A STRATEGY FOR THE DEVELOPMENT OF PSYCHOLOGICAL THERAPY SERVICES. Department of Health, Social Services and Public Safety

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1 A STRATEGY FOR THE DEVELOPMENT OF PSYCHOLOGICAL THERAPY SERVICES Department of Health, Social Services and Public Safety December 2008

2 FOREWORD I am delighted to launch, for consultation, A Strategy for the Development of Psychological Therapies in Northern Ireland. In doing so, I believe that improving access to psychological therapies has huge potential to improve outcomes for individuals, families and carers, and for the wider community. Improving provision of psychological therapies makes good sense. It can, for example, help individuals and families by providing early psychological interventions and, for established conditions, much can be done to relieve anxiety, depression and distress. Through a stepped-care model for psychological therapies, I want people to know what services and interventions are available to them. I aim to promote early intervention, self help and support in the community, but I also recognise the need for specialist services for people complex conditions, particularly those arising from mental health and learning disabilities. Services will need to be redesigned around the needs of individuals. Regardless of the setting in which these services are delivered, they will be designed to be personcentered and flexible. In addition, services will be delivered to agreed principles and standards, and by competent and skilled staff, who are appropriately supervised and accredited by relevant professional bodies. The Bamford Review of Mental Health & Learning Disability (2005) recognised the importance of psychological therapies. I am investing an additional 7million, recurrent from 2010/11, for implementation of this strategy. However, it is recognised that further mapping will be required in order to improve capacity and to meet future demand. I welcome consultation responses from service users and from the statutory, community, voluntary and private sectors. The consultation ends on 31 March Michael McGimpsey MLA Minister for Health, Social Services & Public Safety

3 CONTENTS FOREWORD 1.0 Purpose of this Document 2.0 Background Range of therapies Bamford Review of Mental Health and Learning Disability Impact of Disability Cost of Mental Illness Working with Children and Adolescents Working with Families and Carers Current Gaps in Service Provision 3.0 The Way Forward The Use of Psychological Therapies 4.0 Service Principles Evaluation of Services 5.0 Service Redesign A Stepped Care Model for Adults A Stepped Care Model for Children and Young People A Stepped Care Model for People with a Learning Disability 6.0 Workforce Issues

4 Staffing Requirements Training, Accreditation and Supervision Links to Professional Regulatory Bodies and Associated Issues 7.0 Prioritisation of Service Development 8.0 Conclusion Bibliography Reference Group Membership Appendices A Psychological therapies B NICE psychological interventions for common mental health disorders C Stepped Care Model for Children and Young People D Stepped Care Model for People with a Learning Disability

5 EXECUTIVE SUMMARY This strategy has the overarching aim of improving the health and social wellbeing of the population of the Northern Ireland by improving access to psychological therapies and by being more responsive to service user s needs. Many people in our society suffer from debilitating conditions, as a consequence of their relatively poor physical, emotional, behavioural and/or mental health. These can affect all age groups, for example, children and young people with emotional and behavioural disorders, young mothers with depression, and adults of working age who, because of their ill-health may have relationship difficulties and find it hard to support their family and hold down a job. Older people too may have psychological problems, including those arising from their physical disease and from social and mental health conditions, such as isolation, depression, anxiety and bereavement. In addition, it is acknowledged that carers need psychological support, to maintain and improve their mental health and to assist them to look after their loved ones with long-term physical, mental health and learning disabilities. Improving mental wellbeing in our society, through improved access to psychological interventions makes good sense. It can help individuals and families, for example, through early intervention and, for established conditions, much can be done to relieve anxiety, depression and distress regardless of the cause of the underlying condition. Psychological interventions can help people to be independent and to live as valued members of their community. Even in economic terms psychological interventions have benefits, for example, by improving an individual s physical and mental health outcomes, their ability to work and be economically productive. In addition, improved mental and social wellbeing can help prevent anti social behaviour and family breakdown in children and young people, reduce the burden of anxiety and depression, and input into the rehabilitation of offenders. Also, by assisting in the maintenance of independence it can reduce reliance on residential and hospital care.

