South England Region - quality improvement programme for psychosis

Background and aims

Psychosis is relatively common, disabling disorder affecting thousands of people every year.  It has a hugely detrimental impact on people’s lives and significantly increases the risk of people completing acts of self-harm and attempting or completing suicide.  In addition to this, there is a wider societal economic impact with an estimated cost to the UK economy of £11.8 billion per year. Early intervention is critical to improving immediate and long-term personal, clinical and economic outcomes.  

The first access and quality standards for psychosis were introduced in April 2016 to ensure that anyone experiencing first episode psychosis would receive a specialist assessment by an early intervention in psychosis (EIP) team within 14 days of referral and have access to NICE concordant evidence-based care. Most EIP teams across the South of England were not funded, staffed, or skilled to be able to deliver this standard. As a result, over 4000 people with psychosis were not receiving evidence-based treatments, with worse long-term outcomes. The delivery of NICE concordant care and timely access had not been measured before.

Solution

The Thames Valley early intervention in psychosis (EIP) clinical network was invited to lead the South Region’s ‘preparedness programme’ on behalf of NHS England (South). The objective was to ensure that the 16 trusts in the region would be able to meet the incoming national EIP standards.

The network established a strong governance structure, engaging all the region’s CEOs, medical and nursing directors with the understanding that any improvement programme must be owned and driven by the providers themselves. With clear and strong national and local mandates established, the programme collaborated to build an effective and intuitive online auditing and data analytics tool called the EIP matrix. 

“The way that South of England EIP services collaborate to implement research evidence into practice and measure outcomes has been identified by NHS England as an exemplar approach to be adopted by other mental health priority areas.”
Ann Tweedale, NHS England Senior Programme Manager

The EIP matrix pulls together data for key measures and uses colour coded charts to show the extent to which nationally and locally set standards are being achieved. The EIP matrix has been used by the region’s NHS England managers, commissioners and providers since it was first developed with their input in 2015. The intuitive design of the online tool ensures maximum engagement, allowing users to quickly obtain information relating to current: 

• Investment per patient
• Performance against key targets 
• Compliance with NICE quality standards 
• Workforce capacity and whether this is sufficient to meet demand
• Outcomes being achieved. 

Users can also compare to previous achievement and other service providers. The latter enables EIP teams to learn from each other and share best practice.

Outcomes and benefits

The programme’s annual reports provide an update with both achievements and areas that need improvement. The 2020-21 report includes:

* For the first time in the five years that EIP teams in the South of England have been completing the EIP matrix audit, the majority of indicators have declined, partly due to the pandemic.

Achievements

• People accessing EIP teams: The number of people with first episode psychosis accessing EIP teams grew from 3,670 in 2019 to 3,931 in 2020, a growth of 9%.
• People admitted to hospital: The percentage of people admitted to hospital after they were accepted on to the EIP caseload reduced from 20% to 18%.
• More people in employment: The percentage of people under EIP that end up in employment is 38%, compared to 12% in generic mental health care.
• Reduction in suicide: EIP reduces patient suicide risk from 15% to 1%.

Areas for Improvement

• People Receiving Cognitive Behavioural Therapy for Psychosis (CBTp): There has been a decrease in people receiving CBTp (one of the recommended treatments defined by NICE), from 36% in 2019 to 31% in 2020-21. 
• Physical health monitoring: There has been a decrease in people with first episode psychosis had a comprehensive physical health check in the last 12 months from 68% in 2019 to 65% in 2020-21.
• Family interventions: The number of families that access family interventions decreased from 26% in 2019 to 18% in 2020.
• Access to EIP: There continues to be a large variation in teams' caseloads, whilst some teams caseloads have increased, a significant percentage of people experiencing first episode psychosis are not able to access EIP or are unable to receive the recommended 3 years of treatment.
• Investment: There continues to be a three-fold variation between the best and worst funded EIP teams in the South of England. Only one out of the 14 EIP services in the South of England are funded at the £8,250 per patient recommended to deliver NICE interventions to a full caseload.
• Physical Health: The percentage of people with first episode of psychosis to have a physical health check was 65%, which is lower than the 90% physical health standard.
• Delivery of NICE interventions: There was a deterioration in the delivery of NICE interventions which were due to limiting factors during the COVID-19 pandemic.
  • Clinicians variable access to adequate personal protective equipment for face to face visits
  • Provider’s deployment of laptops, training and guidance to deliver interventions remotely from staff’s own homes
  • Staff skill and confidence in delivering interventions virtually via mediums such as video conferencing
  •  Individual and family preferences and concerns about accessing therapies virtually
  •  Service user’s access to sufficient internet data and access to a private space for confidentiality

The programme’s work was a finalist in the BMJ Awards and the NHS Healthcare Transformation Awards.  

Additional information

You can find out more about the South EIP Programme by accessing the Time 4 Recovery website.

The programme has also worked with people who access EIP and their families and carers to develop resources and these are available on the Epic Minds website.

The Peer Review programme, which is one of the largest ever undertaken, has been published in the International Journal of Healthcare Quality Assurance.