Changing Minds Improving Access to Psychological Therapy (IAPT)

OPERATIONAL POLICY

Changing Minds Improving Access to Psychological Therapy (IAPT)

NHFT policy / OP/IAPT
Version: / 10.06.15
Ratified by: / Clinical Executive
Date ratified: / 00/00/0000
Implementation date: / 00/00/0000
Name of responsible Director / Chief Operating Officer
Review date: / 10.06.16
Freedom of information category: / Policy

TABLE OF CONTENTS

1 / Document Management / ...... / 4
2 / Introduction / ...... / 5
3 / purpose / ...... / 5
4 / definitions / ...... / 6
5 / duties / ...... / 6
6 / process / ...... / 6
6.1 / Philosophy of the Service / ...... / 6
6.2 / Hours of Operation / ...... / 7
6.3 / Service Access Criteria / ...... / 7
6.4 / Clinical Care Pathway / ...... / 8
6.5 / Referral Pathway / ...... / 8
6.6 / IAPT Service Specific Pathway / ...... / 9
6.7 / Treatment Thresholds and Decision Aids / ...... / 10
6.8 / Choice Appointment Not Attended / ...... / 10
6.9 / Non-attendance Step 2 Follow up / ...... / 11
6.10 / Completion of Step 2 Intervention / ...... / 11
6.11 / Step 3 Not Commenced / ...... / 11
6.12 / Non-attendance of Step 3 Follow up / ...... / 11
6.13 / Completion of Step 3 / ...... / 11
6.14 / Referral to step 4 / ...... / 11
6.15 / Discharge Pathway / ...... / 12
6.16 / Detailed Functions / ...... / 12
6.17 / Documentation and Record Keeping / ...... / 13
6.18 / Risk Assessment and Risk Management / ...... / 13
6.19 / Supervision / ...... / 14
6.20 / Performance Management and Review / ...... / 14
6.21 / Complaints, Compliments and Feedback / ...... / 15
7 / Training / ...... / 15
7.1 / Mandatory Training / ...... / 15
7.2 / Specific Training not covered by Mandatory Training / ...... / 15
7.3 / Professional Registration / ...... / 16
8 / Monitoring Compliance with this Document / ...... / 17

Document Management

Document Title / Changing Minds Improving Access to Psychological Therapies(IAPT) Service Operational Policy
Document Purpose (executive brief) / Changing Minds Improving Access to Psychological Therapy (IAPT) Service – to inform on the operational process and pathway of the service
Status: - New / Update/ Review / New
Areas affected by the policy / Changing Minds IAPT Service.
Policy originators/authors / Changing Minds Improving Access to Psychological Therapies(IAPT) Service Management Team
Consultation and Communication with Stakeholders including public and patient group involvement / NHFT Mental Health Services
Primary Care Steering Group
Archiving Arrangements and register of documents / The Trust Policy Lead is responsible for the archiving of this policy and will hold archived copies on a central register
Equality Analysis
(including Mental Capacity Act 2007) / See Appendix
Training Needs Analysis / See Section 7
Monitoring Compliance and Effectiveness / See Section 8
Meets national criteria with regard to
NHSLA / N/A
NICE / N/A
NSF / N/A
Mental Health Act / N/A
CQC / N/A
Other / N/A
Further comments to be considered at the time of ratification for this policy (i.e. national policy, commissioning requirements, legislation) / N/A
If this policy requires Trust Board ratification please provide specific details of requirements / N/A

2.0 INTRODUCTION

Northamptonshire has an established Improving Access to Psychological Therapies Service (IAPT) based on the developmental work of the Changing Minds Wellbeing Service. The Service is based on wellbeing principles, with choice at the centre of all its service provision. The service works to inspire its staff and service users to enhance and maintain their wellbeing within the local community.

The IAPT service provides Improved Access to Psychological Therapies for the population of Northamptonshire. The service is countywide and operates from three localities, Northampton, North Northamptonshire and Daventry/South Northamptonshire.

The service aims to provide improving access to both a range of NICE-approved interventions, including psychological therapies, and other therapeutic and wellbeing enhancing opportunities to people in Northamptonshire with common mental health problems.

