Initial Interventions service - KMPT NHS Trust - HC #MHAwards19

Please briefly describe your project, group, team or service, outlining What you do and Why it makes a difference

The effectiveness of a brief Cognitive Behaviour Therapy (CBT)-based ‘Initial Intervention’ for new clients into adult community mental health services delivered by support time recovery workers.

Mental health services are seeking innovative ways of working effectively with limited resources. With this in mind the Kent and Medway NHS and Social Care Partnership Trust (KMPT) has developed an ‘Initial Intervention’ psychological package for new clients in services designed to be delivered by support time recovery workers and supervised by Psychological therapists. This package is aimed at working age adults requiring secondary care mental health services in the community. This project has been piloted (November 2018 – May 2019) in South Kent Coast Community Mental Health Team’s (CMHT’s) based in Dover and Folkestone and implementation has begun in all CMHT’s across KMPT.

The Initial Interventions pathway has enabled KMPT to define a conceptual service offer of a brief psychological intervention within the first few weeks of being accepted into the service. The intervention supports the service user to understand their difficulties, to learn new coping strategies and come away with a clear recovery plan. For some service users this may lead straight onto referral back to their GP and for others it will be a robust start in their journey onto specialist interventions.

The ‘Initial Intervention’ model was designed by a clinical psychologist drawing on classic Cognitive Behavioural Therapy (CBT) strategies, theorised active mechanisms of change and transdiagnostic research. The package is designed to be a balance between being a manualised and formulation-based brief psychological treatment (Padesky and Mooney, 1990) suitable to be delivered by non-psychologists. This was then co-designed and developed into a full package through a collaborative working group which met fortnightly involving a variety of the trust’s stakeholders, such as people with lived experience, carers, service leads, clinical leads, managers and the project support team.

In addition there has been consultation with and involvement from an extended circle of stakeholders from grassroots through to director level. As part of the engagement work carried out, the trust service user involvement group, clinical care pathways group chaired by the executive director and business teams have all worked collaboratively through each stage of the pilot.

There is a strong evidence base that supports the package, including emerging research into short-term CBT based interventions in NHS services with non-psychologists (supervised by Psychologists) has shown to be effective and positive. The Cost and Outcome of Behavioural Activation [COBRA] trial (Richards et al., 2016) showed that behavioural activation delivered by junior mental health workers was no less effective than CBT delivered by psychological therapists for treating depression. In addition to this, non-psychologists delivering brief CBT interventions improve in their competence and confidence (Armstrong et al., 2017).

The pilot project involved training junior mental health staff (e.g. support workers) working in a community adult mental health service in the package. After training the staff then attended weekly group supervision by a Clinical Psychologist to deliver the intervention to all new clients into service. The pilot, which took place between November 2018 and April 2019, included over 50 clients.

The aims of the Initial Interventions project were:

· To design a transdiagnostic brief psychological intervention which staff in CMHTs can be trained in to deliver.

· To set up a structure in the CMHT which will help support the initial interventions to take place.

· To evaluate the effectiveness of the Initial Interventions.

· To obtain staff and servicer-user feedback.

· To review the pilot, make appropriate revisions and roll out across all CMHTS in KMPT.

The evaluation of the pilot included four categories:

1) data on the service-user flow through the pilot and what their needs were after the intervention,

2) the self-reported clinical outcomes for service users who went through the intervention,

3) the staff outcomes for those that delivered the intervention in terms of their views on their job role, and 4) qualitative feedback from service users and staff.

The results from the evaluation of the pilot have shown that 1) the pilot encouraged flow of service users through the service, with approximately one quarter of completers being discharged back to their GP, 2) reductions in self-reported scores of depression, anxiety, and how their mental health impacts on their living, with an increase in wellbeing, 3) reductions in staff self-reported secondary traumatic stress and burnout and improvements in compassion satisfaction, and 4) positive feedback all round from service users and staff.

What makes your service stand out from others? Please provide an example of this.

From the published literature and to our knowledge we are the only CMHTs in an NHS Trust to have such a robust offer of formulation-based psychological input to the majority of its clients within the first few weeks of entering into services.

The unique components of this work include:

1) A trans-diagnostic approach to treatment

2) Interventions delivered by non-psychologists but supervised by psychologists

3) Treatment based on the individual’s formulation

4) A meaningful intervention delivered in only four sessions

The combination of these in one package is the first of its kind according to the published literature and to our knowledge.

The Initial Interventions initiative has been co-produced at every stage of the model development, from a focus group identifying the initial need, to model development, materials, service set up, evaluation and the plans for implementation across the NHS Trust. This collaborative approach is in-line with national initiatives which we have been able to bring to practice in this work.

The initiative stands out from many others that take place within services as from the beginning we designed feedback from all perspectives to be incorporated into the model. This has meant that we have received positive feedback from all stakeholders involved (service receivers and service deliverers) which demonstrate it is meeting needs all round.

