Early intervention in psychosis is not one specific intervention, it is a system of care that requires access to a range of NICE guideline treatments offered in a sensitive and timely manner through a team which embodies the opportunity of recovery for people who use these services.
Early intervention in psychosis is not one specific intervention, it is a system of care that requires access to a range of NICE guideline treatments offered in a sensitive and timely manner through a team which embodies the opportunity of recovery for people who use these services.
GMW has operated an early intervention in psychosis service in some format since 2002. The initial impetus was through a research project the first in the world to test the ability of a psychological intervention to reduce transition to psychosis in people considered at an elevated risk, i.e. at risk mental state. When the NHS plan was announced GMW built on this initiative and developed EIP teams across the three CCGs in which it relates to but also provided ARMS services to additional CCGs close by.
Since the announcement of the AWT standards GMW has been proactive in collaboratively developing business cases with all three CCGs in order to be in a position to meet the standards as soon as possible. This collaborative approach has been held up as an exemplar of good practice in the AWT implementation guide. NHSE North has also used this approach to commissioning as an excellent example of how commissioning for these services should be approached.
This proactive approach enabled recruitment of staff to take place at an early opportunity allowing for comprehensive induction programmes to take place and also for staff to be in a position to take up the training places available through HEE. The induction programmes were fully evaluated and results are available in the evaluation section.
Another initiative that GMW staff led on was training in assessments and specifically how to assess At Risk Mental States something required for teams to stop the clock and a skill missing in many teams across England. GMW and our Psychosis Research Unit were approached to tender to provide training to skill up the EIP workforce in the North Region to meet this challenge. We put together a training package that would provide capacity across the region over time through a train the trainers approach. It was also stressed that we would want people not just to attend the course but there would also be an assessment of competency. This initial phase of the training has been completed and an evaluation can be seen in the evaluation section. Subsequently we have been approach by other NHSE regions to deliver similar training.
Other regional training initiatives are provided through our Cognitive Therapy Training Centre and we are regional providers of CBT and also ran courses in BFT on behalf of HEE. These provide opportunities to develop the workforce not only locally and regionally but also from a national perspective.
One of the big issues in EIP is how we tackle the physical health inequalities and in order to tackle this further we developed an initiative called RIGHT FROM THE START (RFTS). This is a new resource developed from collaboration between service users and Early Intervention Service practitioners to encourage greater attention to cardiometabolic health in early psychosis, building on the existing Healthy Active Lives (HeAL) and Lester resources. By empowering service users and their families to find out how health professionals can help them to live healthier lives, GMW MH NHS Foundation Trust and its Psychosis Research Unit have found an innovative way to drive up the quality of physical health care offered. The participation of service users in determining content and design of RFTS was central to a process that was conducted in three participative workshops. This accorded with the commitment from the organisation to deliver service improvements by listening and learning from the experiences of those using its services. This qualitative appreciation has added an often-neglected dimension in how an organisation and its practitioners interpret their role in addressing the physical-health consequences of psychosis and its treatments. The qualitative insights gained in the RFTS initiative have helped translate evidence into a practical resource that can broker more shared understanding and decision-making between those who use and those who provide services.
We have also developed links with a local non profit organisation, Ziggys wish. We are partnering with this organisation on an Arts Council Grant to support and evaluate a tour to change societal attitudes to psychosis.
As part of HOAX Our Right to Hope, working alongside and within it, PRU will carry out two mental-health research projects. The first will analyse general audience feedback both before and after each tour event, to see whether HOAX Our Right to Hope can help change society’s attitudes towards mental health and reduce stigma. The second will look at small groups of high-risk audiences, in specially supported tour events, to see whether HOAX Our Right to Hope can act as a clinical intervention to reduce self stigma.
This creates a win-win situation. PRU (health sector) benefits because the artwork provides them with an opportunity to evaluate novel intervention strategies that can impact on health outcomes: and Ziggy’s Wish (arts sector) benefits because, by being part of a valid health study, the artwork is given quantifiable value and social purpose. Further information can be found http://hoaxorth.com
Finally the EIP team work closely with our Psychosis Research Unit located within GMW and a joint initiative between GMW and University of Manchester. This means that services and people who use our services have access to innovative clinical research before it becomes mainstream clinical practice. Some of the clinical trials currently being run within our EIP services include
This approach of working closely with research colleagues ensures access to new treatment opportunities that would not necessarily be available through mainstream clinical services but also embeds the importance of evaluation and outcomes within the work we do.
