The Depression and Anxiety Service across Devon delivers evidenced based psychological intervention for people struggling with common mental health difficulties. The service is delivered across five geographical teams. In addition, we now have an additional specific team working across one CCG area, delivering psychological treatments for people with both a long term physical health condition and a common mental health difficulty. This additional team is part of the early implementation by NHS England for people with long term physical health difficulties; we are a wave 1 site.
Co-Production
From start: No
During process: Yes
In evaluation: Yes
Evaluation
Peer: Yes
Academic: No
PP Collaborative: Yes
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Sue Pike - Clinical and Service Manager, Devon Partnership NHS Trust
The Depression and Anxiety Service across Devon delivers evidenced based psychological intervention for people struggling with common mental health difficulties. The service is delivered across five geographical teams. In addition, we now have an additional specific team working across one CCG area, delivering psychological treatments for people with both a long term physical health condition and a common mental health difficulty. This additional team is part of the early implementation by NHS England for people with long term physical health difficulties; we are a wave 1 site.
We work closely to the original IAPT model, to ensure that our patients receive high quality treatment, which is indicated for their difficulty in line with the NICE guidelines. We use a stepped care approach, so that people have the “least burdensome” treatment to enable an effective outcome. A stepped care approach allows us to see large numbers of people in a timely way. We offer people the “right dose” of treatment relevant to their problem – at step 2 or low intensity we offer up to 8 sessions and at high intensity we offer 12-16 sessions, and on occasion up to 20. It is important to offer effective treatment at the right level and with enough time to enable an effective outcome and full recovery.
Step 2 or Low Intensity: This can be individual sessions or courses and delivered through a variety of mediums – face to face, telephone or via a digital platform as computerised CBT. It is very important that we can offer choice for people. For some people computerised CBT, which links to the clinician via a secure blog, is more convenient and effective, or the value of meeting with others in a course to not feel alone and to reduce stigma is most helpful. Telephone can be more convenient to prevent lengthy travel in some of our more rural areas, and for others face to face contact and coming out of the house for an appointment is a valuable part of treatment. Individual choice and easy access are central. We offer evening and early morning appointments, and support people with work through our employment support coordinator. “…the fact that it was online, I was able to access the programme from the comfort of my own home at a time when it suited me….”
Step 3 or High Intensity:
We offer high intensity treatment to reflect the NICE guidelines. Most people will access CBT (cognitive behavioural therapy) individual sessions, but we also offer EMDR (eye movement de-sensitisation re-programming, a specific treatment for post-traumatic stress, counselling for depression, some couples therapy and interpersonal therapy (IPT). Choice and offering the right number of sessions at high intensity to achieve lasting change is an important part of what we do.
At high intensity, we also offer group work, in particular mindfulness courses for people struggling with relapsing depression, anxiety or long term physical health difficulties.
Most people who see us refer themselves, either by telephoning or via our online form. We also receive referrals from both primary care and from within our own Trust from other mental health services and from a variety of other health and social care professionals.
In addition to our core delivery, we are a first wave early implementer site for long term physical health conditions. Within this early development we are focused on 3 areas – diabetes, COPD and obesity. The treatment we offer is focused on depression and anxiety difficulties for people with the three long term conditions. People who struggle with a long-term condition are two to three times more likely to have a mental health difficulty. The clinicians who are working with this group of people are delivering treatment alongside, and in the same place, as physical health care is delivered. This enables easy access and reduces the stigma of accessing help for emotional wellbeing. It is fully integrating physical and mental health care around the patient. In addition to offering treatment in an integrated model with physical healthcare, we are evaluating the expanded service locally, by comparing data across both acute physical health care and primary care, to demonstrate health savings by a reduction in health utilisation.