The service contributes towards promoting mental health and wellbeing in the Northamptonshire area, liaising with existing organisations, and the development of accessible care pathways.

Changing Minds’ IAPT aims include:

• To develop and provide service models for delivering integrated, stepped-care for people who have mild to moderate common mental health problems and require access to evidence-based psychological therapies;

• To develop clinical protocols to ensure clinically effective treatments are available to service users;

• To deliver support and interventions in primary care and community settings that are optimally accessible to service users;

• To improve access and reduce waiting lists for psychological therapies;

• To improve individuals’ well-being;

• To support people in their occupational functioning and, where needed, support those that require assistance in a return to employment and meaningful activity;

• To provide a learning environment for staff that supports research and innovation.

3.0 PURPOSE

Changing Minds IAPT Service(NHFT)is a primary care mental health service that provides a range of high quality and effective mental health care provision for mild to moderate common mental health problems. The Service provides improved access to timely interventions, including low intensity guided self-help and high intensity psychological therapies.

4.0 DEFINITIONS

Improving Access to Psychological Therapies – IAPT

Northamptonshire healthcare NHS Foundation Trust – NHFT

5.0 DUTIES

There are four IAPT Teams across the county which provide countywide primary care interventions across four geographical areas. In the North and South of the County there is a manager/senior practitioner, an IAPT (Improving Access to Psychological Therapies) CBT Clinical Supervisor, Psychological Wellbeing Practitioners, Wellbeing Workers, Wellbeing Therapists (IAPT High Intensity workers), and Administrative Staff.

Some staff have specific roles (such as Step 2 Clinical Lead, Step 3 Clinical Lead, Diversity Lead, IM&T Lead) as part of their job.

Although some of this Operational Policy encompasses how Peer Support operates, further information on these two parts of the Changing Minds Service is described in other documents available from the Line Manager of those parts of the service.

Medical Responsibility GPs retain medical responsibility for people receiving therapeutic input from the IAPT Service.

6.0 PROCESS

6.1 Philosophy and values of the service

The service operates within the following core values, closely aligned to the Ten Essential Shared Capabilities:

• To provide services which promote recovery, hope and self-management;

• To invest in training and development for staff in order to build a skilled and compassionate workforce that can deliver a range of evidence-based interventions;

• Working towards reducing stigma and discrimination for those we provide a service to;

• To believe that everyone should be acknowledged and respected as an individual with their own beliefs, values, experiences and needs;

• Within legislative constraints to endeavour to empower everyone to exercise personal choice and responsibility for themselves and acknowledge any consequences their actions may have on others;

• To endeavor to use research-based evidence to provide safe and effective care to the therapeutic benefit of people who use the service;

• To endeavour to work positively with risk in order to provide a safe and supportive environment for people who use our service and staff;

• To deliver care in partnership with the people who use our service, carers, and statutory and non-statutory organisations in order to provide an integrated service;

• To use the least intensive interventions suitable for the recovery and return to optimum wellbeing of the people who use the service;

• To promote autonomy, collaborative working and choice in a clear and transparent manner;

• The service works within IAPT national guidance and local policies, professional codes of conduct and legal and ethical frameworks in the provision of care.

6.2 Hours of Operation

The usual formal hours of operation will be Monday – Friday, 9:00am – 5:00pm, exclusive of Bank Holidays. However, the service strives to be flexible in its working hours as commissioned whilst being safe and appropriate for staff and patients who use the services. At times, people are being seen outside these normal operation hours, when staff adhere to the Lone Worker Policy and remain supported by the on-call rota.

