Proposal for the development of effective approaches to ...



“Making Psychological Care Everybody’s Business”

Proposals for the Development of Effective Approaches to Providing Psychological Care and Psychological Therapies across the Adult Network

Contents

1. Introduction

2. Background

3. The Stepped Care Approach

4. Proposal for the Provision of Psychological Therapies – “NICE Guidance Plus”

5. Organisational and Management Arrangements

6. Specialist Psychotherapies Service

7. Eating Disorders Service

8. Workforce Implications

9. Next Steps

Appendices

A. Types of Psychological Treatments as an Integral Component of Mental Health Care

B. Proposed Range of Psychological Therapies/Treatments to be Provided

C. Sample Job Descriptions

D. Key Consideration Questions

1. Introduction

1. This paper puts forward ambitious proposals for significant improvements in the

ways in which psychological care and psychological therapies are managed and provided across the Adult Network. A number of proposals are put forward for consideration and we welcome your views and responses.

2. In 2001 the formal consultation document for the establishment of a new Mental

Health Trust in Lancashire suggested that the proposed Care Trust would be a new type of mental health organisation, which would

“ Create a culture in which social, psychological and medical models of mental health and illness are equally valued”. (p 14)

3. The proposals have important implications for all staff, all services and all teams

and for the ways in which specialist staff in psychological services are organised, managed and professionally supported.

4. Overall, the aim is to meet the needs and aspirations of our service users to have

access, in a timely way, to a level of psychological care or psychological therapy, which meets their needs. The implementation of changes as a result of this consultation plus the effective outcome of active negotiation with commissioners will result in improvements for all service users.

5. Achieving this aim has important implications for the following:

• The development of psychological skills and competence across the whole workforce

• The need for staff (from any professional background) with psychological skills to have the opportunity to use and develop these competencies with appropriate supervision

• The responsibilities of Community Mental Health Teams, other services and their managers for the provision of effective psychological care and for waiting time and waiting list management

• The development of effective clinical and operational governance arrangements for the provision of psychological therapies within teams, localities and across the Network.

In the following sections, a number of key issues are highlighted and proposals are put forward for the way in which these challenges and opportunities can be addressed.

6. Broadly, the proposals in this consultation are organised into four major themes:

i. Proposals regarding the model of service delivery for psychological care and psychological therapies

ii. Proposals about ensuring the range of therapies provided are evidence based and NICE compliant

iii. Proposals regarding the organisational and management arrangements to support the delivery of these agreed services

iv. Proposals regarding the workforce implications of the above.

2. Background

2.1. As part of professional training, all staff working within specialist mental health care should develop knowledge and skills in relation to psychological care and psychological treatment.

2.2. Broadly speaking it may be helpful to consider three types of activity in this area:

i) Type A: - Psychological treatment as an integral component of mental health care

ii) Type B: - Eclectic psychological therapy and counselling

iii) Type C: - Formal psychotherapies

(NHS psychotherapy services in England – a review of strategic planning – September 1996)

Appendix A provides more information about the above three types of activity.

2.3. Building on the above review the DoH document “Organising and Developing Psychological Therapies” (July 2004) indicated that “psychological therapies are part of essential health care…(but that)…in many mental health services psychological therapy provision is patchy, uncoordinated, idiosyncratic, potentially unsafe and not fully integrated into management systems” (p1). This report concluded that “psychological therapies have an important place amongst the range of treatments available as part of comprehensive, user centred mental health services. As the evidence base for the effectiveness of psychological therapies have grown, so has their popularity; they should no longer be regarded as optional components of mental health care” (p39)

2.4. In a recent review of waiting times and waiting lists for specialist psychological

therapies (April 07) across the Network three key issues were highlighted:

2.4.1.There are clear differences in the priority given by commissioners to the

development of specialist psychological services across Lancashire. This is both an historical legacy and a feature of more recent service developments. Across the Trust there are examples of new ‘policy guidance compliant’ services being developed with funding for medical and nursing staff, but not the required funding for specialist therapy provision.

2.4.2.Psychological services have also differed in the ways in which their staff have been deployed to provide services. In some areas staff are embedded as members of multi-disciplinary teams, in others, staff are likely to be based in a department of psychological services.

2.4.3.There are also clear differences in the extent to which providing psychological

care and psychological therapy are seen as either the business of the whole team or the work of a specific group of staff. Generally speaking, waiting times and waiting lists are shorter where providing psychological interventions are seen as central to the work of the whole team and are provided as part of a tiered approach.