Our service is moving ahead with other development, including an increased focus on providing an excellent service for perinatal women. Our Torbay team has already been recognised as an exemplar IAPT perinatal service by The Royal College of Psychiatrists. The team offer priority appointments to perinatal women, work closely and collaboratively with health visitors, midwives and the perinatal mental health Team. In addition, there is a high intensity group specifically for perinatal women. We are currently looking to expand this model across the whole of the service.
Our Service works closely and collaboratively with Exeter University. We have a memorandum of understanding allowing easy collaboration and participation in a variety of research. This close working is clearly demonstrated within our involvement with the COBRA trial:
This large multi-centre randomised trial compared the delivery of behavioural activation at high intensity delivered by PWPs and CBT as normal, delivered by high Intensity therapists. Our therapists and PWPs were involved in the trial, which demonstrated neither treatment was more effective than the other. However, the delivery of behavioural activation by PWPs demonstrated a considerable cost saving. We are now implementing the results of this trial into the service, and have trained a number of our PWPs to deliver high intensity behavioural activation, and will be in a position to offer this, as a treatment choice, within the high intensity part of our service and realise considerable cost savings. Within the current financial environment enabling this skill mix to deliver cost savings, but being confident of the quality and effectiveness of the treatment, is an excellent example of close working with the University. Our close working with the university, enables development opportunities for our staff, an ability to implement research quickly into practice, and allow our research partners to work alongside us within usual practice. This close partnership is a unique and successful component of the service we offer.
DAS is committed to the ongoing development of the clinicians who work within it. It is key to maintain knowledge and create opportunities for development. We have trained, through our partnership with Exeter University, most of our psychological wellbeing practitioners (PWPs) and our high intensity therapists. We would recognise that working within an IAPT service is demanding and work closely to develop innovative ways to enable the good emotional wellbeing of our staff.
People who see us are asked for feedback after the initial appointment and at the end of treatment. The common themes of feeling heard, understood and not alone, as well as feeling confidence with the tools and the effectiveness of therapy to move forward are good to hear. We also listen carefully to feedback to help improve what we can offer.
Wider Active Support
We work closely with a wide variety of partners to expand and improve our service.
Within primary care we are linked closely with GPs and Practice Nurses. This close partnership enables us to deliver treatment from GP Practices, reducing the stigma and make it easier for people to access treatment. GPs highly value our service “It’s good being able to access evidence-based psychological therapy in a timely way;” (Local GP) “I can’t imagine life without it (DAS)! It is very useful resource and is valued by many patients”. (Local GP)
Within our expansion for people with long term physical health conditions we have developed closer working links with health psychology and liaison psychiatry, meeting regularly. We are seeing patients within acute care settings, and working in close liaison with the multidisciplinary team. We are integrated and working within the Macleod Endocrine and Diabetes Centre in Exeter with both the Diabetes Service and the Exeter Medical Obesity Service. We are based in GP Surgeries and delivering clinics alongside Practice Nurses and GPs. The close working with partner colleagues in physical health care is essential as we continue to further expand our service for people with long term physical health difficulties.
Within our own Trust we work hard to develop clear pathways between the Crisis and Home Treatment Teams, the Liaison Teams and the Mental Health Assessment Teams. We have clear guidance within our inclusion criteria, to enable safe and effective referrals. We meet in some of the areas weekly to discuss referrals, and have close collaborative relationships. We also share learning with incident reporting, complaints and analysis of serious incidents across the Trust. Although there are challenges at the interface between services, we strive to maintain good relationships that enable a better experience for the person who is struggling with their mental health.
At a wider level, we have many partners – we link closely with perinatal services, both with the perinatal mental health team, and also with health visitors and midwives. We deliver clinics within children’s centres. We work with employers and Occupational Health Departments and the Job Centre. Within the third sector we are working alongside carer’s organisations, and with Age UK. Where ever we can, we look to see people within places they usually go or are non-stigmatising – such as the Age UK building. We can and do work with all organisations and partners that will enable easier access for as wide a range of people as possible to our service.
Co-Production
We value the feedback and involvement within our service of people with lived experience of mental health difficulties, and people who have experience of accessing DAS.
