Counselling and Psychological Therapies Care Pathway Workshops

INTRODUCTION Liverpool CCG held a six two hour workshops between December 2013 and Feb 2014 to explore the care pathway for counselling and psychotherapy services in Liverpool. Issues were shared and debated at the various workshops. Practitioners and clinicians from primary care, Inclusion Matters, Mersey Care and third sector providers were invited, as well as commissioners from CCG and LCC. The workshops were themed as follows:

4/12/13: Introduction & review of current care pathways 12/12/13: Ideas & proposals for lifting the current provision from good to great? 8/1/14: Draft outline of a new care pathway 15/1/14: Working with step 4 and other specialised services 29/1/14: Working with the Third sector 5/2/14: Working with children and young people’s services

The report is presented in 7 sections as follows:

1. Understanding the current care pathway 2. What would lift this from good to great? 3. Outlining the proposed care pathway 4. Understanding step 4 provision 5. Integrating step 4 into the care pathway 6. Voluntary sector 7. Children and young person’s services

Attendance is summarised on the final page, though for note, not all attendees were invited to every workshop, depending on the themes & topics under discussion.

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Counselling and Psychological Therapies Care Pathway Workshops

Step 1

UNDERSTANDING THE CURRENT CARE PATHWAY What have we got already? (4th December 2013)

What would lift this from good to great? th (11 December 2013)

Samaritans Walks for Health/Exercise for Health Mental Health Day Services (LCC) Health Trainers Directory of Services Healthwatch 3rd Sector Social Support Advice on Prescription Healthy Homes C.A.B Advocacy Project Workforce Support Alcohol Addiction CBT Friends & Family Liverpool Bereavement Service LCAS Suicide Prevention Training Universal/Primary care informal support Active monitoring if situation breaks down for an individual Mainstream Imagine Delivering Race Equality CDWS

Better use of groups for people with enduring needs Understand my identity & experience and choice Create a culture of services which are friendly and encouraging

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Assessment – Decision to Treat

Assessment – Decision to Refer

Counselling and Psychological Therapies Care Pathway Workshops Asylum Link Intensive Care Endoscopy Pain Management Cancer Services Employment referral form Imagine COMPASS Bereavement Service Asperger’s Services Learning Disability Services Transgender Services Merseyside Chinese Community Association Liverpool Housing Trust Age Concern Crisis Team CMHT Health Visitors A&E Liaison GP holding at step 1

360◦ assessment – psychological, holistic, social Understand distress, social circumstances

Face to Face @ IML Initial Telephone Assessment @ IML Opt in @ IML COMPASS (Self referrals) Paper Screening @ IML GP’s

Clarity about what is being assessed I.e. How do we define assessment for CPT? Empowering clients to understand & say what matters to them Encourage self-assessment Better relationships between commissioners & providers Easy Pathways so patients are not bounced back to GP’s therefore they don’t meet criteria Personal O/C’s agenda – meaningful O/C measures Interoperable information systems User-defined outcomes (e.g. Recovery Star)

Drop in service e.g. Hartlepool MIND Zero waiting More timely access I.e. people receiving help earlier Introduction of a mutual model Self-referral of patients

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Mutual Model Positioning Diversity within workforce Communication Supervision Better use of systemic psychological approaches for people with multiple/complex needs Class Age Gender Bespoke services for minority groups Familiarity with my world? Choice? More flexible ‘on demand’ access – not limited. E.g. 6 x 30 min sessions but based on users’ expressed needs What are the access issues to step 2 IML for people with learning disabilities? ?

Step 3

Inclusion Matters COMPASS Student Counselling Services Veterans IAPT (regional) Liverpool Bereavement Services

Acceptance of dual or triple diagnosis & PD – step 2 can still help

Refugee & Asylum Seekers (Allotment Project) Psycho-sexual Services Gender Dysphoria Services

Veterans IAPT service – need to check this – may fit better at step 1 & 2 for Liverpool

Step 2

No priority listing @ IML Sign Health BSL LCC & NHS Occupational Health Schemes Post Natal Depression @ PSS Exercise on Prescription Low intensity self-help guidance @ IML

Step 3/4

Counselling and Psychological Therapies Care Pathway Workshops

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Counselling and Psychological Therapies Care Pathway Workshops