6 Service users and their carers also want better access to a range of evidence based therapies delivered by trained therapists. This is supported by the Bamford Review of Mental Health and Learning Disability (2005) which supports psychological therapies as a treatment option for common psychiatric conditions. In developing a psychological therapies strategy, the Department of Health, Social Services and Public Safety recognises the importance of early intervention and self help, the development of psychological therapy services in the community and the need for specialist services for complex conditions, particularly those arising from mental health disabilities. Regardless of the setting in which services are to be delivered, psychological services need to be developed to agreed principles and standards, be delivered by competent and skilled staff and be redesigned to take account of evidence based practice. A stepped care model is supported in this strategy so that service users can receive the level of intervention appropriate to their needs. The Strategy will inform service development over the next three years. To underpin development, an additional 7million, (recurrent) from 2010/11, will be invested. Further mapping will be required to assess need and to improve capacity to meet demand. This Strategy proposes implementation of the following recommendations: 1. Psychological therapies should be a core component of mental health and learning disability service provision. Services should be delivered by staff with the skills and competence appropriate to the level of interventions required. 2. Clinicians and the public should have information on the range of psychological therapy services that are available and how to access them. 3. Recognising the importance of psychological interventions, if a new care pathway or service framework is being developed, especially for

7 mental health and learning disability conditions, due consideration should be given to the inclusion of psychological therapies within the pathway and service standards. 4. Service users and carers should be involved at all levels of service development, planning and implementation of psychological therapy services. 5. A Regional Psychotherapies Group should be established as a matter of urgency to oversee implementation of this strategy and to advise the Department on the future development of child and adolescent and adult psychological therapy services. It should be representative of commissioners, service providers, carers and users. 6. The HSC should develop an agreed service specification for relevant therapies, taking account of the service principles contained in this Strategy. 7. Psychological therapy services should be subject to service, therapeutic and economic evaluation which takes account of the views of service users and carers. 8. The organisation and delivery of psychological therapy services should be based on a stepped care model. 9. There should be a single point of access to psychological assessment to direct to the appropriate tier of intervention. 10. In order to improve early intervention and reduce pressure on specialist services, a detailed map is required of demand and associated workforce skills in adult, and child and adolescent psychotherapies with particular reference to tiers 1 and 2 interventions and the necessary supervision arrangements.

8 11. Agreed referral pathways should be developed for child and adolescent, and adult psychological therapies that incorporate face to face assessment by a competent mental health practitioner (band 6 or above) to ensure that a person s needs are appropriately addressed by a relevant professional with the appropriate skills and level of expertise. 12. The Recommendations contained in the Review of Clinical Psychology Workforce (2008) should be implemented. 13. A consortium of stakeholders, including accredited training providers, should be commissioned to agree a regional approach to undergraduate and postgraduate training to meet the requirements of a stepped care model. 14. A supervision framework should be developed, which sets out the core competencies and accreditation required for supervisors at the different levels of intervention.

9 1.0 PURPOSE OF THIS DOCUMENT 1.1 The Department of Health, Social Services and Public Safety has identified the development of psychological therapy services as a particular element of its overall strategy to reform and modernise mental health and learning disability services. This document provides a strategic framework for the development of these services in a way that is consistent with a range of strategies to improve health and well being and the management of long term conditions, and the recommendations of the Bamford Review of Mental Health and Learning Disability. 1.2 This document provides commissioners, service providers and training bodies with: a strategic overview of what is needed to develop psychological therapy services in line with the recommendations of the Bamford Review of Mental Health and Learning Disability; service principles to inform the commissioning and provision of psychological therapy services; a proposed service structure for the organisation of psychological therapy services within the statutory, voluntary, community and private sectors; and, recommends the underpinning training and accreditation required by practitioners and supervisors working at the various levels within a stepped care model. 1.3 The aim is to provide a range of services that are: Clinically effective Safe

10 Cost effective Comprehensive Co-ordinated and user friendly and delivered to a standard consistent with the National Institute for Health and Clinical Excellence (NICE) and other relevant national guidelines. 1.4 As therapy services are provided by the statutory, voluntary and private sectors it follows that, irrespective of which sectors services are commissioned from, they must be provided to similar standards. 1.5 To provide the necessary cadre of trained therapists and to enable the progressive development of services will require a comprehensive and coordinated training and HR strategy to underpin the process BACKGROUND 2.1 In this document the term psychological therapies means an interpersonal process designed to modify feelings, cognitions, attitudes and behaviour which have proved troublesome to the person (or society) seeking help from a trained professional (STRUPP)). They are often called talking therapies. 2.2 Psychological therapies are an essential part of modern mental health care. Appendix A provides further detail on these therapies. The term psychological therapies covers a broad range of models including: Cognitive Behavioural Therapy; Psychodynamic/Psychoanalytic Psychotherapy; Systemic and Family Therapy Humanistic, Person-Centred/Experiential Therapy (National Occupational Standards List)