We work with various outside agencies including
AqUA NHSE NIHR – In our efforts to reduce the time of untreated psychosis and roll out the expansion of early intervention into the over 35’s and those people with at-risk mental states, we have engaged in a programme of engagement with referrers from a wide variety of outside agencies. As well as partnering with service users to deliver our Away Days, we have invited local agencies, including child and family mh services, non-statutory drug and mh services to participate. With the finding that longer duration of untreated psychoses are associated with previous CAMHS use, we have focused specific efforts to improve referral and screening for psychosis in CAMHS. Onemethod was to offer a joint training placement for trainee clinical psychologists between the two partner agencies, which allowed improved communication and a specific audit project on improving the screening and referral process within CAMHS. This project is ongoing, but early indications are that it is improving referral and duration of untreated psychosis.
Partnership with the Octagon Theatre Headspace was developed alongside service users in collaboration with The Octagon Theatre. Led by a constituted group of carers and service users they provide opportunities for creative development and empowerment. Participants can engage in creative workshops:-eg animation, stand-up comedy, script writing.
Following on from these courses participants can enrol on leadership training and progress into developing and delivering creative courses (e.g. animation, creative writing) and mental health awareness/stigma training courses to a wide range of local agencies.
Partnership with BEST Developing a close working relationship with local employment agencies to jointly prepare people for work and link them to employment opportunities maximising their job prospects.
Sports As part of our determination to support physical wellbeing, engagement, community cohesion and development of support networks for our service users we have established, alongside service users a series of community integrated sporting activities such as Boxing, rock climbing, outdoor pursuits, badminton,
Partnership with Wildlife Trust Working alongside the wildlife trust to offer opportunities community conservation voluntary work opportunities.
Placing service users and carers at the heart of service provision and planning is a core value of early intervention. GMW have ensured that this is meaningful by involving our service users in a vast range of voluntary and paid activities. Service users were integral to the selection of our new cohort of staff employed to meet the RTT targets, contributing to shortlisting and interviewing. They have co-facilitated the training of new staff, delivered groups on mindfulness as part of the Trust’s recovery academy and have led on developing web-based information on psychosis and designing a user-friendly crisis card. In addition, they have been involved in presenting outcomes from evaluation projects at national and international conferences.
In an effort to reduce the stigma of psychosis and increase access to help, 12 of our service users collaborated with a local film-maker and BBC actress to produce a 4-minute film on what psychosis is and how EI can help in people recover (https://youtu.be/ PQxZCbZ97Vc). The film was launched in 2015 by one of our service users at an innovative event funded by the Wellcome Trust and organised by the University of Manchester that brought together artists, mental health professionals, academics and service users and their families to reduce stigma around psychosis. As well as being watched by thousands of people on YouTube, the film has reached tens of thousands of people via the national terrestrial Community TV Channel.
In recognition of the central and valued role that our service users play in delivering and developing early intervention services, we have developed an annual local award ‘Recovery Champion’ awarded to service users making a contribution to the team. In addition, two of our early intervention service users received a Highly Commended award from the region wide Trust values awards for their volunteer work supporting other EI service users in acute crisis, delivering therapeutic groups and their contributions to national and international conferences.
Peer Work We recruit volunteers to support the work that we do and utilise their expert by experience skills to help people entering services develop an awareness of the recovery process engendering hope from the moment they access services.
Headspace Led by service users and carers and training participants to confidently and competently take on leadership roles within our service.
Website We have employed a service user to develop a website that will enable people experiencing psychosis to access useful information about a range of resources and advice to manage any distress.
The challenges faced in GMW are no different to those within any other large Mental Health Trust. We constantly need to ensure we raise the awareness of Parity of Esteem at all levels, we fight to ensure funding is available in order to deliver quality services required for people who use our services and we continually strive to innovate and develop our service offer. This is against a back drop of tensions in the NHS with shortages of staff, difficulties with funding and reductions in social care budgets. A proactive approach to all of these difficulties ensures that transparent and honest discussions not just within the organisation but with commissioners and other partner organisations helps to ensure these challenges are met head one.