2.5. Nationally, mental health has become one of the three clinical priorities for the

NHS (along with cancer and heart disease). National policies have emerged over the past decade, notably the 1998 White Paper ‘Modernising Mental Health Services’ and the National Service Framework for Mental Health (NSF) (DoH 1999).

2.6. The underlying ethos of the National Service Framework (NSF) for newly

developing services is to maximise service user choice and involvement. Providers must strive to ensure that the services they deliver are:

• User centred, meeting individual needs

• Recovery focused

• Socially inclusive, assisting with problems such as accommodation, finance etc.

2.7. At a local level the Lancashire Mental Health and Social Care Partnership

Board produced ‘A Comprehensive Mental Health and Social Care Strategy for Adults of Working and Older Age residing in Lancashire’ (2004) and a subsequent consultation document ‘Working Together to Improve Mental Health” (2006). These documents set out a comprehensive mental health delivery programme for the whole of Lancashire.

2.8. A new, integrated LCT and LCC (Lancashire County Council) adult mental

health management structure has now been completed and a number of professional lead posts were identified as part of the Network leadership team.

2.9. In relation to primary care mental health services there are different

commissioning arrangements and service delivery models in place across the Trust, and this is likely to remain true in the near future. LCT’s involvement in this area is likely to be determined by the commissioning intentions of PCTs. However we intend to compete to develop primary care mental health services:

a) In collaboration with commissioners

b) By competing for tendered services

c) Through working closely with other agencies and partners to secure LCT involvement in the provision of PCMH services.

2.10. With the development of the Improving Access to Psychological Therapies

(IAPT) programme the place of psychological therapies becomes central to the provision of high quality primary care focused mental health delivery. Such services should be ageless, and link with a range of social care components aimed at providing holistic approaches to people’s mental distress. The component psychological therapy skills will need to focus on the delivery and evaluation of high volume, low intensity interventions including brief CBT, and solution focused therapy as well as larger scale psychoeducational groups. There will also be a foreseeable need for high quality supervision of practice from skilled psychological practitioners, whether as a direct part of the PCMHT, or co-opted in via SLAs.

2.11. CMHTs have been a core element of mental health services in Lancashire for

over fifteen years. However each team has developed different ways of delivering a service to their local population. It is proposed that through the Service Transformation Programme the functions of CMHTs are systematically reviewed and that new operational models are explored. The following ideas are under consideration:

1. Separate Primary Care resources from the CMHT and create separate PCMHTs

2. Develop New Ways of Working within PCMHTS and CMHTs

3. Clarify the responsibilities of the CMHT to manage Psychological Therapy referrals and interventions as a core element of the team

4. Create core functions within the CMHT (see figure one below). For example:

▪ Develop an assessment and treatment team made up of all members of the current multi-disciplinary CMHT. This team would include skilled Psychological Therapists.

▪ Develop a complex treatments team made up of multi-disciplinary workers with advanced skills who would treat service users with highly complex and variable mental health problems.

▪ Develop a long-term conditions team - a group of multi-disciplinary workers who would treat, care for and support service users with severe mental health issues. This team would also treat and support carers. The team’s emphasis would be on treatment, recovery and social inclusion. It is likely that this team would be made up of Psychiatrists, Social Workers, CMHNs and Support, Time and Recovery Workers.

5. Describe and create capacity models in PCMHTs and CMHTs based on treatment modes (NICE Guidance) and diagnosis (e.g. the number of service users with depression requiring an agreed number of therapy sessions; the number of service users with family / relationship issues requiring family group therapy).

Figure 1 provides a diagrammatic illustration of how a CMHT could function.

FIGURE 1

Locality CMHT Model

2.12. Service users would be able to access assessment and treatment by means of

agreed care pathways focusing on achieving and meeting NICE guidance. For example, a service user with a psychosis (in the long term conditions team) would be able to access CBT for depression treatment and management from the complex treatment team. Staff would also be able to work into the three teams to provide sessional time for specific therapies and interventions, for example when supervision was required by a CMHN or SW who was delivering family therapy for a service user with Bi-Polar Disorder symptoms.

2.13. The crossover of skills and capacity would be limited to delivering treatment as

part of an assessed package of care. Mostly staff would remain dedicated to focusing on providing treatment within their own intra-CMH team.

2.14. This model would allow the CMHT to focus its resources more efficiently on

delivering effective, evidence based treatment and care. It would help the team to organise its work more efficiently and be able to describe service and resource shortfalls.

2.15. In terms of workforce development, greater clarity would emerge about the level

and type of training which the Trust would support, in regards specific agreed psychological therapies which would be required to meet demands, and identified.