11 2.3 The following describes the existing levels of intervention in more detail: Primary intervention recognition of the problem and short-term interventions to prevent conditions becoming severe. Secondary interventions more intensive interventions to treat mild to moderate conditions. Tertiary interventions - High intensity specialist interventions to treat chronic and complex conditions. 2.4 Psychological therapy provision is a multi-professional and multi-agency endeavor. Psychiatrists, psychotherapists, psychologists, counsellors, nurses, social workers, occupational therapists, arts therapists and many other groups are involved, all of whom need to communicate and co-ordinate effectively with one another. Therapy can also be provided by a range of practitioners in the voluntary and private sectors. 2.5 Psychological therapies should be available to all age groups in a variety of settings and for a range of physical, emotional, psychological and psychiatric conditions. Their purpose is to promote individual, group and family wellbeing, and provide effective treatment, particularly for common physical, mental health and learning disability conditions. 2.6 In addition, it is recognised that psychological therapy intervention can play a significant part beyond the health and social care sector, for example, in schools and youth settings, and in the youth and adult justice systems. It is acknowledged that many services are delivered outside of the statutory system. The place of community, voluntary and private sector is pivotal and, irrespective of which sector provides the service, standards for training, accreditation and supervision should be comparable with relevant national guidelines.

12 2.7 The main focus on this document is on psychological interventions in the context of commissioning and provision of HSC services and training, with particular reference to:- - child and family services; - child and adolescent mental health services; - adult mental health services; - learning disability services; and - physical disability services. Bamford Review of Mental Health and Learning Disability 2.8 The Bamford Review of Mental Health and Learning Disability noted the advances in the sophistication and range of psychological therapy services. It also highlighted that research shows that the use of certain therapies are effective in the treatment of particular conditions. However, it found that access to psychological interventions was extremely poor. A need for training across all mental health professional groups was identified to develop the skills of therapeutic relationship building. At the same time there was a need to use evidence based psychological therapies. 2.9 The Bamford findings reflect the impact of Troubles related trauma on both the adult and adolescent population and the ad hoc way in which psychological therapy services have developed. Part of the problem has been that there is no overall framework that acknowledges their effectiveness on health and wellbeing; describes the current service gaps; highlights the settings in which they should be available; and, documents the training, competencies, supervision and accreditation which commissioners should take account of when commissioning services In response to the Bamford findings on access to psychological interventions the Department included in its 2008/09 Priorities for Action a target to reduce

13 waiting times fro psychological therapy to a maximum of 13 weeks by March The Impact of Disability 2.11 The impact of disability on individuals, families and society can be profound. For individuals the suffering and mental anguish arising from mental disability can be extreme. Professor Lord Layard in the Depression Report (2006) highlighted how crippling depression and anxiety can be on individuals and our society, and how psychological interventions are both clinically and costeffective; thus requiring major investment. This is supported by the National Institute for Health and Clinical Excellence (NICE) which acknowledges the place of psychological interventions in a range of physical conditions in addition to the management and treatment of mental health including depression and chronic anxiety conditions.

14 Figure Figure 1 above shows how important mental ill-health, in its broadest sense, is on disability accounting for over 43% of all disability. Layard et al found that while depression and anxiety accounted for a third of all disability, they attracted only 2% of NHS expenditure (in Northern Ireland mental health represents 8% of HPSS spend). In addition, it was recognised that most expenditure in mental health goes on the most seriously ill, for example, those with major psychotic illness. Such adults are approximately only 1% of the population and are desperately in need of care but so too are the significant majority who suffer common conditions such as depression and chronic anxiety disorders. Cost of Mental Illness

15 2.13 The cost of mental illness to the economy of Northern Ireland is huge. A 2003 study undertaken by the NI Association for Mental Health and the Sainsbury Centre for Mental Health Counting the Costs: The Economic and Social Costs of Mental Illness in Northern Ireland found that the cost of mental illness in NI in 2002/03 was 2.8bn. In the same year the total budget for DHSSPS was 2.4bn Mental illness remains the main cause of incapacity. Statistics published by the Department for Social Development in February 2008* show the numbers of claimants of Incapacity Benefit by diagnosis group. These show that: 43.8% have mental health or behavioural disorders 17.9% have musculoskeletal system and connective tissue diseases 10.1% have symptoms, signs and abnormal clinical and laboratory findings 6.4% have injury, poisoning and certain other consequences of external causes 5.9%. have circulatory system diseases Together these conditions account for over 84% of all claimants. *Department for Social Development: Incapacity Benefit and Severe Disablement Allowance Summary Statistics February In 2006/7 the annual prescription costs for antidepressants and anxiolytics in Northern Ireland were: Year Number of Prescriptions Ingredient Cost Before Discount m 22m m 21m

