Developing evidence-based and acceptable stepped care systems in mental health care

398 Pages·2010·8.22 MB·English

Developing evidence-based and
acceptable stepped care systems
in mental health care: an
operational research project
David A. Richards,1 Alice Weaver,1 Martin Utley2 Peter Bower,3
John Cape,4 Steve Gallivan,2 Simon Gilbody,5 Sue Hennessy,5
Judy Leibowitz,4 Karina Lovell,3 Lilian Owens,6 Christina
Pagel,2 Roger Paxton,7 Steve Pilling,2 Angela Simpson, 5 David
Tomson and Christos Vasilakis.2

1 University of Exeter
2 University College London
3 University of Manchester
4 NHS Camden
5 University of York
6 Independent Service User
7 Newcastle, North Tyneside and Northumberland Mental Health Trust
8 Newcastle University

Published August 2010
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Address for correspondence:

Professor David A. Richards,
Professor of Mental Health Services Research
Mood Disorders Centre
School of Psychology
University of Exeter
Room 118, Washington Singer Building
Perry Road
Exeter
EX4 4QG

Email: [email protected]

This report should be referenced as follows:

Richards, D.A., Weaver, A., Utley, M., Bower, P., Cape, J., Gallivan, S., et al. Developing
evidence based and acceptable stepped care systems in mental health care: an
operational research project. Final report. NIHR Service Delivery and Organisation
programme; 2010.

Copyright information:

This report may be freely reproduced for the purposes of private research and study and
extracts (or indeed, the full report) may be included in professional journals provided
that suitable acknowledgement is made and the reproduction is not associated with any
form of advertising. Applications for commercial reproduction should be addressed to
NETSCC, SDO.

Disclaimer:

The views and opinions expressed therein are those of the authors and do not necessarily
reflect those of the NIHR SDO programme or the Department of Health.

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Contents
Contents..................................................................................................3
List of tables ............................................................................................7
List of figures...........................................................................................8
Glossary of terms/abbreviations..................................................................9
Acknowledgements ................................................................................. 10
Executive Summary ................................................................................ 11
Background............................................................................................ 11
Aims..................................................................................................... 11
Methods ................................................................................................ 11
Results.................................................................................................. 12
Conclusions............................................................................................ 12
The Report............................................................................................. 14
1 Introduction...................................................................................... 14
1.1 Background................................................................................. 14
1.2 Access........................................................................................ 15
1.3 Organising the Delivery of Mental Health Care in Primary Care to People
with Common Mental Health Problems..................................................... 16
1.4 Stepped care............................................................................... 17
1.5 Aims and objectives ..................................................................... 20
1.6 Overview of research approach...................................................... 21
1.7 A note on the Improving Access to Psychological Therapies Programme
(IAPT) ................................................................................................ 22
2 Modelling in health service delivery...................................................... 25
2.1 Brief history of applications ........................................................... 25
2.2 Basic concepts used in modelling patient flow systems...................... 25
2.2.1 States................................................................................... 25
2.2.2 Movements between states...................................................... 25
2.2.3 Variability.............................................................................. 26
2.3 Modelling approaches................................................................... 26
2.3.1 Deterministic approaches that do not incorporate variability ......... 26
2.3.2 Stochastic approaches that incorporate variability....................... 26
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3 Objective 1 – development ................................................................. 28
3.1 Settings...................................................................................... 28
3.2 Pre-implementation activities of sites.............................................. 29
3.3 Method for Stakeholder Consensus Building..................................... 30
3.3.1 Inputs................................................................................... 30
3.3.2 Structuring the stakeholder interactions..................................... 32
3.3.3 Outputs................................................................................. 34
3.4 Results....................................................................................... 34
3.4.1 Participants ........................................................................... 34
3.4.2 Access to the Stepped Care System .......................................... 35
3.4.3 Interventions to be provided in the stepped care systems ............ 38
3.4.4 Patient progress through the step care system ........................... 40
3.4.5 Key action points from the Consensus Meetings.......................... 41
3.5 Summary.................................................................................... 41
4 Objectives 2 and 3 – Implementation................................................... 43
4.1 Setting....................................................................................... 43
4.2 Method....................................................................................... 51
4.2.1 Study Design......................................................................... 51
4.2.2 Quantitative study.................................................................. 52
4.3 Quantitative results...................................................................... 54
4.3.1 Patient Flow data.................................................................... 54
4.3.2 Treatment Inputs data ............................................................ 68
4.3.3 Treatment Outcome Data ........................................................ 74
4.3.4 Demographics........................................................................ 77
4.3.5 Summary.............................................................................. 80
4.4 Qualitative study.......................................................................... 81
4.4.1 Method ................................................................................. 81
4.5 Qualitative results........................................................................ 84
4.5.1 Participants ........................................................................... 84
4.5.2 Interpretation and result ......................................................... 84
5 Objective 4 - Modelling....................................................................... 97
5.1 Introduction................................................................................ 97
5.2 Simulation to illustrate key concepts............................................... 97
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5.3 Initial plans for modelling: estimating outcomes and the optimal use of
resources............................................................................................ 99
5.4 Analysis and modelling based on pilot site data................................ 99
5.5 Models incorporated within tool.....................................................102
5.6 Estimating demand for each service within a stepped care system .....103
5.7 Estimating throughput.................................................................104
5.8 Limitations of the model...............................................................107
5.9 Considerations influencing software design.....................................107
5.10 Tool architecture......................................................................108
5.11 User Interface..........................................................................109
5.12 Tool Output.............................................................................112
5.13 Summary................................................................................113
6 Objective 4 – Implementation of tool and manual at sites ......................114
6.1 Methods ....................................................................................114
6.1.1 Study Design........................................................................114
6.1.2 Setting.................................................................................114
6.1.3 Participants ..........................................................................114
6.1.4 Data sources/measurement (Data analysis) ..............................114
6.2 Results......................................................................................117
6.2.1 Participants ..........................................................................117
6.2.2 Demographics.......................................................................119
6.2.3 Qualitative results .................................................................121
6.2.4 Summary.............................................................................132
7 Summary, discussion and recommendations ........................................133
7.1 The Constituency Approach: a model for assisting the NHS to design
care systems......................................................................................134
7.2 Design uncertainties in stepped care services and their impact on
patient pathways ................................................................................138
7.3 Barriers to implementing stepped care: the experiences of staff and
patients.............................................................................................142
7.4 Using a stand-alone modelling tool to aid system planning................147
7.5 Limitations.................................................................................150
7.6 Implications and recommendations................................................151
References............................................................................................154
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Appendix 1: Consensus development reports.............................................168
Appendix 2: Phase I site reports ..............................................................207
Appendix 3: Reconfiguration tool and manual ............................................285
Appendix 4: Interview topic guides...........................................................356
Appendix 5: Analytical methods for calculating the distribution of the
occupancy of each state within a multi-state flow system. ...........................366
Appendix 6 Mathematical Appendix ..........................................................394