Step 4

IML provides ‘Step 3b’ (Personality Disorder; complex PT&D) Early Intervention Psychology Acute Care Psychology (Acute Wards, PICU) Student Mental Health Service Psychotherapy – CBT, Family, CAT Adult & Older Adult - CMHT Psychology, Integrative work Facilitative Aspect Trauma & rehab services MCT (part of regional service) Psychosexual services (LCH) Eating disorder services MCT Democratic therapeutic community day programme (Rotunda, MCT) Psychotherapy services MCT Personality disorder hub and spoke service MCT Out of area treatments – various

Equal emphasis on psychological formulation not just psychiatric diagnosis in 2◦ care Resources increased for step 4 provision Real explanation around need for threshold for step 4 and clearer pathways to step up Many people fall into ‘gap’ between Primary and Secondary therapies

15th January 2014 Individualised & Formulation driven integrative therapies CAT 16 – 24 sessions CBT 16 – 24 sessions Positive Behavioural Support Group analytic therapy Eye movement desensitisation & reprocessing EMDR Psychodynamic therapy Systemic therapy Dialectical behaviour therapy MBT – mentalisation based therapy Schema based therapy Brief parenting-infant work

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Counselling and Psychological Therapies Care Pathway Workshops What would lift this from good to great?: (Across Whole Pathway) Build community resilience & improve wellbeing (prevention) Psychosocial activities Creative Therapies/Support Mindfulness Prevention Clear and accessible referral pathways/routes to support Improved information & support around self-help, linking and signposting to social activities & support at each stage of stepped care model Training – Basic MH & wellbeing training for non-mental health staff to support people to self-help Awareness raising to reduce stigma & discrimination around MH Emotionally and psychologically literate communities Better informed GP’s – awareness of NICE guidelines E-therapy Awareness of psychological distress in local schools & communities Targeting at specific pop’s Real ? about local prevalence initiatives to engage those who could benefit from 4 therapy Active working relationships across organisational boundaries Patient ‘held’ records – EMIS, baby system, LD system? More secure funding for 3rd sector Better forward planning One governance framework across multiple providers Possibilities of longer term help than 6 sessions standard Joined up clinical training & clinical supervision across ‘steps’ Standardised referrals (pro-forma) & mechanisms of sending referrals All comms to GP’s electronic directly to GP systems – MIH? Full intr?? Between providers? system to serve/report relevant information and improve audit trails. E-Comm between providers for referrals, discharge and reports Centralised reporting i.e. uploads for commissioning Integrated care pathways Joint working instead of hand-offs More shared ownership of referral pathways & clearer referral routes Health Action plan/relapse/prevention plan/recovery plan Collaborative care for people with LTC’s Better awareness within each sector of what other sectors can provide Better liaison with practices & services

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Counselling and Psychological Therapies Care Pathway Workshops What can I contribute? Intelligence needs time Advocate for psychological therapies, prepare the strategic case, be open to change and criticisms IML – Commit to working collaboratively Commit to working flexibly and if required change delivery model Contribute experience of attempting to manage capacity & demand Procurement advice Make good contractual arrangements & monitoring Offer public health advice & support Work in partnership with PMHC Continue to support, champion and influence decisions around the Public Health agenda locally and across the Cheshire & Merseyside Network Suicide reduction plans and activities Local face experiences: GP for > 30 years MD +20 JL +10 Karthi Credibility amongst fellow GP’s Commitment to see things through Advocacy IM&T systems – Advice, Delivery, Integration, Reporting

Establish relationships Collaboration Willingness to change

Facilitating of independent service user/carer/stakeholder/input Co-ordination/collation of stakeholder input Offer explanation about specialist therapies Contribute to a guide for FAQ’s Provide a concise evidence and use for the effectiveness and efficiency of therapy.

What do I need in order to make my contribution? Intelligence needs time Better intelligence and information about what we’ve got currently & haven’t; info from organisations Data about activity and outcomes

Intelligence, shared learning, financial mapping, collaborative working Commitment to try & improve services Resources, collaboration and time

Dedicated time Support of fellow GP’s Experience of previous iterations / Levels of service Recognition of gaps in services

Understand services – stakeholder requirements: Existing systems; Service as is/to be Info requirements to support process Buy in from all levels Person-centred articulation of life issues Systemised access to non-clinical (needs joint working with LA) Clarify ‘routes’ between non-clinical sector therapy services Time, Resources

Time to attend meetings, support from 2◦ care colleagues to collaborate in process

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Counselling and Psychological Therapies Care Pathway Workshops Provide previous work scoping needs of Liverpool pop against PBR clusters & implications for appropriate 4 response & workforce Engage the interest participle of stakeholders in MCT in agenda for developing 4ical services

MAD • Action to Step 1 provision – constant change, lack of clarity • Lack of sustainability 3rd sector • Waiting times, lost letters • We still haven’t got the pathways & relationships in place • Lack of joined up commissioning