16 2.16 Many psychological interventions have been proven to be as effective as drug therapies. General findings suggest that evidence based psychological therapies are as effective as drugs in the short-term and that both are better than no treatment. It has also been shown that in the longer term therapy has a more enduring positive outcome than drugs (Depression report 2006). Working with Children and Adolescents 2.17 Psychological interventions can provide positive long lasting outcomes for children, young people and their families, and can in the longer term result in cost savings for the HSC, and in improved outcomes in education, social care and youth justice systems. Areas requiring psychological interventions include children and adolescents with physical and mental health conditions, fostering and adoption services, children and adolescents in care, children affected by trauma and bereavement, eating disorders, substance abuse, autism spectrum disorders, learning disabilities and forensic services The evidence of effectiveness of psychological interventions in children and adolescents is good. A systematic review (Kennedy et al 2004) looked at the impact of psychoanalytic psychotherapy in children and adolescents involving children with a range of diagnoses and problems. Overall the results demonstrated effectiveness and follow up into adulthood showed long-term improvements. Some studies showed that younger children were more likely to improve with treatment and that work with parents or families alongside the individual was an important component of the treatment. The level of intensity of the treatment varied with the severity of the disturbance with children with emotional/internalising disorders appearing to respond to psychoanalytic psychotherapy better than children with disruptive/externalising disorders In addition, specific studies identified evidence of effectiveness for children suffering from depression, anxiety disorders, behaviour, personality disorders, specific learning difficulties, developmental disorders, eating disorders, deprived children and children in foster care, sexually abused girls and children with poorly controlled diabetes.

17 Working with Families and Carers 2.20 Families and carers of people with a diagnosis of a mental illness play an extremely important role in helping the recovery process and preventing relapse of the person who is unwell. In order to do that, families/carers require access to family work. The contemporary model of Family Work aims to achieve the following: psychoeducation, involving education about the biopsychosocial impact and the biopsychosocial treatment of the illness; and, family education which includes, enhancing/developing coping strategies, family well-being, getting on with their lives, key resource in maintaining and extending social networks, managing/coping with a crisis and recognising early signs of relapse. It also involves working in partnership with either or both service users and carers to improve outcomes in psychosis, thereby attempting to place service users and carers at the heart of service delivery. Current Service Provision 2.21 Attempts to establish the number of professionals and range of therapies being delivered across Northern Ireland have been problematic. A point in time survey within HSC Trusts (October 2008) found that there were 158 psychologists, 90 psychology assistants and over 60 other therapists specifically employed within Trusts to provide psychological therapies for a range of conditions Staff who provide psychological treatments but who do not have this specifically identified in their job title namely psychiatric nurses, social workers, occupational therapists and psychiatrists have not been included. It is likely that the therapeutic interventions provided by these professions will vary depending on the services in which they are employed The professionals who provide services for children and adolescents in HSC Trusts are mainly clinical psychologists, family therapists and child

18 psychotherapists. Clinical psychology is the largest group, with an established clinical doctorate training at QUB for up to 10 trainees per year (a 3 year fulltime course). It is centrally funded and divided between the HSC Trusts, with trainees normally on a training salary. Most trainees have some experience of working as an assistant psychologist. The training is generic but around 20% of all CP graduate work is within child and adolescent or related children s services. Most clinical psychologists who work with children are normally based within CAMHS teams Family therapy is a relatively new profession within the HSC. Currently there are 10 designated family therapy posts within CAHMS services in Northern Ireland, with half of these based in the regional Family trauma Centre. There are at least 20 more qualified family therapists practising in non designated posts in a variety of CAMHS settings, both within the statutory, voluntary and youth justice sectors. Some of these professionals have had family therapy training alongside their main post -, e.g. clinical psychologist, or child psychiatrist. Most family therapists work as part of a multidisciplinary team Child and Adolescent Psychoanalytic Psychotherapy (CAPP) is also a relatively new profession in Northern Ireland. There are now 7 qualified CAPPs with only 3 in designated HSC child and adolescent mental health posts in two Trusts. There has recently been an appointment of a trainee in a specialist CAMHS service. There are other child psychotherapists in NI who are working privately. CAPP training is not available in Northern Ireland and those who graduate from Dublin training programmes wishing to work in NI need to obtain top up training to be eligible for registration with the UK professional body- Association of Child psychotherapists In general practice there are no formal therapy services directly available within the practice. However, one HSC Board has a scheme to augment therapy services within GP practices. A directly enhanced service for mild to moderate depression will also be available in early This will provide additional resources for GPs to access counselling services that meet defined standards and recognised accreditation. Part of the additional resources