6.3 Service Access Criteria

In order to ensure that an efficient service is being run which adheres to IAPT national guidance all referrals are audited. GPs and other clinical staff who have referred people who are outside of the inclusion criteria will be contacted to discuss the referral to address the issue. The Changing Minds IAPT service is commissioned to provide a service for the following patients:

INCLUSION CRITERIA
People aged 16 and over who experience common mental health problems which impact on their capacity to self-manage, whose scores are PHQ9=10 and GAD7=8 or above and who are not at risk of suicide are suitable for referral, unless they have a Long Term Condition where their low level mental health problems impact on their ability to self-manage, a diagnosis of dysthymia, health anxiety, PTSD, OCD or specific phobia.
People with PTSD symptoms, OCD, health anxiety, specific phobias and dysthymia may score under the PHQ9/GAD7 threshold, but still experience significant psychological distress. These people are eligible for referral to the service.
People with medically unexplained symptoms and long term conditions who are experiencing mild to moderate presentations of depression or anxiety which impact on their ability to self-manage may be referred.
People must be registered with a Northamptonshire GP, or eligible to be registered, to be suitable for the IAPT Wellbeing Service.
EXCLUSION CRITERIA
People scoring under 10 on PHQ9 and under 8 on GAD7
People at significant risk of self-neglect, suicide or dangerous levels of harm to themselves or others.
People attending psychiatric outpatient clinics.
People supported on Care Program Approach (CPA) within Secondary Care.
People with psychosis or organic impairment such as dementia or brain injury.
People with a primary problem of substance or alcohol misuse.
People with enduring personality difficulties and who clearly have more complex treatment needs.
Relationship problems & Adjustment Disorders
People with eating disorders as the primary diagnosis
People with anger as a primary problem

Due to the structured nature of CBT it may not be suitable for people with more complex mental health needs or learning difficulties.

CBT focuses on the individual’s capacity to change themselves and does not address wider problems in systems or families that often have a significant impact on an individual’s health and wellbeing.

6.4 Clinical Care Pathway

The IAPT Service follows the Stepped Care Model for common mental health problems.

Stepped care is a system of delivering and monitoring intervention so that the most effective, yet least resource-intensive, intervention is delivered to the person using the service. This model is recommended by the National Institute for Clinical Excellence (Common mental health disorders - Identification and pathways to care. National Clinical Guideline Number 123).

6.5 Referral Pathway

The IAPT and Peer Support service operates within Primary Care and accepts self-referral from patients and referrals from health professionals. Referrals from health professionals will be made via the ‘Single Point of Access’ and must include patient contact details, PHQ 9, GAD 7, summary of the patient problem and a risk assessment. Should a patient self-refer the above information will be collected by a member of the IAPT team at time of their referral.

IAPT Northamptonshire commissioning agreement stipulates that patients waiting time for an assessment appointment should not exceed 28 days/6 weeks.

6.6 IAPT Service Specific Pathway

• All referrals will be triaged and allocated to the appropriate part of the care pathway. Where patient need is unclear, the patient will be contacted via a telephone call in order to gather further information;

• Allocation to the care pathway will trigger a letter to be sent to the patient informing them of how to book an assessment appointment.Letters will also include information on how to access the services ‘Webinar’ groups and self-help information patients can utilise prior to their assessment appointment to support their recovery;

• Patients will opt into the service by calling to book their appointment. Patients will be offered the choice to attend either a face to face appointment within their GP surgery or a telephone appointment at Step 2 or a face to face appointment within an appropriate community setting at Step 3;

• Assessment at both Step 2 and Step 3 will allow time for the patient to discuss their difficulties and agree an appropriate care plan based on evidence based interventions for the distress they are experiencing;

• Following each assessment each patient will be reviewed within clinical supervision as per IAPT clinical supervision guidance (Reach out 2012). Part of the supervision process will be to review whether the patient is being seen within the relevant part of the care pathway (Step 2 or Step 3) and decision making can be made with regards to step up or step down at this time;

• Once within the treatment phase of the care pathway patients will be reviewed within clinical supervision as per IAPT policy guidance (Reach out 2012). Decisions regarding movement within the IAPT or wider NHFT service care pathways will be made within clinical supervision, or where urgent need dictates, via discussion with the patients GP and the duty worker.

The Wellbeing Service operates within Primary Care and therefore accepts referrals from Primary Care services. At the present time people can opt-in via their GP to The Wellbeing Teams, and people can self-refer to the Peer Support Service.