SAD • Lack of joined up services • Wasted appointments • Wasted precious resource • Quality of GP referrals • Can’t get services to the right people at the right time • People who drop out • We still haven’t got the pathways & relationships in place • Rationing • Psychological therapies still a Cinderella service • Level of need exceeds provision • Real & serious need is overlooked by requirement to deliver a ‘lowest dosage’ model

GLAD • Skills • Commitment • Passion • Quality of services, step 2, 3 and 4 • Availability of psychological therapies, 7000 – 8000 people • Partnership working • Collaborative working • Priority

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Counselling and Psychological Therapies Care Pathway Workshops OUTLINING THE PROPOSED CARE PATHWAY 8th January 2014 Key Issues • Significant & increasing levels of mental health need • Current care pathways are resistive • Access – unclear, fragmented • Need to improve preventative & quality outcomes • Access to psychological therapies for people with LTC • Need to tackle risk factors & complexity – poverty, loneliness, social exclusion, dual diagnosis Role of Psychological Wellbeing Practitioners Assess and treat people with common mental health problems Assist people to help themselves Work through telephone and internet contact methods See clients face to face Provide support with medications management Work with Health Trainers Work with Employment Advisors Work within a collaborative Care approach Receive both case management and clinical skills supervision Work with the local community to enhance access and self referral such as psychosis or bipolar disorder

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Counselling and Psychological Therapies Care Pathway Workshops Feedback on the model: Consider demand currently going through A&E Motivational Interviewing better described as Active Listening and CoProduction Consider a shared approach to Assessment across the pathway. The Step 2 role is skilled work – do we need to invest in this workforce? Include Psycho-educational Groups within ‘signposting’ destinations Signposting destinations could become a managed network The Step 1 services need to ‘wrap around’ all the steps Psychological distress is not to be equated with SMI Some people need specialised psychological therapies but don't need to be part of a service for Mental Illness. There is a psychological framework which sites inside secondary mental health care – we need a care pathway into psychological therapies Need to consider Assessment and Interface in more detail (with Informatics support) Enablers for the model Information and Intelligence Shared Information Systems Communications and Liaison Outcomes for Active Listening and signposting Workforce development and training Skilled Workforce

UNDERSTANDING STEP 4 PROVISION 8th January2014

The majority of Step 4 psychological therapies in Liverpool are provided by clinical psychologists and psychotherapists in Mersey Care Trust. All referrals to MCT come through the single point of referral. (The only exceptions to this are the Eating Disorder Service which accepts direct referrals with clear threshold criteria and the Student Health Service which is separately purchased for students of Liverpool University), Specialist Step 4 practitioners are integrated into community and acute care teams, for Liverpool these include:5 CMHT’s (7.8 WTE) 10A CMHT (2.0 WTE) EI (1.8 WTE)

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Counselling and Psychological Therapies Care Pathway Workshops Home Treatment (1.0 WTE) 4 Acute Wards (1.6 WTE) PICU (0.6 WTE) Provision of specialist psychological therapy within teams is negotiated at multidisciplinary meetings, clinical psychologists work ‘to capacity’ therefore do not have referrals, rather work with teams to negotiate who could most benefit from the resource for psychological therapy. Access to the stand alone Psychotherapy and PD Hub Service is via internal referral from MCT teams. (This is on a notional capped basis as the service has the capacity to accept up to 20 initial referrals per calendar month). Initial triage from the MCT single point of access occasionally refers non CPA service users directly for specialist psychotherapy and to the Rotunda therapy day community (with the GP’s consent and support to facilitate a robust crisis plan ). Broader psychological practice is provided throughout MCT by non-specialist practitioners who have had basic training in psychological approaches, we are developing our workforce plans to recognise this resource (and time for clinical supervision) with job plans. Limited access to psychological therapy during an acute phase is available in our adult inpatient settings, where continued therapy is required post discharge, these recommendations are made to the community teams.

Detail on capacity for the following MCT services to follow … EDS – Ruth Carson PD Hub and Psychotherapy Service – Paddy Conroy Brain Injuries and Learning Disabilities – Richard Whitehead

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Counselling and Psychological Therapies Care Pathway Workshops INTEGRATING STEP 4 INTO THE CARE PATHWAY 15th January 2014

WORKFORCE DEVELOPMENT Learning and Training Opportunities Change clinical psychology training to make it modular (PT / Bursary) – utilize existing skills and build on. Service Transformation – Nurses and Psychiatrists / other disciplines trained to deliver psychological therapies as well as CBT therapists / Psychotherapists / Clinical Psychologists. (Similar to CYP IAPT services)

Paradigm Shift Away from illness model towards a model of psychological distress. Non medics RC to aid paradigm shift – use savings to train psychotherapies

Include service users and carers and third sector Managing Risks Joined up Governance Framework Understanding Available Services Better understanding at all levels of the range of available services at Step 4 and how to make appropriate referrals. Would it need a review of Psychotherapy within CMHT?

