Transcript Why Commission Early Detection Services?

Why Commission Early
Detection Services?
John Marshall
Assistant Director Commissioning
ALWPCT
What I want to cover
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Policy Context for commissioning
Policy Context as it relates to mental health
LDP Targets
Evidence
DUP /DUI
Economics
Added Value of Provider
Summary
Personal thought.
Policy Context for
Commissioning
• NHS Plan (2000)
• Shifting the Balance of Power (2001)
• National Health Service Reform and Health Care Professions
Act (2002)
• Delivering the NHS Plan (2002)
• Plans for Foundation trusts (2002)
• NHS Improvement Plan (2004)
• Choosing Health (2004)
• Our health, our care , our say (2006)
• CPLNHS (2006)
Effective commissioning makes the best use of
allocated resources to achieve the following
goals:
• improve health and wellbeing and reduce health inequalities and
social exclusion;
• focus on prevention and early intervention
• secure access to a comprehensive range of services;
• improve the quality, effectiveness and efficiency of services; and
• increase choice for patients and ensure a better experience of
care through greater responsiveness to people’s needs.
Policy Framework Mental Health
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‘New Ways of Working for
Psychiatrists’ – enhancing
effective person centred
services through new ways of
working in multi-disciplinary and
multi-agency context;
Out Health, Our Care, Our Say
– a new direction for community
services;
Everybody’s Business:
Integrated mental health
services for older people – a
service development guide;
Making it Possible: Improving
Mental Health Well-being in
England – Care Standards
Improvement Partnership &
NIMHE;
From Values to Action: The
Chief Nursing Officers review of
Mental Health Nursing;
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The Neglected Majority –
Sainsbury Centre;
Social Perspectives Network for
modern mental health;
NSF’s, Children/ Adults Older
People
The NSF 5 Years on.
The Journey to recovery
The Future of Mental Health:
Out Vision for 2015 – Sainsbury
Centre/LCA/NHS
Confederation;
Services Users and Carers:
Our Vision – Rethink;
Mental Health Act;
PbC, PbC, PbC/PbR, PbR,
PbR.
LDP Targets.
• PCT’s are required to commission Early
Intervention in Psychosis Services.
• Number of people with newly diagnosed
cases of first episode psychosis receiving
early intervention in psychosis services
• Local target is for 164 places over 3 years.
• Recovery target of 54 places per year.
• Our needs assessment indicated that we
would need no more than 90 places.
• This was based on ………
Number of people receiving early intervention
services.
• Assumptions of numbers requiring early intervention figures are based
upon local needs assessment.
• Population aged 15 – 34 in Wigan = 78,889 (2001 Census)
• Actual number of in-patient admissions to Wigan services for individuals
aged 17 – 25 with first episode diagnosis of schizophrenia.
• 1998 = 25, 1999 = 24, 2000 = 22
• Incidence figures from study by Scully suggest an expected
prevalence rate of 2 – 4 individuals per 10,000 of relevant population
which equates to an assessed need between 16 – 32 individuals per year.
• Given the actual number of admissions and the expected prevalence we
believe that our plans for a service for 30 new case per year, leading to a
total case load of 90 over 3 years are adequate.
Current performance against
target
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62 people in service over 2 years
Expected Outturn of 30 this year.
3 potential reasons for this.
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ii.
The trajectories are not accurate.
The services within Wigan have affected the prevalence rate
of psychosis thereby affecting trajectories.
The current EI service is not effectively capturing all new
cases of psychosis.
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Evidence
• There is a growing body of good evidence to
support the development of Early Detection
Services.
• However Cochrane review States
“At the moment it is not clear whether treating people presenting
with prodromal symptoms of schizophrenia provides any
benefits. There is insufficient data on personal and social
consequences of providing treatment to people who will not
necessarily become unwell. Specialised treatment services for
people with prodromal symptoms are only justified on an
experimental basis.” (Marshall et al 2006)
Cochrane also says
“For people in their first episode of psychosis there is
little evidence to support the intervention of specialist
teams for people in their first episode of psychosis.
However, since such people do require treatment in
some form, the ethical issues are less intense than
for people with prodromal symptoms.”
However
• Many other mental health services have
been developed without solid RCT
methodology, initially, and have proved
to be successful.
• Case Management, Home Treatment,
Assertive Outreach,
• Treatment for Hay fever ………
• Early Intervention is a National priority.