We have collaborated with the regional AQUA programme to develop quality assurance tools to ensure that our high attainment of RTT targets is maintained over the long term. Working closely with AQUA, we have developed visual tools that are used within our teams to represent live data to ensure that the team know if we are continuing to meet our RTT targets.
GMW has worked with the external improvement agency AqUA who award top performing organizations. The Advancing Quality Awards aim to recognise the trusts who have achieved the highest results. There were eight mental health trusts in the North West and RDASH and GMW MH NHS Foundation Trust beat the 7 other trusts in the First Episode Psychosis Categories. The awards were received based on performance and GMW NHS Foundation Trust had an Appropriate Care Score Target of 50.00% but gained a score of 83.67% overall for the year to date. With regards to the First Episode Psychosis team at GMW, the Appropriate Care Score Target was 67.41% and the overall score for the year to date was 97.66%. The Appropriate Care Score is a measure of how many of our patients (in the case of Dementia all those discharged from inpatient wards with a dementia diagnosis, in the case of First Episode Diagnosis all patients admitted to the Early Intervention Service) had all the reportable quality measures completed within the required timescales.
The Trust participates in the Advancing Quality Programme which is a quality improvement initiative live across all North West Hospitals that aims to raise the standards of care in common acute clinical conditions and diseases, including pneumonia, heart failure and heart bypass surgery, and mental health conditions, such as dementia and first episode psychosis.
During the Advancing Quality Programme Leads meeting there was a presentation of the End of Year Audit Results by Grant Thornton, the presentation of the AQ Awards, Year 7 – results to date, Public Reporting, Clinical Focus Area Update, AQ from Commissioning Perspective, AQ in Primary Care and an evaluation. There was also a report from the external auditors that are responsible for checking that our submission is backed up by evidence recorded in ICIS, and GMW received a verbal commendation for being the only mental health trust with 100% accuracy.
CAARMS train the trainers evaluation.
The training was delivered by a team of clinicians and researchers who have not only been using this tool for well over a decade but have also undertaken many of the research trials which have developed intervention strategies to work with this client group. Staff were exposed to a ‘gold standard’ training day on the use of the CAARMS which they would then be expected to replicate in their training of others. This day starts with delivering a background to the detection of At Risk Mental States (ARMS) and to the CAARMS assessment tool. Given the breadth of knowledge and experience in the delivery of clinical assessment tools in service settings, the rest of this day is spent practicing and discussing scoring with pre-recorded assessment role plays. This includes the use of agreed gold standard ratings.
The expectation for the facilitator being trained is to be able to deliver these days encompassing both this background knowledge and expert facilitation of the discussion and learning aimed at ensuring assessors can correctly administer and score the CAARMS assessment tool. Using the CAARMS is not an easy process and often offers many complex areas that can be experienced when attempting to rate ambiguous or confusing clinical presentations. In order to be able to deliver this to the highest of standards to correct scoring or procedural issues, delegates on the train the trainers programme spent an additional day and a half scoring and discussing further vignettes based on real cases with agreed gold standard ratings. Four of these were scored under test conditions and assessed according to a previously agreed criteria for what would constitute a pass (see below).
The final session involved undertaking exercises in preparation for their planned facilitation role. Delegates were asked to consider what they had learnt about the use of the CAARMS and how they had learnt these things. They were asked to consider how they could replicate this in the sessions they will be delivering. Additional time was spent on planning these sessions e.g. who should be trained, by whom as well as content of the day. Plans were also made for the additional work which staff will be required to participate in to enable their continued practice as a CAARMS trainer.
Delegates 30 staff from across the North of England region attended the residential course over three days in Manchester. The 30 staff have all provided their commitment to train others within their locality to use the CAARMS in clinical practice.
Assessment A requirement of the course was that participants pass the course as assessed by 4 vignettes rated on the CAARMS with a requirement that they scored clinical information accordingly on the CAARMS positive subscales. A vignette would be considered to be passed if the severity score was within 1 point of the gold standard, the frequency score was correct, the drop in functioning was detected and the outcome was right e.g. allocation of the group (below, ARMS, FEP). To reach competency level delegates had to pass 50% (2 of 4 vignettes) at this point with an expectation this this should be maintained over the next 12 months with the additional training days and supervision offered via conference call. Where delegates don’t reach the required competency we advise delegates to co-deliver training with someone in their local area who has reached this competency level. There will be further assessment points to pass continually over the 12 month training period so this can be updated efficiently.