WHAT WOULD NEED TO CHANGE IN ORDER TO INTEGRATE STEP 4 INTO THE CARE PATHWAY?

CLINICAL LIAISON GPs and Other Providers Less bureaucracy and not dependent on medical diagnosis. Step 4 practitioner supervising GP / groups of GPs (GP s are only practitioners working within MH who do not have regular supervision) Feedback on referral with consent of patient. GP education services available. Community Based.

RESOURCES Look at resource allocation between Step 3 and Step 4 and equalize. Guided direct GP referral and more therapists

SERVICE USER LED / PERSONALISED

Step 3 and Step 4

Clinical reports to follow service users

Regular clinically focused meetings. Defined links at Clinical Lead level. Joint working (perhaps secondment?). An agreement to accept referrals between steps.

INNOVATIVE SOCIAL VALUE DRIVEN PATHWAYS Third sector standards in contracting. Co-production / Accreditation of service by Voluntary services

No Wrong Door Feedback to referrers

ACCESS AND ASSESSMENT More joined up assessments & Information to avoid repetition and duplication (Service user experience and resources). Opportunity for referring patients for Step 4 treatment / intervention. Robust links with existing established charities for some of the targeted groups (eg veterans). Rapid pathway, Responsive, Few Hurdles. ‘Front end’ psychological assessment routinely offered in secondary care. Psychological assessments and formulation on entry to mental health system. Facilitators to help patients get to appointments. Earlier access by GP straight to Step 4 once initial assessment has taken place and all other steps have been tried or deemed unsuitable (less costly, less time consuming, less stressful for service users) Longer appointment times with GP

STEPPING Improved communications and a single pathway agreed by all providers. IM Step 3 to Step 4 direct – so keep community base

OUTCOMES Outcomes focus to demonstrate efficacy / efficiency of psychological therapies

INTELLIGENCE AND UNDERSTANDING OF EFFICIENCIES Proportionately according to numbers using both and numbers of therapy hours needed. Ring fenced additional funding. Use the scoping information we have to know the minimum likely demand for Step 4 therapy.

15.1.14.

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Counselling and Psychological Therapies Care Pathway Workshops VOLUNTARY SECTOR Wednesday 29th January 2014 What does the Voluntary Sector need in order to make their contribution? Continued and sustainable funding To be ‘visible’ to clinical and statutory sector organisations and commissioners Involved and networked “Approved referrer” Money Respect Understanding/relationship between services Recognition for its provision Investment Referral pathways to be developed Trust from partners in other sectors (i.e. GP’s) Retention of independence Being part of strategic plans without losing what makes it unique Funds for more than £12m Endorsement of value of contribution Excellent governance frameworks Development of outcome measures to demonstrate efficacy of services – evidence base Their contribution to be acknowledged and valued by wider system, and trusted Involvement and engagement “Active Listening” Collaboration/Partnership Collaboration not competition Support from public sector (e.g. sharing of resources such as training, accommodation) “Light touch” contracting Relationships/partnerships with other providers “Volunteers” Support – Strategic, financial, developmental and professional Security Equality Sense of being valued and included Financial input Recognition of worth and value What can the Voluntary Sector contribute? Independence Resourcefulness Innovation Accessibility for people who don’t use their GP Part of wider support system

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Counselling and Psychological Therapies Care Pathway Workshops Longer term Links to other resources and people who are interested and want to help Flexibility and choice Can offer informal (unpaid) support Personal approach Value for money Commitment Partnership Accessible, normalising outside formal MH framework Objectivity “Outside the box” creativity Innovative practice Better at community development Better at “participation” Better at service user and carer involvement “Non-medical” perspective Holistic Specialism with a particular field Services that are already developed Non stigmatizing services/settings Community based The overall strategy and psychological therapies pathway has gained welcome coherence To feeling positive, both as a citizen of Liverpool and as an NHS partner Being more visible More flexible way of working e.g. appointments Multidisciplinary team, support worker, group work Self-referral protocol Less clinical Identifying gaps Voluntary Sector has a huge contribution to make in regards to community engagement and social inclusion Hope that the Voluntary Sector is not decimated by the cuts in funding The Well-being Liverpool directory of resources has huge potential Uncertainty about the future of 3rd sector organisations in Liverpool post he budget being made public Relationships with clients – different to statutory services Levels of independence and trust may be different/complementary and useful to other sectors Skills, knowledge, commitment Quality Assurance Improved access Joint thinking and joint working framework Early intervention VCS takes risks Familiar with being accountable “Swim in the Mud” together (cross sector services)