How do you ensure an effective, safe, compassionate and sustainable workforce?
Models of leadership, transformation and change were drawn upon in deciding how to enthuse and engage staff from day one. Staff were encouraged to embrace the pilot as something we could develop together to help improve our service and the experience of all those involved in the service. When the idea was introduced staff were consulted in a focus group and asked their opinions on what it should look like, this was so it could be owned by the whole team. As the initiative progressed they were upskilled by being provided in-depth training on the intervention and were asked for their feedback at the end of each training session. We developed a bespoke online feedback questionnaire to capture their thoughts and feelings on the project before getting started and were given the PROQOL to fill out to capture how they felt about their job. They were fully aware that we were interested in how they felt and how this might change over the course of the pilot. Staff then received effective and collaborative group supervision which took place weekly with the clinical psychologist, and knew that they could ask for additional help if needed. They also knew that this was a reflective and supportive space to be able to communicate if issues needed addressing or processes needed changing. The wider structure around them was such that they had supportive management which took this work into account within their job roles and helped them to build their confidence. At the end of the pilot, when we were planning implementation across the trust, the staff had a feedback session to share their thoughts and were involved in the training of the new CMHTs. The approach used in the pilot formed the basis of the implementation plans moving forward, and a led to a monthly forum to encourage staff to come together regularly and reflect on their initial intervention work.
Who is in your team?	Band/grade	Number	Whole-time equivalent
Support Time Recovery Workers	3	9	5.4
Occupational Therapist	5	1	.5
Team leaders	7	1	.5
Clinical psychologist	8a	1	1

How do you work with the wider system?

Within our NHS Trust, the package is being implemented across the care group and plans are developed to adjust the package for the older adult care group.

Outside of our NHS Trust, we have made steps to improve joined up working by providing information within the initial intervention materials on local and national resources. In addition to this, we specifically chose pre-post clinical measures that were widely used across services therefore aiding communication and flow between services.

Do you use co-production approaches?

As mentioned above, the Initial Interventions initiative has been co-produced at every stage of the model development. This involved reading service-user written reports which identified the need, attending the trust’s service-user involvement group to ask for feedback at the beginning of the initiative, having a service user and carer on our pathway working group that met fortnightly throughout the pilot, and including all feedback that was generated in the project (this was clearly documented in a ‘you said, we did’ document). In addition to this, we have plans to go back to the service-user involvement group to share with them the results and include them in all ongoing plans now that the pilot has finished.

We have used an approach which we hoped would be very much in-line with national initiatives on service user involvement and coproduction,

Do you share your work with others? If so, please tell us how.

We are excited to present the initial interventions to the World Congress for Behavioural and Cognitive Therapies, July 2019 in the form of a poster presentation. In July the project will be presented formally to the KMPT Trust board, and from there it will be presented formally to the Kent CCGs. Submission for publication in a peer reviewed journal has been prepared.

What outcome measures are collected, how do you use them and how do they demonstrate improvement?

As described in the introduction, there were four categories of outcome data:

1) The outcome for the service (i.e. discharge from service, referral to psychology team).

2) Service user self-reported pre-post symptomatology data (PROMS). This was included measures of depression (Patient Health Questionnaire-9; Kroenke et al., 2006), anxiety (Generalized Anxiety Disorder-7; Spitzer et al., 2006), wellbeing (Recovering Quality of Life; Keetharuth et al., 2018), and how mental health impacts on their life (The Work and Social Adjustment Scale; Mundt, Marks, et al., 2002).

3) Staff self-reported pre-post measures of compassion satisfaction, burnout and compassion fatigue (ProQOL questionnaire; Stamm, 2009)(PREMS).

4) Qualitative service user and staff feedback (an online survey of bespoke qualitative questions)(PREMS)

The outcomes demonstrate improvement across the board, specifically in the following ways.

1) The outcomes for the service were demonstrated by investigating the service flow following the introduction of the pilot. 85 service users were offered the initial intervention, from this 55% went on to engage in the sessions. Approximately half of those completed the intervention. Out of the completers, 26% required no further treatment and were referred back to GP, 22% required specialist psychological treatment, and 52% went on to be reviewed which for some led to a bespoke care package developed within the team.

A longitudinal review of this we hope will confirm one of our objectives which is for this intervention to get quick access to treatment to those service users most in need of ongoing specialist treatments.

2) The service user clinical outcomes pre-post intervention showed the following:

	Pre	SD	Post	SD
Depression (PHQ9)	18.95	3.47	14.81	6.30
Anxiety (GAD7)	16.10	3.69	12.48	5.39
Impact (WSAS)	30.20	6.47	22.85	9.55
Wellbeing (Reqol)	13.38	4.66	17.95	8.89

The results indicated that on average symptoms of depression, anxiety and how mental health impacts on their life reduced, and wellbeing improved.