Assessment Outcome Delegates completed scoring for the vignettes alone and submitted for marking (see table 2) for the outcome of this. Out of 30 delegates 27 delegates (90%) achieved the required level of competency. The majority (80%) of these passed to a high level (75% – 100%) (see fig. 1).
Greater Manchester West Mental Health NHS Foundation Trust 5 Boroughs Partnership NHS Foundation Trust Cheshire and Wirral Partnership NHS Foundation Trust Mersey Care NHS Trust
Assessment percentage
0% 1 25% 2 50% 3 75% 16 100% 8 Table 2. Assessment outcome for all 30 delegates
3 delegates (10%) did not yet reach the level required to recommend them as CAARMS trainers at this point. These delegates have been informed of this outcome and the advice to co-facilitate sessions with a delegate who has passed. These pairings have been suggested and we await the outcome of these co-facilitated sessions as the year progresses. These three delegates will be re-assessed at the earliest opportunity.
FAIL 10% LOW PASS HIGH PASS 10% 80%
Number of people Outcome Percentage
Assessment outcome
Feedback Delegates completed questionnaires to understand more about their expectations and desires for the training sessions. Questions related to level of confidence in assessing for ARMS criteria and in the training of others in this assessment were also asked. Questionnaires were repeated at the end of the course to assess for change as a result of the training attended. At the start of the training days delegates rated their confidence in using the CAARMS in assessing for ARMS on average was 44% (ranged between 0%-75%). At the end of the three day training period this had almost doubled to an average score of 79% with a score range of 50%-100%. Confidence in training others in the use of CAARMS in the assessment of ARMS was low overall at the beginning of the training days 31% (ranging between 0%-75%). By the end of the training delegates reported this to be on average of 62% (ranging between 25%-85%), double the baseline rating. Both of these reports suggest that delegates found significant benefit from attending the training. When asked to say what in particular had helped in these new ratings, delegates listed a number of areas which had been useful for them including: repeated discussions, video role plays, use of assessment and opportunity to gain feedback.
Next steps It is recognised that participants often feel a sense of false security when immersed in a training course and it is only when they return to clinical practice that some more challenging scenarios may arise which have not been tackled or the participant feels unsure about how to rate a specific symptom. Therefore in order to overcome this, there will be 3 further days spread out over the course of the year where participants will be invited to a full days training in Manchester in order to explore issues or difficulties associated with the application and scoring of the measure. Additional phone call support will be provided for participants outside of these training sessions should there be issues that arise which cannot wait until the follow up sessions. All delegates have been actioned to practice using the CAARMS in service settings in order to maintain what they have learnt so far and to continue to develop new knowledge. All those delegates who have reached the required competency will also be required to start facilitating sessions and those who have not yet reached these will be co-facilitating sessions with a matched delegate in their local area. Examples of both of these will be brought for further discussion in the planned phone call support and additional days training.
Finally in this section we are currently meeting the AWT standards across the organisation for April 2016 Bolton 80% Salford 84.6% Trafford 50% Trust 75%
GMW recognises the importance of dissemination and through the academic connections with the Psychosis Research Unit has published widely in relation to EIP
A wider selection of publications can be seen at our Psychosis Research Unit website. www.psychosisresearch.com
Additionally, Headspace participants are researching the outcomes of the stand-up comedy which appears to be showing extremely positive outcomes in relation to self- esteem, confidence, illness awareness, destigmatising psychosis and group cohesion. The group have now branched off into a comedy collective and are being booked to perform in various venues across the North West thus expanding on the mental health literacy of the general population. Their work is always exhibited, performed and showcased to wider organisations.
We feel that this coordinated and multifactorial approach to improving the life chances of people with early psychosis is vital. The organisation has worked hard with local commissioning teams to secure funding to not only meet the 2 weeks waiting time standard the teams will also be compliant with the NICE concordant treatments. But more than this the teams are looking beyond these challenging standards to augment this excellent care offer with further developments including access to new clinical treatments rigorously evaluated through research will ensure that the life chances of people with emerging psychosis continues to improve.