At the end of the first appointment and at the final session we send everyone a patient experience questionnaire and invite both their feedback and an opportunity to engage with us in developing the service. We also invite people to respond through the family and friends test, 93% would recommend us to their friends and family for treatment. As important is the feedback we receive where people have not felt completely happy with their experience with the service, through either the questionnaires or through concerns and complaints. We work closely with people raising concerns to make changes to the service.
We have developed groups of people in each area who are keen to work together with us to develop and influence the service. We involve people within our recruitment process and in various consultations and forums when we make changes. We also look to coproduce – an example of this has been the development of our website:
People with lived experience tell their story on the website of both their difficulties and their experience of accessing our service. The impact of their story is far reaching, and enables many people to feel they are not alone and to feel some hope that they can tackle their difficulties.
Listening carefully to the staff who work within DAS is important. We are currently working with our staff following completing a staff survey across the Trust. The specific team feedback we are following through is connected to the wellbeing of staff, and we are doing a further survey to work together with the teams to establish practical and helpful ways to maintain wellbeing.
Within our expansion for long term conditions we have engaged and looked to work alongside Diabetes UK. An example of this has been a person with diabetes coming along and participating in the away day for the team at the very early stages of the team’s development.
Looking Back/Challenges Faced
The service has been running since 2007. The IAPT expansion has been in place since Oct 2016.
One of the bigger challenges we face is the security and potential financial cost of the clinical space and estate, where we see people. We have a large geographical patch. Initially, when the service started, we pragmatically set up a variety of venues to enable easy access for people and in non- stigmatising environments. These arrangements were in the most part based on relationships and goodwill. As the service, has expanded, and the financial climate has become more challenging, GP space is more pressured, and some of the clinical space we are delivering treatment from is therefore insecure or at risk of incurring financial cost.
If we could set up differently, we would look to have established clinical space on a more secure footing, and to have worked with our CCGs to address the financial implication at an earlier stage. We are currently engaged in some significant work to address this, to reduce the financial risk and ensure the space we are in is on a secure footing. Within 15/16, we experienced a challenge in reaching our 15% prevalence/access target and enabling 50% of all the people we see to reach full recovery.
Within 15/16 we sustained a significant marketing effort, enhancing the profile of our service through GPs, online through development of our website, radio, visits to multiple organisations and presentations. This significant campaign resulted in an increase of referrals that have now been well sustained over time, so that within both 15/16 and 16/17 we have been able to achieve a 15% prevalence. Our challenge now is to move forward to increase this in line with the Five Year Forward View for Mental Health. With the increased volume, we have looked to maintain a healthy workforce, by a mixed delivery at low intensity of groups, telephone, computerised CBT and groups.
Within 15/16 we were also challenged with achieving 50% recovery consistently. We have done extensive work within the teams, to drive change forward with this. We have used a combination of fully understanding the outcome measures we use and ensuring the quality of treatment we deliver is effective. Within 16/17 we have achieved 50% over the year. We continue to work to further improve outcomes. It is important within the teams, to recognise that improving outcomes and recovery is not chasing a target, but achieving the best possible outcome for people, so that they can move forward and reduce the risk of relapse. We continue to see people with severe presentation at the start of treatment, and although many of these people do not reach the 50% recovery, due to the longstanding nature of their difficulties, we work effectively to enable significant change for at least 65% of people.
Sustainability
The service has 6 team managers and an overall service lead. This leadership group works together closely and meets regularly, enabling sustainability through cover and sharing of knowledge and experience when there are changes and new managers appointed.
Within each area the management and clinical supervision is shared across the team and delivered by both the immediate managers and more senior and experienced clinicians within the team. This enables a more robust and sustainable structure, that is not reliant on a single person.