3) The staff reported outcomes pre-post being trained on the intervention showed the following:

STAFF OUTCOME -PROQOL	Pre	SD	Post	SD
Compassion Satisfaction level	34.90	5.76	40.10	3.48
Secondary Traumatic Stress level	20.90	4.94	19.90	3.51
Burnout level	28.20	4.98	23.00	4.00

The results indicated that on average staff experienced increases in compassion satisfaction in relation to their job and decreases in burnout and secondary traumatic stress.

4) Qualitative data collected from staff and service users was positive across the board, and is characterised by the following quotes:

“I found it to be the same as CBT I have had in the past for the first two sessions, but after the session periods increased to every week rather than every two weeks, I found it to be much more effective and helped me a great deal.”

“The formulation was most helpful as it allowed me to see how everything connects so I could identify this at early stage”

“All of it I do write things down now, it has been helpful for me, it all related to my life, the good and the bad.”

Has your service been evaluated (by peer or academic review)?

The project has been evaluated by our Trust Quality Improvement team, and submission for peer-reviewed publication is in preparation.

How will you ensure that your service continues to deliver good mental health care?

We have developed a sustainable, cost-effective and evidenced-based model that is now one of the main clinical treatments in our community mental health service. It is clinically led and supervised by experienced psychologists, with the full backing of service managers. We will ensure that this good work continues by keeping clinical outcome measures and feedback as an essential part of the package, and regularly analysing these to ensure that the model continues to produce positive results. In order to help to sustain this further our implementation plan had an entire section dedicated to ‘ongoing support’ which included the introduction of a Trust-wide monthly initial intervention forum where all staff would attend and keep each other updated about the progress in their CMHTs, problems and successes.

What aspects of your service would you share with people who want to learn from you?

It is essential that you have a dedicated team to support implementation of such an intervention model. Having sign-up from operational support was invaluable and allowed the intervention to be prioritised in a busy service, from this they are now reaping the benefits. On a practical level this meant ensuring that all staff involved had clear identified job plans and that this was part of their appraisal process.

Another essential component was ownership in the sense that all those involved had a sense of ownership and pride in the project from the beginning, knowing that they had the opportunity to make changes and share their experiences.

Lastly, the intervention is both accessible and enjoyable for staff and service users and this was important in keeping the energy and enthusiasm high. The training for staff was interactive, for example used donuts to draw clients formulations (cycles of difficulties) and candy sticks to draw exposure hierarchy ladders. For service users the materials were accessible, visual and utilised items that clients could try out or take home (sensory boxes for grounding techniques and cue cards with a picture to prompt a strategy).

How many people do you see?

200 people have been accepted for the intervention as of 13 June 2019.

How do people access the service?

Service users who are already in the service access the intervention by being referred from the active review.

Service users who are new to the service will have a choice assessment where an option of being self-refereed to the intervention will be offered as an option

Psychology team manage the referees and then allocate service users to their support worker.

How long do people wait to start receiving care?

Service users will attend the choice assessment when they are referred into the Community Mental Health Team. The intervention will be discussed with an option of self-referral to the intervention and they would be contacted within 4 weeks to arrange the first meeting to begin the intervention.

How do you ensure you provide timely access?

This is discussed at weekly team meetings first thing in the morning with prioritisation and agreed by the service manager if appropriate.

·Weekly supervision between the psychologist and the support workers take place to ensure learning and to maintain work flow.

**What is your service doing to identify mental health inequalities that exist in your local area?**

Establishing perspectives from our service users

What inequalities have you identified regarding access to, and receipt and experience of, mental health care?

Benefits entitlement

Mental health stigma

Undiagnosed either autism or learning disabilities that could be impacting the treatment they are receiving

**What is your service doing to address and advance equality?**

The Initial Intervention’s approach is inherently destigmatising in its approach as it normalises human distress rather than labelling it and pathologising understandable responses to adverse life events. The normalising approach gives more hope for recovery because the distress is seen within a context that makes sense for all involved.

How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?

We use the psychometric measures to asses’ depression and anxiety symptomology and difficulties functioning and then the interventions building a formulation of someone’s current psychological difficulties.

How do you meet the needs of people using the service and how could you improve on this?

Service users are receiving individual tailored psychological informed intervention which the measures used so far proved to be having a positive impact on their functioning and symptomology. The intervention provides further information to inform the next step of services that are required for the individual service users.

What support do you offer families and carers? (where family/carers are not the service users)

Service users are given a preparation pack in the beginning of the intervention which includes information for family and cares and further support they might want to get access to.

Is there anything else you want to share about what makes you an example of positive practice?

Initial Interventions is a truly co-produced evidence-led intervention for people with severe mental health problems. For many service users this is a fresh perspective on their difficulties and allows them to think creatively about how to address them.

It has shown valued community mental health team staff how to deliver a meaningful intervention, as well as increase the efficiency and flow through the system, which will also enable our teams to provide timely access to interventions and allow us to provide specialist treatment to those that need it most.

It has invigorated all those involved, leaving people feeling confident and proud.

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Initial Interventions service – KMPT NHS Trust – HC #MHAwards19

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