19 provided in general practice will be increased availability of Cognitive Behavioural Therapy through a computerised cognitive behavioural therapy package, accessed by patients and supported by therapists, as appropriate. 3.0 THE WAY FORWARD The Use of Psychological Therapies 3.1 There is now a strong evidence base for the use of psychological therapy services in the treatment of a wide range of conditions particularly for mental health. Appendix B (1&2) provides an overview of relevant National Institute for Health and Clinical Excellence guidance on psychotherapeutic interventions for common mental health disorder in children and adults. These include: - depression; - bipolar disorders; - generalised anxiety states and panic disorders; - schizophrenia; - post traumatic stress disorder; -Obsessive compulsive disorders; - Anorexia nervosa and bulimia nervosa; - self harm; and - personality disorders. Psychological therapies should be a core component of mental health and learning disability service provision. Services should be delivered by staff with the skills and competence appropriate to the level of interventions required (Recommendation 1). 3.2 In order to make informed choices about the most appropriate therapy to access in relation to a particular need or specific health condition clinicians and the public should have information on the range of psychological

20 therapy services that are available and how to access them (Recommendation 2). 3.3 It is acknowledged that psychological therapies can also be beneficial in a range of other conditions, including chronic physical conditions, bereavement and terminal care. They can also assist and support families and carers. Recognising the breadth of conditions that can be assisted by psychological interventions, it is recommended that: during the course of development of a new care pathways and service frameworks, particularly for mental health and learning disability, due consideration should be given to the place of psychological therapies within the pathway and standards (Recommendation 3). 3.4 People with established chronic mental health conditions, including those who are inpatients must also benefit by investment in psychological therapies. In this context, there is a need to balance how access to psychological therapies is achieved to ensure that those in greatest need of intervention are not disadvantaged and that reduction in waiting times is not achieved at the expense of inpatient provision. 3.5 In order to develop accessible and responsive services it is essential that future service development is informed by the views of those who use the services and their families or carers. It is recommended that: service users and carers should be involved at all levels of service development, planning and implementation (Recommendation 4). 3.6 Given the range of psychological therapy models, the age spectrum and conditions of those requiring therapeutic interventions and the various settings in which therapies can be delivered it is recommended that: a Regional Psychotherapies Group should be established as a matter of urgency to oversee implementation of this strategy and to advise the Department on the future development of child and adolescent and adult psychological therapy services. It should be representative of commissioners, service providers, carers and users (Recommendation

21 5). Its remit should include service development, training requirements, supervision standards and a service evaluation framework. 4.0 SERVICE PRINCIPLES 4.1 It is recognised that psychological therapies can be delivered in a range of settings and by staff with different professional backgrounds, for example, psychologists, nurses, occupational therapists, social workers, psychiatrists, counsellors, family therapists and arts therapists. But regardless of the professional background or the setting in which it is delivered the service principles for commissioning and delivery of therapies should be broadly the same. 4.2 The key service principles which service commissioners and providers in the statutory, voluntary, community and private sectors should work to are outlined below. What is needed to underpin the delivery of effective and safe therapy services are: evidence based interventions; appropriate training and skills: appropriate supervision: and, a robust monitoring and evaluation function to drive improvements The service principles should provide a greater focus on the needs of service users and effective organisational arrangements. 4.4 Service users will need to have: Access to psychological therapies appropriate to age, diagnosis and severity of the condition. Services should be flexibly delivered and take account of local needs, complexity of conditions and available resources; services should follow a stepped care model.

22 Information information in an appropriate format on treatments available, how to access services and likely waiting times should be provided to service users and carers to inform decision making. Involvement in decision making service users need to be involved in decision making about their care. To do this not only involves provision of information but also needs to be condition specific and relevant to the age of the individual. Safe and effective interventions like any other treatment, psychological therapies can have the potential to do harm; hence there is a need to develop a number of service and quality standards and outcome measures to promote effective practice. Ideally, such services should be capable of being bench-marked against other comparable services. Trained staff and appropriate supervision arrangements- there is a need for an agreed approach to effective selection criteria, recruitment, training and supervision arrangements to provide therapies at all tiers of psychological interventions. Evaluation criteria measurement of outcomes should be able to demonstrate, for example, access to services; improved patient outcomes in terms of health and wellbeing; promotion of social inclusion and improvement in employment status; and, service user/carer satisfaction. 4.5 To ensure psychological therapy services are provided to the same standard across all service sectors throughout Northern Ireland it is recommended that the HSC should develop an agreed service specification for relevant therapies, taking account of the service principles contained in this Strategy (Recommendation 6). Evaluation of Services