Within the teams we seek to encourage innovation and leadership broadly to develop skills and longer term sustainability. An example of this would be the “Champions”, we have in place in each team who are leading development in a specific area. We are currently developing perinatal care, looking at the quality and delivery of supervision, improving our recovery and increasing the effective use of computerised CBT and group work. These areas have a relevant clinical champion. This gives a good opportunity for leadership and instigating change, and enables development of staff for leaders for the future.
Within the service we have secondment opportunities. When there have been gaps in recruitment of either the team managers or the service manager, we have enabled a period of acting up as secondment, this has given opportunity for senior and experienced staff to develop their leadership and management skills.
The service culture is supportive and based on teamwork. All the high Intensity therapists operate as senior clinicians on a rota, and will solve and respond to clinical issues and managerial issues in collaboration with the team manager, and will do this independently when the team manager is on leave or away from the immediate workplace.
The task of an IAPT team to deliver against very clear standards helps to ensure a sustainable model of delivery. Everyone is clear about their role and what they need to do.
Evaluation (Peer or Academic)
We are evaluated each month through the submission of national key performance indicators.
We measure access through a prevalence target – to see 15% of the population who have depression and/or anxiety. This gives clear data that is reported each month. In the last financial year, we met this target across the service.
We measure the effectiveness of the treatment delivery using clinical questionnaires, taken at every patient session. This enables both individual progress within treatment to be monitored by the therapist and the patient, and for the service to be evaluated with the effectiveness of treatment. We are measured against the national IAPT standard of 50% of people who enter treatment (2 or more sessions) meeting full recovery on the clinical measures. Within the last financial year, we met the 50% target.
In addition to the national recovery KPI, we also measure and evaluate clinical significant improvement, defined by a specific drop in scores on the clinical measures. We measure against 65% of people we see making a clinically significant change. We regularly exceed this target, demonstrating effective treatment. Some of the people within this group have more severe and complex difficulties and would not often reach full recovery. The ability to evaluate against a clinically significant drop allows us to demonstrate effectiveness with this more complex group.
We are evaluated against waiting times with a national standard of 75% of people being seen within 6 weeks of contacting the service and 95% of people within 18 weeks. Within our service we exceed the 75% target of 6 weeks. It is important to offer timely access to treatment from when the person contacts the service and to commence sessions promptly to maximise the person engaging with treatment.
In addition, we also seek feedback to evaluate the effectiveness of the service. Every person that we see has a patient experience questionnaire sent to them for feedback following their first appointment and those people who enter treatment receive a patient experience questionnaire at the end of treatment. The questionnaires gather feedback about satisfaction on:
Did staff listen and treat your concerns seriously
• Do you feel the service has helped you to better understand and address your difficulties?
• Do you feel involved in making choices about your treatment and care?
• Were you satisfied with the time you waited for your first and subsequent appointments
• On reflection, did you get the help that mattered to you most
• Did you have confidence in your therapist and his/her skills and techniques
We also ask if the person would recommend treatment from our service to a member of his family or a friend.
We have positive feedback from the questionnaires. We also give an opportunity for people to write, and receive many comments and ideas. We have recently completed an analysis, to understand the themes and implement changes
We are currently starting to evaluate the impact of the service we are delivering as a wave 1 early implementer site for long term conditions. Our evaluation will compare data across both acute and primary care to look at cost savings through reduced health utilisation, and will also use a patient self-report measure of health utilisation. This evaluation is complex, with data sharing across organisations, but valuable to demonstrate the effectiveness of our delivery.
Outcomes
We measure outcome at every session and for an episode of treatment overall. One of the outcomes we have worked on and improved is enabling a 50% recovery overall in the service. For individual patients moving to full recovery if possible is important. It indicates a lack of clinical symptoms and a lessened chance of relapse.
To enable full recovery for as many patients as possible we have:
• Worked with staff to fully understand and use the clinical measures effectively with patients. To collaboratively work with patients to understand their symptoms and target areas where there are still residual problems. Using the clinical measures effectively with the patient promotes hope and helps the person to see change.