And it is not just us.
Canada’s Early Intervention Services
Newfoundland
British Columbia:
•EP Initiative of British Columbia
•EPIVMHC,Victoria Alberta:
•Vancouver
•EPT&PP, Calgary (930,000)
•EPIP, White Rock
Saskatchewan:
•EIPP, Saskatoon
Key figures:
•Jean Addington
•Bob Zipursky
•Ashok Malla
•Lili Kopala
•N&L EPP
Quebec:
Nova Scotia:
•Levis
•NSEPP
•Montreal
•Quebec City •Halifax -
Ontario:
•PEPP, London
•FEPP, Toronto
•Psychotic Disorders U., Hamilton
•Ottawa FEPP
•KPP&TP, Kingston
Early Psychosis Programs in the USA
Portland, Maine
Salem, Oregon:
•Early Assessment & Support Team (EAST)
(pop 600,000) Managed care funded
•PIER service (McFarlane)
Yale, New Haven:
•PRIMHE (T. McGlashan)
Bethseda, MD:
•NIMH research:(Wyatt etc)
New York:
•Prodrome (Cornblatt)
Pittsburg:
LA California:
•EI program (Keshevan)
•UCLA (Ventura, Neuchterlien etc)
N. Narolina:
•FEP & prodrome studies
(Lieberman)
New Zealand’s
Early Intervention Services
New Zealand National Early Intervention Group
• Auckland: EPI Centre, Kari Centre, Taylor Centre, Manaaki CMHT
- FEP, St Lukes FEP, Hartford House EPI, Campbell team Lodge EI
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team
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•Wellington: Wellington EI service (400,000)
•Christchurch: Tatara House EIP service (380,000)
•Dunedin: Aspiring House EI service (150,000)
Early Psychosis Programs in Australia
National Early Psychosis Project (based at EPPIC)
Queensland:
•Uni of Brisbane studies
New South Wales:
•YPPI service, Gosford
•EP program, Marouba
•EP program, North Sydney
•EPIP-SWAHS, Liverpool
•EPIC, Penrith
•Western Sydney FEPP
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Western Australia:
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•First Psychosis Liaison Unit,
Bentley
South Australia:
•EPOES, Fremantle
•Noarlunga EP Program
•EEPP, Rockingham
/Kwinana
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ACT:
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•Canberra EI service
Victoria:
•EPPIC
•Dandenong
•EP Program, Alfred Hosp.
•Central East EP Project
South East Asian Early Psychosis Network
South Korea
Tokyo, Osaka
Hong Kong: EASY
- 4 teams cover 7M
(Eric Chen et al)
Singapore:
EPIP
1 team covers 4 M
(S. Chong et al)
(South Africa)
Palau,
Miconesia
Swiss Early Psychosis Programs
Bern:
•Uni Hosp. of Social & Comm. Psych.
(Gekle) (Merlo - moved to Geneva)
Basil:
•Uni Hosp. Basil: Basil FEPSY screening
study (Gschwandtner et al)
Geneva & Zurich:
Swiss Early Psychosis Project SWEPP
(Simon, Umbricht & Merlo)
German Early Psychosis Programs
Dusseldorf:
•RCT of psychological Rx in FEP
(Klinberg)
Cologne:
•Cologne early Recognition study
(Klosterkotter, Schultze-lutter et al)
Bonn:
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•Prodrome Rx (Hambrecht et al)
Mannheim:
•Central Insitute of Mental Health
(Hafner, Maurer et al)
Heidelberg:
•Heidelberg Early Adolescent & Adult
Recognition & Therapy Centre for
Psychosis (HEART) EI service since
since 1994 (Franz Resch et al)
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Vienna, Austria:
•Adolescent EI program at University
Hosp. of Vienna (Amminger, Edwards)
Scandinavian Early Psychosis Services
Finland:
•Turku: Detection of early
Psychosis project
(Suomela et al)
Norwegian Services:
•TIPS - Roskilde/Stravanger
(Larsen, Johannessen etc)
•UNA-projektet, Oslo
•EOP, Skien
Swedish Services:
•Parachute Project (1.5 M), Stockholm
•Sodertalja Psykiatriska Sektor, Sodetalje
•TUPP Project, Stockholm (Cleland)
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Early detection
Standard
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DUP (median in weeks)
Dutch & Belgian EI Programs
Netherlands:
Belgian Projects:
•PECC (Janssen-Cilag)
•Academic Medical Centre (Don Linszen)
•University of Maastricht: NEMESIS (Van
Os, J.)