The following refers to the Pathway for the Wellbeing Teams specifically:

• Wellbeing workers will only see patients for a Choice Appointment once a referral has been received and an appointment has been booked;

• People will on receipt of a referral have the choice to opt into the Wellbeing Service by booking their own Choice Appointment/Assessment at Step 2. People are expected to arrange their Choice Appointment within one month from referral. Where patients do not book their appointment within this period their GP will be informed and a re-referral would be required if necessary;

• People can access and can be offered a ‘Choice Appointment’/Assessment at Step 2 at the GP Practice or at Community venues where Wellbeing staff are based;

• An important aspect of the Choice Appointment (entry level) is that the person is guided through a process that will enable them to choose from a range of therapeutic options at Step 2, including a therapy modality choice as well as signposting to other relevant services appropriate for their presenting needs;

• Changing Minds’ contract for The Wellbeing Teams requires that waiting times are not to exceed 28 working days/six weeks from referral to assessment (i.e. Choice Appointment).

6.7 Treatment Thresholds and Decision Aids

• At the end of an initial assessment (“Choice”) appointment the worker and patient consider therapeutic options together and the worker may make some recommendations. One of the options to consider is one-to-one Step 2 follow up. This usually consists of up to 4 further appointments and could include telephone follow up. Where more appointments may be required this should be discussed in supervision, ideally before the fourth follow up appointment. Usually up to 2 additional Step 2 appointments may be agreed in exceptional circumstance when making progress and not suitable to step up. The majority of people are successfully discharged following step 2 interventions;

• Step 3 therapy may be considered following a review of needs with the patient and in clinical supervision. As long as step up criteria are met. The referrer is informed by letter if a Step 3 intervention has been agreed with the patient. Patients are advised in writing to consult their GP and/or the Peer Support service if they are concerned about their wellbeing in the period following Step 2 interventions and before Step 3 has commenced;

• Step 3 interventions should be considered in clinical supervision under the following circumstances:

• Where the Minimum Data Set (MDS) rating scales indicate continuing significant distress following a Step 2 intervention;

• Presentations of Post-Traumatic Stress Disorder, Obsessional Compulsive Disorder, or Complex and Persistent Anxiety and/or Depression.

• Step 3 contracts need to be agreed with patients for continuation into Step 3 therapy.

6.8 Choice Appointment not attended

Where a person has booked a Choice Appointment and does not attend without notification, the IAPT Worker will attempt to contact the patient by telephone and they will have the opportunity to re-book an appointment, and this will be documented on their clinical record. Where it is not possible to speak directly with the patient a standard letter is sent in which they will be invited to re-book an appointment within a fortnight from receipt of the letter. Should a patient not rebook within this time the clinical episode is closed and the referrer informed.

6.9 Non-attendance Step 2 follow-up

Where a patient does not attend a scheduled follow-up appointment the worker will initially attempt to contact them by phone to reschedule. In the event of failure to contact by phone, a standard letter will be sent inviting the patient to re-book an appointment within 14 days of receiving the letter. Should the patient choose not to respond to this reminder or declines another appointment, their clinical episode will be closed and the referrer informed. Cases of non-attendance at Step 2 should be discussed in case management supervision.

6.10 Completion of Step 2 Intervention

People who complete an intervention at Step 2 will usually be discharged. The clinical episode is closed and the referrer is informed.

6.11 Step 3 not commenced

Where a Step 3 intervention has been offered, but the patient chooses not to attend, the Step 3 worker should consult the patient, the clinical record and the GP to determine the most appropriate course of action, and the outcome recorded. Cases of non-commencement at Step 3 should be discussed in clinical supervision.

6.12 Non- attendance of Step 3 follow-up

Where a patient does not attend a scheduled follow-up appointment the worker will initially attempt to contact them by phone to reschedule. In the event of failure to contact by phone, a standard letter will be sent inviting the patient to re-book an appointment within 14 days of receiving the letter. Should the patient choose not to respond to this reminder or declines another appointment, their clinical episode will be closed and the referrer informed.Cases of non-attendance at Step 3 should be discussed in clinical supervision.