• We have as a staff group better understood the cut off points for the measures
• We are doing a series of CPD workshops to look at supervision. Our clinical supervision structure is strong, but we would strive to always improve the quality. The supervision workshops look at delivering supervision and measuring the quality of this against a specific tool using taped material of supervision sessions. This learning will be embedded into the service by having a supervision champion in each team who will continue to monitor supervision through taped material. Effective supervision ensures fidelity to the model, continued development of the therapist and leads to the most effective treatment for the person
• We have recovery champions in each team, who provide data and feedback individually to each clinician about their own rate of full recovery of the patients they are seeing, and work closely and supportively with clinicians if a problem is identified. This has been a helpful intervention, as this is a peer interaction rather than a managerial process, and enables change and more effective treatment for the person being seen within the service
• We have also been targeting perinatal depression, to improve outcome for this group of women.
• We have a specific piece of work contacting all the people who have dropped out of treatment in the last 6 months. If people remain in treatment their outcome is generally good. If they stop attending appointments, generally they have not reached full recovery. We would like to better understand the reasons why people stop coming along to sessions, so that we can adjust and make changes, to enable as many people as possible to remain in treatment and achieve recovery.
The sustained improvement or recovery overall has been challenging, but we have achieved this. We continue to work on this, to enable the best outcome for every person that we see. It is important for us as a service to see full recovery as the best outcome for each individual person.
Sharing
We are committed to dissemination and sharing of the knowledge and skills we hold within the service. We have many trainees, both employed within the service and on placement from the undergraduate PWP course. We invest in sharing the skills we have to develop these groups of trainees.
At a wider level, we share our knowledge and skills. An example of this within the Trust is the current delivery of training to our colleagues with the local community mental health teams to delivery brief psychological interventions to the people who they see. We are also currently sharing the structure and skills within our IAPT service with the team delivering psychological intervention and mental health support within the prisons locally, to help this team develop effective intervention for the people they are working with.
Our current IAPT expansion with long term conditions is part of a national group of services. Within this arena we share the good practice of our implementation and learn from other sites. We are engaged at a national level through the online forum set up to discuss and share ideas to help this development and innovation move forward successfully both locally and nationally.
Our long-term conditions team are delivering workshops at the South West Peninsula Diabetes Education master classes on the 19th June, the workshop entitled “No health Without Mental Health: Dealing with Diabetes Distress” will be attended by many diabetes clinicians throughout the day. We are part of the North Devon Integrated Diabetes Pathway Project Team, comprising of diabetes consultants, GPs, podiatry lead, pharmacy lead, LTC commissioner and a patient engagement lead. The development both formal and informal of links within physical health care at acute and primary care level is enabling learning and sharing for clinicians across physical and mental health which will in turn enable better outcomes overall for the patients we see.
We regularly attend GP Practices, Practice Nurse Forums, CCG events and support groups and many other arenas, where we share what we are doing within our own service and engage in discussion to improve and to understand the services and support delivered by others.
Is there any other information you would like to add?
Locally within our STP (Sustainability and Transformation Plan) footprint, we are integral to the development of an Integrated Psychological Medicine strategy. This local strategy led by Devon Partnership Trust is in collaboration with the Centre for Mental health, the University of Exeter Medical School, the Royal College of Psychiatrists. It is aimed at addressing all aspects of associated mental health with long term physical health conditions and medically unexplained symptoms. It is connected to the development of Liaison Psychiatry Core24, Clinical health Psychology and neuropsychology, IAPT and medical psychotherapy. The local commitment to this strategy supports of our development as a wave 1 site for LTC and we would see our future growth and movement forward with the 5 Year Forward view, to be integrated into this overall strategy.
Our service has a high level of commitment to the transparency and integrity of the data that we submit, both locally and nationally. We are proud of the achievements to date, and are confident that the data we use and are measured by accurately reflects our service. We are audited regularly locally.