•University Med Centre, Utrecht (Dutch
Prediction of Psychosis Study- DUPS)
Other European Projects:
•European Prediction of Psychosis (EPOS) study (6 centres: Birmingham,
Amsterdam, Cologne, Turku, Santander, Dannstadt)
•Dublin: SJOG Hospital (E. O’Callaghan)
•Bordeaux: (Helen Verdoux)
•Barcelona, Madrid, Santander: 4 prodrome research programs
•Lisbon: planning EI service
•Eastern European, Russian & Middle East: research programs & plans for services
Summing up RCT’s
“Strictly speaking randomised controlled trials are still needed to
confirm the effectiveness of early detection and intervention
services. However, the testimony of patients and families, non –
randomised evaluations of services such as those provided by
EPPIC and obvious validity or common sense supports their
wider introduction.” (Lewis and Drake 2001)
“It should be acknowledged that scientific evidence is not the
only driver of service reform; socio-political factors, including
political pressure and community demand based on perceived
gaps and deficiencies are also potent forces.” (Edwards et Al
2005)
DUP / DUI
• Duration of Untreated Psychosis DUP
the amount of time from onset of symptoms of
psychosis to the prescription of antipsychotic
medication
• Duration of Untreated Illness DUI
the amount of time from the recognition that
things are not going well to the prescription of
antipsychotic medication
Duration of Untreated Psychosis
Duration of untreated Psychosis and
Duration of untreated illness
500
DUP
450
DUI
400
350
Weeks
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250
200
150
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Loebel et al 1992
Beiser et al 1993
Hafner et al 1993
Studies
McGorry et al 1996
Drake et al 2000
Reduction of DUP/DUI should be the core business
of Early Intervention services
“DUP has been reported to be 1 to 2 years. Case note narratives
and studies of pathways into care suggest that this period is
characterised by contacts with criminal justice services, visits to
a and e and interruptions to employment. All of these
consequences incur costs, and interventions to reduce DUP
should reduce these.” (McCrone 2007)
YET
“DUP is not a valid measure for establishing the effectiveness of
early intervention services that aim solely to provide evidence –
based care in an assertive manner without an early detection
arm” (Swaran P. Singh (2007)
Economics
• Schizophrenia 2 to 3% of total NHS budget.
• Extrapolating PCT total budget of £450m
• £9m to £14m of a £30m mental health
budget.
• Locally just under 1000 people with psychotic
disorder.
• Per person = £9000 to £14000 per patient per
year, NHS costs.
Economics cont’d
• Service sees 60 people per year
• Potential costs if 100% Transition
• Range £480,000 - £840,000
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Potential cost of 30 – 40% transition
2% £480,000
30% =£144k 40% = £192K
3% £840,000
30% = £252k
40% = £336k
Unknown savings on SS costs
Potential significant saving for those who may have
transited without early intervention.
The provider
• BST are one of the few organisations in the world
delivering Early Detection Services.
• BST have the relevant skills to deliver the service.
• The service is and will continue to be subject to
robust research and evaluation.
• The service will provide additional expertise to
our whole system and bring added value.
• The service will complement and enhance our
current early intervention service.
• Wigan residents will benefit from a cutting edge
service.
In Summary
• NHS policy expects commissioners to be effective
commissioners who increasingly focus services upon wellbeing,
prevention and early intervention.
• In mental health terms this is about transforming services to
focus upon individuals rather than services
• The requirement to deliver Early intervention Services is a
recognition of these agendas.
• This service will help the PCT to meet it’s targets around Early
Intervention.
• Commissioners need evidence of effectiveness to commission
services, however, evidence comes in many shapes and forms
and services have not traditionally been developed after
successful RCT’s
Summary cont’d
• The evidence for Early Intervention and Detection is developing,
but there is growing international evidence that these services
are effective. This is supported by the level of both international
and national resources being ploughed into this area.
• There is an emerging view that Early Intervention Services will
not reduce the duration of untreated psychosis without an Early
Detection function associated with the service.
• The economic arguments for preventing or delaying the onset of
psychosis are compelling.
• The added value in terms of skills, training,research and
evaluation that this service will bring cannot be underestimated
Finally
• A Personal Thought…………..