Wessex Academic Health Science Network and Southern Health NHS Foundation Trust have developed and implemented a best practice integrated care pathway for psychosis (TRIumPH – Treatment and Recovery In PsycHosis) that prescribes timeframes around access and interventions for secondary care services.
What We Did
Wessex Academic Health Science Network and Southern Health NHS Foundation Trust have developed and implemented a best practice integrated care pathway for psychosis (TRIumPH – Treatment and Recovery In PsycHosis) that prescribes timeframes around access and interventions for secondary care services. Patients and clinicians have been heavily involved in development of the pathway and as a result there is a strong emphasis on ensuring early access to assessment, engagement and interventions.
Duration of Untreated Psychosis (DUP) is considered to be the strongest predictor of symptom severity and outcome. Delayed treatment can lead to significant impairments in social functioning and recovery which become increasingly difficult to repair. With this in mind, teams are now working towards assessing and engaging with patients within seven days.
Initially pathway development began by gathering learning from successful pathways in physical health, for example, in cancer, cardiac and stroke, where early identification and treatment have also been effective in improving outcomes and recovery. Extensive engagement with patients, carers and staff was also undertaken. This has now resulted in the pathway being implemented in four Early Intervention in Psychosis (EIP) teams within Southern Health NHS Foundation Trust. The pathway is supported by a narrative document that provides additional information for clinicians using the pathway.
Staff report how beneficial having a clear pathway of care is to guiding their practice and how useful it is for communicating expected standards of care throughout teams.
Achievements so far: The pathway has been rolled out within four Early Intervention in Psychosis Teams across Hampshire covering a population size of 1.3 million; There has been the development of a standardised referral form and assessment pack, an embedded physical health check process, the development of IT systems to support data capture, regular feedback to teams to identify what is working well and the provision of training and education; To date there have been some significant improvements: - time to assessment, from Jan – April 2016, 94% of people have been assessed within 2 weeks of referral being received by EIP, compared with 63% at baseline - 70% are being assessed within seven days compared with 37% at baseline - NICE compliant physical health assessments are now being embedded as standard practice
Inclusion within the pathway of a ‘Stepped Care Approach’ to offering psychological treatments: enabling clinicians to offer the least restrictive treatment option for early engagement and the ability to tailor interventions to people’s needs; Monthly steering group meetings continue to drive improvement; timely interventions have impacted upon A&E attendances and disruptive and costly admissions.
Wider Active Support
Partnership working has been critical in both the development and implementation of TRIumPH. Much of this has been achieved through partnership working within three areas: coproduction and co design, engagement through the effective use of data/ information and stakeholder engagement.
- Coproduction and co-design At the beginning of our journey we worked with a company called Stripe Partners who assisted us in running a coproduction workshop to gain insights and understanding of what is important to users, carers and staff in their experience of living with or working with those who have experienced psychosis. Over 100 stories/insights were gained which helped us to shape the pathway.
HealthWatch has also been very important in helping us to engage with local service users and also kindly provided rooms for us to hold our engagement event. We also used ‘Creative Options Community Project’ when needing refreshments. They are a local charity who train mental health service users in food preparation and food hygiene and provide a buffet preparation and delivery service.
- The effective use of data/information: During the initial stages of development we worked with a company called Janssen Healthcare Innovation to understand psychosis data in relation to Wessex (they had purchased HES and MHMDS data and assisted us with analysis). When compared to other mental health service users, we found that people who suffer with psychosis experience a 17% higher A&E attendance rate, a 25 day longer average length of stay and use 3 times as many healthcare professional contacts. This data was shared with both CCG and provider organisations. Our local audits also demonstrated long delays to access and assessment, which is also consistent with national data. The ability to share local data
made the issue real to commissioners and primary care colleagues and galvanised support for the work.
- Stakeholder engagement
Partnership working with local CCGs has been hugely important and mental health commissioning leads regularly attend our monthly steering groups. Their insight and guidance has been invaluable in progressing the work. Their involvement in the programme has also resulted in additional money being made available for the development of services and training.
