Early intervention in psychosis: action plan

Annex A: Outputs from Diagnostic Exercise

The information in this Annex has been gathered via the work of the Short Life Working Group (SLWG) that was formed by Healthcare Improvement Scotland (HIS)

NHS Health Boards: Early Interventions in Psychosis (EiP) Services Questionnaire

To identify the current position across Scotland in relation to EiP a questionnaire was developed and sent to all 14 regional health boards, as well as The State Hospitals Board for Scotland.

Responses were received from all of the boards except for NHS Borders, NHS Lothian and NHS Orkney. NHS Grampian, NHS Highland and NHS Tayside submitted multiple responses from different services/areas within their board. Seventeen completed questionnaires were received in total. This report outlines the responses received.

Specialist EiP Services Across Scotland

Within Scotland there are only two dedicated specialist services for EiP – NHS Greater Glasgow and Clyde and NHS Lothian CAMHS. At the time of this analysis, no response from NHS Lothian had been received.

Early Intervention Psychosis Definition

When asked to define EiP, a variety of responses were received. However, responses were consistent in that they included ‘suspected first episode (non-drug induced) psychosis, displaying onset psychotic symptoms’.

Boards varied in their definition of ‘early’ in relation to psychosis, with a range of 6 months to 3 years from initial display of symptoms.

The age of people experiencing symptoms of psychosis affects whether they are diagnosed as first presentation. This also varied between boards.

Early Intervention Psychosis Treatment and Intervention

Referral criteria to EiP services should be based on evidence of current best practice. Diagnostic categories, suitability of referral, multidisciplinary involvement, and the timescales to action referrals, were elements mentioned within the board definitions.

Following referral to service for initial presentation of early psychosis, a range of interventions were mentioned. These included:

• Easy and rapid access to assessment
• Access to psychological therapy and psychologically-informed care
• Multidisciplinary intervention
• Tailored, evidence-based service to patient and family
• Evidence based, within local policy
• Educational and vocational interventions

Additional recommendations from the guidance, or alternative practice guidance, which have been implemented include the following:

• Integrated Care Pathways or Care Programme Approach
• Assertive follow-up or outreach, in alignment with DNA/CNA policies
• Medication, and physical health, monitoring and recording in line with local policy
• Promotion of Advance Statements
• Community Mental Health Team (CMHT) or specialist team support
• Peer support
• Collaborative working – interagency, multidisciplinary and family services.

9 out of 17 responders have implemented SIGN guideline 131: Management of schizophrenia. 8 out of 17 have implemented the Access and Engagement key recommendation from the guideline.

Quality Indicator T5 (% of first presentation psychosis patients that start SIGN or NICE guideline evidence based treatment within 14 calendar days of referral to specialist mental health services)

Of the respondents, only NHS Greater Glasgow and Clyde confirmed that data on access/return to treatment (RTT) is collected. However, NHS Dumfries & Galloway is developing a framework to measure a wide range of quality indicators which will include T5. The cross system Quality Indicator Steering Group in NHS Grampian is collecting information and considering T5 indicator.

NHS Board Reflection on Early Intervention Psychosis

When asked to consider EiP services and where this work sits in the board’s local priorities, there was an overall agreement that early intervention is a high local priority and an ask of The Scottish Government.

‘Early Intervention in Psychosis is recognised as central to our Mental Health service delivery and as such our service has mainstreamed EiP throughout our various community and inpatient services offering robust diagnosis, care and treatment and recovery support to individuals and families.’ NHS Ayrshire & Arran

‘We are currently significantly investing in a range of service models that deliver earlier interventions for individuals. This is in line with our Directorate Plan and feeds into the HSCP Performance Framework.’ NHS Dumfries & Galloway

‘Across NHS forth Valley our services are interested in developing work to enhance the provision of care and treatment to people with first episode psychosis and to strengthen the provision of assertive outreach. We would welcome support on this.’ NHS Forth Valley

‘The NHS Highland Mental Health Improvement Group recognises that this is a vulnerable group of patients and that there is an obligation to produce local service development recommendations which reflect the priorities indicated in the Scottish Government mental health strategy.’ NHS Highland

Boards see the gains from early intervention, such as improved health of the patient and services. Bespoke EiP services have not always been the chosen delivery model, with incorporation of the ethos of EiP services into generic mental health services being the delivery plan for some boards.

‘Leads have been identified to look at process to deliver this within existing resources and within the model of an enlarged generic CMHT.’ NHS Fife

‘Effective collaborative working between members of the CMHT ensure that the patient’s needs are addressed in a person centred way with the involvement of the most appropriate skilled professionals depending upon presentation.’ NHS Grampian

Some more rural and remote services have highlighted their view that lower referral numbers and lower population may not necessitate a separate EiP service.

‘In a small rural mental health service, such as Moray, covering a population of 100,000 it is not possible to have specialist teams/services for specific diagnostic groupings. The demand upon the service for early presentation psychosis would not merit the use of resources for a specific team.’ NHS Grampian

‘Working in a remote and rural location it is difficult to support specialist dedicated services for specific conditions. The current number of referrals is also low in this area and potentially over a large geographical area. There will be additional work required to support early intervention in psychosis.’ NHS Highland

‘We recognise the potential gains which may be expected from providing high quality care early in the course of illness to reduce longer term morbidity and disability. We also recognise particular challenges in delivering such services across a sparsely populated remote and rural area. For this reason, in our local context we do not advocate the development of a discrete EiP service but we do aspire to deliver an early intervention approach by co-ordinating input from existing resources.’ NHS Highland

Esteem in NHS Greater Glasgow and Clyde, as one of the two dedicated EiP services in Scotland, shared their thoughts on how their service has developed.

‘Early Intervention in Psychosis is recognised as central to our Mental Health service delivery and as such our service has mainstreamed EiP throughout our various community and inpatient services offering robust diagnosis, care and treatment and recovery support to individuals and families.’ NHS Greater Glasgow and Clyde

The following dedicated w.t.e. (whole time equivalent) staff are working in EiP within GG&C:

• Medical 3.4
• Nursing 15.6
• Allied Health Professional (AHP) 3.7
• Psychology 3.9
• Admin 4.4

An in-depth piece of diagnostic work is taking place with NHS Greater Glasgow and Clyde and NHS Highland’s Argyll & Bute Health and Social Care Partnership to increase understanding of current EiP services. The approach will assist in identification of need, resource requirements and will help inform future actions.