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Counselling and Psychological Therapies Care Pathway Workshops CHILDREN AND YOUNG PERSON’S SERVICES Wednesday 5th February 2014

What does the information that has been shared tell us about our current services and what we need to do next? Group 1 Self-referral – Manage risks, gradual introduction Join up effectively Significant conversations Training (early) Awareness of other services, partnerships, joint thinking, working assessments Communicate with each other Speak to YP; what are their real journeys? Sophisticated participation – reach beyond usual key information

Group 2 Need to think about young adults Still more to do to understand children’s and adults MH services work together or are accessed Primary care – is it accessible for young people? Workforce development and training Use new technology to build relationships and engage with young people Model for young adults – what would it look like for Liverpool? Young people are failing to engage in MCT and have the highest rate of DNA’s. Services are not attracting young adults

What do we now need to do to move the service from good to great? Group 1: Identify barriers and plan to remove them Establish agreed thresholds Is the service accessible/credible, in the right place? Bespoke 1◦ care for GP Champs vulnerable groups ( C&YP) Awareness raising with GPs Mental Health complexity Pathway to services Unravel functions of step 2 and explain General MH promotion in communities to motivate and inform YP

Group 2: Look at what we have got Make it a strategic priority Bring people together Develop a shared vision Expand the CQUIN 14-25 Youth Services Embracing E1 psychosis philosophy of care Diagnostic uncertainty Vocation Support Decrease stigma? Normalising mental distress Flexible but assertive Psychological Interventions Psychological model

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Counselling and Psychological Therapies Care Pathway Workshops What do we need to do as we move forward to ensure the services are current and relevant for children and young people? Group 1: Group 2: Participation is a golden thread Look at other models throughout Use technology Ongoing evaluation throughout Monitor and evaluate Improve evaluation of patient Innovate, be creative experience – increase its status Ask them! Establish ‘hub’ of services Involve young people and adults, and Ask them? – review current families and carers contributions from YP Look at settings – move away from Strategic join up between children clinics and adult developing Mental Health and emotional wellODG for CAMHS/AMHS development being – need to give C&Y the skills What is the role of technology

What would we need to do to improve the children’s service? Group 1: Sharing practice, outcomes, learning Greater collaboration on cross over area Spread attitude and culture Own message with CAF Look at E1 approach for other levels of need Understanding what an open door approach means Make referral process open/accessible

Group 2: More young people and adults participating in developments IAPT current services – literature/reading based services can exclude IAPT current services – Access via self-referral Keep trying to find ways to keep C&YP safe Keep finding out more about how our current services work e.g. are outcomes for young adults as good for older people?

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Counselling and Psychological Therapies Care Pathway Workshops Appendix A – Liverpool CCG Counselling & Psychological Therapies Care Pathway Workshops – ENGAGEMENT

Attendee

Representing

4 Dec

11 Dec

8th Jan

15th Jan

29th Jan

5th Feb

Clare Mahoney Andy Kerr Antoinette Egan Teresa Clarke Sam Clements Lisa Nolan Jonathan Lock Karthi Moya Duffy Nicky Carter

CCG CCG CCG CCG CCG CCG CCG: MH Lead CCG: MH Lead CCG: MH Lead CCG: Gender Dysphoria Lead CCG: Eating Disorders Lead Liverpool Mental Health Consortium IM&T IML IML LCC LCC Mersey Care Mersey Care Mersey Care Mersey Care Mersey Care Mersey Care Independent consultant Compass Compass YPAS YPAS Sahir House Alder Hey / Mersey Care Mersey Care Mersey Care YPAS Bernados

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Nicola Mazey Clare Stevens Chris Green Jacqui Howard Kieran Doherty Sue Neely Gina Perigo Jane Jamieson David King Richard Whitehead Jim Cousineau Paddy Conroy Kayleigh Syrett Catherine Webster Rosena Kirke Margaret Harvey Nicky Martin Monique Collier Donna Jackson Nicky Fearon Phil Laing John Stevens Val O’Donnell Louise Wardale

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