Wider engagement events have also occurred with patients and their carers, clinicians, managers and third sector organisations and academics. Dr Geraldine Strathdee (previous National Clinical Director, Mental Health) has also been very supportive with championing the work. Our monthly Psychosis Steering Group Meetings enable members to share challenges and solutions to issues that they are encountering and share best practice to accelerate the spread of good work. Southern Health’s Research Department and Wessex Clinical Research Network are also supporting evaluation of the pathway.
Service users and carers have been central to the development of the pathway. We held a coproduction workshop with patients, carers and staff at the outset of the work and their stories and feedback have underpinned the development of the pathway.
The workshop was facilitated by Stripe Partners and was really well attended with nearly 30 people present for the day. Rather than start with any assumptions, the facilitators let participants define what was important to them by asking them to write postcards about a chosen experience and address it to a person who they felt should hear their story (we had postcards addressed to local provider CEOs, Commissioners, MPs and the Prime Minister David Cameron). Over one hundred postcards were obtained, yielding many first hand experiences of current care. The feedback was then collated into themes which were rated by individual participants in terms of importance. People told us they wanted care to be: Preventative; Consistent; Responsive; Empathetic; Seamless.
This approach helped understand what was intrinsically important to patients and carers. The pathway attempts to support provision in these key areas. For example, the pathway emphasises and facilitates responsiveness through early access and provides a standardised approach to assessment and treatment, it promotes consistency and seamless care through communicating expected standards of care for every patient entering an EIP team.
Evaluation of the pathway includes patient and carer experience. This will be achieved through questionnaires and we plan to run focus groups in the summer to find out how people who have experienced care in line with the pathway have found it.
Looking Back/ Challenges Faced
Looking back, the scale of the project has been larger than expected and we did not anticipate the amount of work required to get this far. The project is widely supported but has not only required practical changes to processes and procedures but a culture change within teams. This has required a focus and commitment at all levels and strong leadership to drive the agenda. Factoring in more time for these activities, if undertaking a project like this again, would help make the work load more manageable.
One of the key challenges has been to influence practice within referring teams/ organisations to ensure referrals are made in a timely way. As the pathway has set the standard for assessment within seven days, it is very important that all teams recognise the role they play in ensuring that clinical standards are met. A delay in referrals reaching the right team can hinder care, in some cases by over six weeks, where referrals are mistakenly treated as routine referrals.
Outreach work to teams, educating and supporting referrers and informing management to help understand the urgency of EIP referrals has been critical in changing the culture of how referrals for suspected first episode psychosis are being treated. Data evidencing delays within services has been important in changing practice and has involved over 16 referring teams. Although not there yet, progress is being made and we will continue to work with these teams until identifying and passing referrals on urgently to EIP teams is standard practice.
IT systems have also required changes to ensure that teams are supported in recording assessments, physical health data and information about NICE interventions. This has required consensus within teams on the best way of recording things, influencing IT teams in understanding the urgency of the changes and standardising practice to ensure everyone is using the system as intended.
One of the biggest challenges has been achieving culture change within teams, this has been supported through training events, engaging with team leaders and securing the role of a pathway facilitator to support front line staff in delivering care differently. This work has contributed to teams developing trust and enthusiasm to support the pathway.
There are a number of initiatives that ensure sustainability: • Ensuring data is routinely recorded and having IT systems that support clinical practice is paramount – this now well underway. • Southern Health have also invested in a system called Tableau, which processes millions of records on a daily basis and means data is more readily available for teams to utilise in real time. EIP teams are currently having training in using this system.
The Psychosis Access and Waiting Time Standard (AWTS) will also help in sustaining the benefits of the work and we hope the pathway will ensure clinicians don’t just treat the AWTS as a target but a vehicle to focus on the quality of care.
A robust evaluation plan, supported by the NIHR (National Institute of Health Research) and Wessex Clinical Research Network is underway. Outcomes will be assessed at baseline, 12 months and 24 months. An economic evaluation will also be completed.
There is a commitment to share our work and the knowledge gained with other interested parties who may benefit from the work. We have presented and submitted posters at a number of conferences and had a number of enquiries from around the country wanting to understand more about the work. We have successfully disseminated this work through commissioning networks and at a National AHSN Network Meeting. We have published a guide on the development of the pathway in collaboration with Rethink Mental Illness and Royal College of Psychiatrists. We will be publishing the results of the evaluation to disseminate the work further.