23 4.6 A service evaluation framework will be required to ensure local implementation protocols meet regional standards in terms of: Clinical effectiveness (e.g. measures of symptom reduction, improved psychological well-being and indices of social inclusion); Efficiency and cost effectiveness ; Accessibility targets (e.g. waiting times, meeting targeted population etc); Governance of workforce (e.g. training and supervision); Service user experience and satisfaction with service; 4.7 It is recommended that: psychological therapy services should be subject to service, therapeutic and economic evaluation which takes account of the views of services users and carers (Recommendation 7). The proposed Regional Psychological Therapies Group should advise on this. 5.0 SERVICE REDESIGN 5.1 In the future, mental health and learning disability services will be structured around a stepped care model. The model for child and adolescent mental health services (CAMHs) will need some modification; however, the principle should be that all services should follow a stepped care approach. The rationale for this model is to ensure that the best intervention is delivered in the right place, at the right time, by the right person to meet a person s assessed needs. Considerable work has already been undertaken to set this in train. There is widespread support at both regional and national levels for a similar approach to the organisation and delivery of psychological therapies. This model has also been endorsed across professions. The model also recognises the growing body of evidence indicating which therapies are effective and when. It is recommended that the organisation and delivery of psychological therapy services should be based on a stepped care model (Recommendation 8).

24 A Stepped Care Model for Adults 5.2 A stepped care model assumes that patients can be delivered a range of interventions appropriate to their assessed need. This model assumes that there will be a single point of access to a psychological assessment to direct to the appropriate tier of intervention (Recommendation 9). For example, those people needing therapy interventions at steps 1 and 2 could be treated with computerised cognitive behavioural therapy in general practice, guided self-help and/or group education. Such interventions will, in the future, be delivered in a primary care setting by different staff with a range of skills and an appropriate level of supervision. This approach will bring the therapies closer to the patient and improve access in line with Bamford. 5.3 On the other hand, step 3 interventions would be for moderately severe conditions and delivered mainly in the community by staff trained to the appropriate level of skill such as clinical psychologists, Cognitive Behavioural Therapy (CBT) and Interpersonal Therapy (IPT) therapists, in liaison with a psychiatrist where drug therapy is also required. For the minority of patients with severe/complex disorders (steps 4 and 5) there is a need to access specialist teams who have specialist therapy training. 5.4 The diagram below shows the generic stepped care model for adult psychological therapies, the range of therapies that are delivered at the different levels of intensity and the training and supervision required at the different levels of intervention.

25 Stepped Care Models of Psychological Therapies (Adult) Step No. Intens What Delivered? Who Delivers / Training? Pts. ity Step 1 Recognition and Assessment Step 2 Treatment for Mild Disorders Advice / support / watchful waiting / screening Supplemented by single point of access psychological assessment service to direct to correct tier subsequently. Low intensity treatments (e.g. CCBT, brief behavioural and CBT, psycho education, guided self-help, group education, adjustment counselling, further assessment) Front line primary care staff trained to monitor / screen for mental health difficulties resourced with screening tool kits and liaison with single point of access centre. Low intensity (LI) workers (Bands 4-5) e.g. Assistant / Associate Psychologists, counsellors, mental health workers, OTs, nurses and SWs (Band 6 and above) Leadership, governance and supervision provided by Band 7-8 Clinical Psychologists OR CBT therapists in ratio relationship to number of LI workers. Step 3 Treatment for Moderate Disorders High intensity specific therapies - e.g sessions of CBT or interpersonal; therapy for anxiety, depression, uncomplicated PTSD etc. Circumscribed psychological therapies where there are evidenced based principles of treatment e.g. for agoraphobia, panic, phobias, adjustment to illness, recent onset non-organic presentations etc. High Intensity workers - Clinical Psychologists, CBT and IPT therapists with liaison from secondary care psychiatry when pharmacological adjuncts to therapy as required. Capable of delivering CBT protocols for mood disorders, problem solving therapy, EMDR, exposure therapies etc. Steps 4 5 Treatment for Severe / Complex Disorders Integrative or highly specialised therapies e.g. co-morbid and complex presentations (e.g. mood, addictions, trauma, attachment disturbances, personality disorder; psychosis, conversion disorders, persistent self-harm, neurological). Secondary care mental health teams comprised of Psychiatrists, Clinical Psychologists and other professions with specialist Range of uni-modal, specialist therapies, plus therapy training e.g. capacity to integrate and fit therapeutic approach to psychodynamic, CBT, patient where proceduralised pathways are absent or systemic psychotherapy, unlikely... Dialectical Behaviour

26 Therapy, Cognitive Analytic Therapy etc. (all from the three main schools of therapy as specified in SFH); Specialist psychotherapy services (e.g. for personality disorder, eating disorder, severe and complex presentations. Services will be supported by LI workers to deliver circumscribed elements of therapeutic programmes and psychological assessment.

