other therapies/psychological
treatment for which there are a variety of different evidence bases . Appendix C provides a summary of the main approaches to psychological therapy that are currently available.
4.4.It is proposed that the Trust takes a clear view on the range of therapies and
treatments that will be provided and which are consistent with a clear evidence base.
4.5.Views are sought on the development of an agreed range and menu of therapies and treatments that should be available in the Trust.
4.6.The development of effective governance arrangements for the provision of
psychological therapies and treatments is considered crucial and is an area where the Trust wishes to make specific improvements.
4.7.It is therefore proposed that a formal group is established which will aim to
assure that those treatments and therapies that have been agreed by the Network are being provided to the highest standards.
4.8.Views are sought on the proposal to develop effective
governance arrangements for the agreed range of therapies and treatments within the Adult Network.
- Organisational and Management Arrangements
5.1.Effective, well organised and efficient management arrangements are crucial in
facilitating the provision of high quality service user care.
5.2.It is therefore proposed that there will be clear professional leadership and
operational line management arrangements for the provision of psychological therapies.
5.3.Professional leadership and supervision arrangements will be formally
established in each locality with the overall responsibility for these arrangements resting with the locality professional lead.
5.4.The operational management of staff providing psychological services will be
undertaken by the manager of the team or service area within which staff work.
5.5.Team managers will have the responsibility for putting in place a stepped care
model to meet the psychological needs of the local population, making best use of the levels of expertise which exist within teams.
5.6.It is proposed that the above changes will take place gradually as teams develop in line with the overall service transformation programme.
5.7.The development of the proposed new models of service described above,
ultimately means that a new and flexible workforce is required.
The following actions will need to be undertaken:
- Develop new job descriptions for CMHT Managers and Deputy Managers, Modern Matrons, Ward Managers and Deputy Ward Managers. The job descriptions would need to take account of the new responsibilities and accountabilities for the team.
- Describe the range and type of psychological therapies required in each CMHT, PCMHT and specialist service. This would then determine the numbers of staff and the levels of skill required in each team.
- Develop new job descriptions for the above workforce.
- Agree the relative numbers and skills of staff required at each band from Band 5 to Band 8C.
- Clarify which other members of the workforce, i.e. Community Mental Health Nurses and/or Occupational Therapists, have acquired other skills and qualifications such as CBT, CAT or Group/Family Therapy. With the clarification of the new job descriptions these staff would be able to work sessionally to provide these therapies, and be rewarded accordingly.
5.8.It is recognised that even if these changes were implemented, team capacities