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List of tables
Table 1 Definitions of three functions of modelling (Fulop et al, 2001, p 158) . 22
Table 2: Professional and role details of workshop attendees......................... 36
Table 3: Decisions taken about access to new stepped care systems.............. 37
Table 5: Demographic details of Phase I sites ............................................. 52
Table 6. Number of patients who accessed each part of each service.............. 56
Table 7: Average waiting times from referral to assessment of each site and
overall (range in brackets)....................................................................... 67
Table 8: Duration (number of sessions) of treatment data for all clinical
activities at all sites (no data for step 1)..................................................... 70
Table 9: Outcome data by site (completeness)............................................ 75
Table 10: Clinician-assessed subjective improvement rates by site................. 76
Table 11: Demographic details of sites....................................................... 78
Table 12: An overview of the analytical process in the interpretation of themes
and subthemes....................................................................................... 83
Table 13: Summary of theme and sub-themes for Phase I............................ 85
Table 14: Demographic details of Phase II sites..........................................119
Table 15: An overview of the analytical process in the interpretation of themes
and subthemes......................................................................................120
Table 16: Summary of themes and sub-themes for Phase II ........................121

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List of figures
Site 1 - Structural diagram of service......................................................... 47
Site 2 - Structural diagram of service......................................................... 48
Site 3 - Structural diagram of service......................................................... 49
Site 4 - Structural diagram of service......................................................... 50
Site 1 – Patient flows............................................................................... 58
Site 2 – Patient flows............................................................................... 60
Site 3 – Patient flows............................................................................... 62
Site 4 – Patient flows............................................................................... 64
Overall duration of treatment for step 2..................................................... 71
Overall duration of treatment for step 2 for Site 4 ....................................... 72
Overall duration of treatment for step 3..................................................... 73
Figure 13 – Illustration of a traditional configuration for a mental health care
system.................................................................................................. 98
Figure 14 – Illustration of stepped care configuration for a mental health care
system.................................................................................................. 98
Figure 15. Model output concerning the time-varying occupancy of different
states comprising the system for the provision of mental health services. ......101
Reproduced from Utley et al, IMA MM 2009 ...............................................101
Figure 16: An example of how a stepped care system might be configured.
(Boxes with dashed borders represent exits from the system.).....................102
Figure 17: Example of a portion of a stepped care patient-flow system containing
a cycle. ................................................................................................103
Figure 18: Using the duration of treatment distributions, we can calculate the
distribution of the number of patients seen, for example, over 26 weeks. ......105
Figure 19: Potential pathways through a stepped care system......................105
Figure 20: Calculating input and throughput of one treatment (low intensity). 106
Figure 21. Conceptual data model structure of the database underlying the
software tool.........................................................................................109
Figure 22. The main ‘Interface’ worksheet.................................................110
Figure 23. The ‘Patient Movement’ worksheet ............................................111
Figure 25. The ‘Summary of system performance over a 6-month period’ output
form. ...................................................................................................113
Figure 26: Recruitment flowchart.............................................................118

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Glossary of terms/abbreviations
cCBT Computerised Cognitive Behavioural Therapy
CBT Cognitive Behavioural Therapy
CMHT Community mental health team
CORE Clinical Outcomes for Routine Evaluation
CSIP Care Services Improvement Partnership
GMHW Graduate mental health worker
GP General Practitioner
HI High-intensity
IAPT Improving Access to Psychological Therapies
IMD Indices of multiple deprivation
LI Low–intensity
MRC Medical Research Council
MREC Multicentre Research Ethics Committee
MS Microsoft
NHS National Health Service
NICE National Institute for Health and Clinical Effectiveness
NIMHE National Institute for Mental Health in England
NSF National Science Foundation
OCD Obsessive Compulsive Disorder
PATS Psychological assessment and treatment service
PCMHT Primary care mental health team
PCMHW Primary care mental health worker
PCT Primary Care Trust
PHQ9 Patient Health Questionnaire 9
PTSD Posttraumatic stress disorder
UCL University College London
VBA Visual Basic for Application

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Acknowledgements
We would like to acknowledge the contribution of the NHS clinical staff,
patients, managers and commissioners who were involved in our four initial
NHS clinical service sites. We would also like to thank those managers and
clinicians who tested the modelling tool.
Grateful thanks are owed to all the participants in our qualitative interviews
and focus group. We are also grateful for the diligence of our site-based
NHS audit clerks who collected and collated the data on patient
throughputs.
Final thanks are due to Kerry Cipriano and Joanne English who provided
administrative support at the University of York and University College
London respectively.

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