27 A Stepped Care Model for Children and Young People 5.5 Child and adolescent mental health Services are currently provided within a stepped structure (Appendix C) that mirrors the Stepped Care approach being promoted in adult services. It is important that the organisational structures within the two areas can work together to allow the seamless transition from child to adult services. 5.6 The model is not a hierarchical model, as children often require intervention from a number of tiers, sometimes at the same time in order to achieve the most comprehensive treatment and care plan. Inadequate resourcing of step 2 services has resulted in significant overuse and misuse of step 3 services, leading to long waiting lists and frustrations for referrers. Information regarding services located within step 1 & 2 is poor and this would need to be addressed in order to determine gaps in service provision and governance arrangements. 5.7 Bamford has highlighted a number of key areas where service provision has particular needs and these are important to keep at forefront of any service developments, regardless of which Tier is being considered. Services need to provide for children and young people up to their 18 th birthday. Promoting Infant psychological wellbeing and intervention at the earliest possible opportunity is the only way to effect long term changes in the reduction of the need for mental health services. The greatest area of need is in Tier 1 & 2 service provision. Until this is addressed Tier 3 & 4 services will continue to have an inefficient use of resources as they attempt to plug other gaps. It is recommended that: In order to improve early intervention and reduce pressure on specialist services, a detailed map is required of demand

28 and associated workforce skills in child and adolescent psychotherapies with particular reference to tier 1 and 2 interventions and the necessary supervision arrangements (Recommendation 10). This should be part of a comprehensive service mapping exercise to identify current staffing levels and existing and future demand to inform future resourcing at all levels 5.8 To ensure that the most appropriate psychological therapy is provided it is recommended that: agreed referral pathways for child and adolescent, and adult psychological therapies that incorporate face to face assessment by a competent mental health practitioner (band 6 or above) to ensure that a person s needs are appropriately addressed by a relevant professional with the appropriate skills and level of expertise (Recommendation 11). A Stepped Care Model for People with a Learning Disability 5.9 Learning disability is a life-long developmental disorder and categorised into 4 levels: mild, moderate, severe and profound learning disability. People with a learning disability have a high incidence of epilepsy, autistic spectrum disorder, sensory impairments and physical health conditions. They also have a higher incidence of mental health needs than the general population There is a significant and growing body of evidence that demonstrates the effectiveness of psychological therapies for people with a learning disability. This has demonstrated that such therapies are more effective and acceptable than pharmacological interventions for the management of a significant number of mental health difficulties However, simple adaptations to the implementation of traditional psychological therapies are often required when engaging with people with a learning disability. The degree of adaptation will be commensurate with the person s specific needs. For example, a person with mild learning disability

29 can participate in cognitive behaviour therapy with the adaptations noted above The current policy to support people with a learning disability in the community, rather than in a hospital setting, will shape the development of psychological therapy services and the training needs of staff delivering therapies. An adapted stepped care model will be required and an example is provided in Appendix D. 6.0 WORKFORCE ISSUES 6.1 Future development of psychological therapies will require a competent workforce that has undergone required training in evidence based therapies and are supervised appropriately by trained and experienced therapists. 6.2 Delivery of low and high intensity therapies to an appropriate standard requires competent practitioners who are able to offer effective interventions. At the same time services will need sufficient numbers of appropriately experienced and trained supervisors familiar with the range of interventions. Supervisors will also require support so that high quality supervision is available to all trainees and qualified staff within the service. Staffing Requirements 6.3 The Department of Health in England has a programme Improving Access to Psychological Therapy Services designed to deliver NICE-compliant services to help people with depression and anxiety disorders. It estimates that for a population of 250,000 people with average levels of need some 40 trained therapists are needed. The programme recognises the need for a national training programme to provide the necessary number of trained therapists and enables the progressive expansion of local NICE - compliant services in primary care settings. The basic service model envisages a team of therapists taking referrals from GPs and delivering therapies at the required level in primary care of community settings.

30 6.4 Applying the IAPTS formula (40 therapists per 250,000) to a Northern Ireland population of 1.8m and using best estimates of current provision there is a need for an additional 180 practitioners for levels 1-3 (Primary and Community service levels). For level 4 (specialist interventions) and level 5 (highly specialist interventions) it is estimated that a further 160 practitioners will be required. These figures are consistent with estimates made by Bamford. 6.5 Available investment for psychological therapy services in the current Comprehensive Spending Review period ( ) of 7m will enable a significant start to be made to recruiting additional staff to develop these services. Developments will include the introduction of computer based CBT for use in Primary Care and the recruitment of additional community based therapists to improve access to therapeutic interventions. However, it is recognised that delivering this strategy will be a longer term endeavor. 6.6 While funding is a key pre-requisite for delivering this strategy, ultimately the timescale will be determined by the training requirements of the additional staff at the various levels of intervention and the capacity of local training bodies and organisations to deliver that training. Training, Accreditation and Supervision 6.7 Those working in psychological therapy services must have relevant training, accreditation and supervision to provide effective and safe services to standards required by relevant bodies. 6.8 Many professional staff, e.g. nurses, social workers, occupational therapists have already undergone training in psychological therapies. Others have obtained accreditation with recognised therapy bodies. 6.9 Work has already begun to address some of the training needs of a range of staff. For example, the University of Ulster has trained over 100 Health

31 Service staff to certificate level in CBT. QUB has trained 25 staff to qualification level with a Masters qualification in Systemic Psychotherapy and more than 100 Health Service staff to Intermediate and Foundation levels and THORN training has been provided to a range of Health Service professionals, mainly nurses A review of the Clinical Psychology Workforce, published earlier this year, recognised that training in psychological therapy involved three stands general awareness; ability to deliver specific therapies to complex cases; and, specialist training to provide supervision and deal with the most complex cases. It acknowledged that there was a need to expand psychological services into primary and community care levels. Also, there is clear scope to develop practitioners at more junior levels than a Doctorate, thus developing a more tiered provision of services. In addition, it also acknowledged that a career pathway was needed to support those entering the service at various levels, to help retain a motivated and appropriately skilled workforce in the future. It also recommended a Trust level assessment of workforce needs to be carried out in line with service development planning. The Recommendations contained in the Review of Clinical Psychology Workforce (2008) should be implemented (Recommendation 12) The development of psychological therapy services will require a regional approach to training that is comprehensive and co-ordinated to ensure that practitioners have the necessary skills and competences to deliver the relevant therapy or therapies at the appropriate level in the stepped care model. Training approaches need to address the range of training needs from new therapists entering this field, existing healthcare professionals wishing to become skilled in a particular therapeutic intervention to those providing very specialist interventions. It is recommended that; a consortium of stakeholders including accredited training providers should be commissioned to agree a regional approach to undergraduate and postgraduate training requirements, with particular reference to needs of therapists at the different levels within the stepped care model (Recommendation 13).

32 6.12 A complementary training programme for supervisors must also be implemented. It is recommended that: a supervision framework should be developed, which sets out the core competences and accreditation required for supervisors at the different levels of intervention (Recommendation 14). Links to Professional Regulatory Bodies and Associated Issues 6.13 Psychological therapists are not equivalent across professional groups and training pathways. Traditionally psychological therapies have been delivered by chartered clinical and counselling psychologists, psychiatrists psychotherapists and members of other professional groups (e.g. nurses, social workers, occupational therapists, arts psychotherapists) who have attained additional training in single modality psychological therapies, not part of their core professional training, accredited by relevant organisations. Psychiatrists and psychologists who have wished to develop further expertise in specific therapeutic modalities have also undertaken such additional training Whilst psychiatry will continue with statutory regulation by GMC and Royal College of Psychiatrists, clinical and counselling psychologists will become subject to statutory regulation by the HPC in 2009, as well as professional regulation by BPS for chartered status. At the same time talks are ongoing to have non-medical psychotherapists regulated by the same body but the timescale for this is unclear at present. It should be noted that arts psychotherapists are already regulated by the HPC. 7.0 PRIORITISATION OF SERVICE DEVELOPMENT 7.1 Current psychological therapy services have developed in an ad hoc way. The range and capacity of services varies significantly across HSC Trusts. It will take time, resources and a regional training strategy to develop services to a level that meets users needs and the Bamford vision. HSC will have to

33 focus finite resources on those areas of greatest need and where that investment will have greatest effect. A balance will have to be achieved between tier 1 and 2 services that provide effective early intervention and higher levels services to meet the needs of those requiring specialist interventions. At the same time the therapeutic needs of those in receipt of inpatient services must not be overlooked. Service scoping and capacity modelling exercises will help inform critical investment decisions. 7.2 It must be remembered that the Bamford vision for the development of psychological therapy services is over a 10 to 15 year timescale. This will require a strategic approach to service development that can be used to inform future Comprehensive Spending Reviews to ensure the necessary resources to underpin that development can be secured. 8.0 Conclusion 8.1 This strategy endorses the development of psychological therapies as a core component of mental health and learning disability services. In doing so, it acknowledges that the recommendations in this strategy will take some time to develop and that further mapping is required, particularly at tiers 1 and 2 to promote early intervention and timely access to care. Services need to be developed flexibly to meet service users needs. It is acknowledge that many services currently provided are delivered to a high standard by the private, community and voluntary sectors in addition to those provided in the statutory sectors. The implementation of a stepped care model for psychological therapies is essential to ensure that service users access care at an appropriate level. 8.2 Further work will be required to ensure that there is an appropriate skill mix, training and supervision at all levels of intervention. Key to the success of this strategy will be the development of agreed service specifications which will embed key service principles to be implemented across the HSC. Fundamental to the success of this strategy will be the Regional Psychotherapy Group to co-ordinate action.