2.16. In relation to inpatient services, a number of recent publications, including the

MH “NSF–5 years on” have indicated the need to improve access to psychological therapies as part of the care package provided to service users receiving in-patient care. There are a number of appropriate models available, although currently there is a dearth of provision across LCT (with some exceptions). The two current models are; provision of assessment and therapy from a Clinical Psychologist who provides sessional input or, via Nurse Practice Development staff who are ward based and aim to provide direct assessment/therapy, as well as upskilling all ward staff members in a range of skills to enable a more psychologically informed regime of care to be developed.

2.17. Views are therefore sought on how to improve the provision of

psychological therapies within inpatient settings.

2.18. Within LCT it is recognised that change is an ongoing part of service

development and this can result in services being restructured. Changes to the delivery of psychological care will impact on a range of staff and this will result in roles and duties having to change. Changes to posts will be managed in accordance with the Trust’s policy on The Management of Organisational Change (HR 025).

2.19. It is also important to note that the proposals outlined in this paper will need to

take place within the existing total resources for psychological services.

2.20. Finally, whilst the emphasis in this paper is the provision of psychological

therapies and treatments, it is also recognised that a coherent psychological contribution to specialist mental health care is about more than one to one or group assessment and therapy. In some parts if the Trust good use is already being made of psychological skills in consultation, training, supervision, service audit, evaluation and research. It is recognised that all these areas of activity need to flourish and be supported within new professional and management arrangements.

3. The Stepped Care Approach

3.1. It is proposed that a stepped care approach to the delivery of psychological therapies and treatments is adopted across all primary and secondary care mental health teams.

3.2. This approach aims to initially provide a range of minimal/brief interventions

combined with monitoring to determine whether the patient needs to be moved either to the next/more intensive step, or to a less intensive service provision. The stepped care approach contrasts with a more traditional approach where large numbers of service users are referred to specialist services, which then either become overloaded, or inefficiently provide interventions not wholly suited to the person’s needs.

3.3. The adoption of a stepped care approach, allied to the broader context of new

ways of working, would respond to the needs of service users and their journey through clearly defined steps following a single point of access. Figure 2 below provides a diagrammatic representation of the stepped care approach.

FIGURE 2

Example of an Overview of the Stepped Care Approach

3.4. It is recognised that this approach is already in place in some parts of the Network and allows for high quality psychological care and psychological therapy to be provided by appropriately skilled staff across a range of disciples working in the context of clear supervision arrangements.

3.5. Views are sought on the proposal to implement a stepped care approach across all primary and secondary mental health teams.

1. Proposal for the Provision of Psychological Therapies – “NICE Guidance Plus”

1. The Trust is aware of its responsibility to provide a range of NICE guidance

compliant services which include the provision of an identified range of psychological therapies.

2. It is therefore proposed that teams and services will be audited to indicate

whether they are guidance compliant in all areas, including the provision of psychological therapies.

3. It is also recognised that there are a range of other therapies/psychological

treatment for which there are a variety of different evidence bases . Appendix C provides a summary of the main approaches to psychological therapy that are currently available.

4. It is proposed that the Trust takes a clear view on the range of therapies and

treatments that will be provided and which are consistent with a clear evidence base.

5. Views are sought on the development of an agreed range and menu of therapies and treatments that should be available in the Trust.

6. The development of effective governance arrangements for the provision of

psychological therapies and treatments is considered crucial and is an area where the Trust wishes to make specific improvements.

7. It is therefore proposed that a formal group is established which will aim to

assure that those treatments and therapies that have been agreed by the Network are being provided to the highest standards.

8. Views are sought on the proposal to develop effective

governance arrangements for the agreed range of therapies and treatments within the Adult Network.

2. Organisational and Management Arrangements

1. Effective, well organised and efficient management arrangements are crucial in

facilitating the provision of high quality service user care.

2. It is therefore proposed that there will be clear professional leadership and

operational line management arrangements for the provision of psychological therapies.

3. Professional leadership and supervision arrangements will be formally

established in each locality with the overall responsibility for these arrangements resting with the locality professional lead.

4. The operational management of staff providing psychological services will be

undertaken by the manager of the team or service area within which staff work.

5. Team managers will have the responsibility for putting in place a stepped care

model to meet the psychological needs of the local population, making best use of the levels of expertise which exist within teams.

6. It is proposed that the above changes will take place gradually as teams develop in line with the overall service transformation programme.

7. The development of the proposed new models of service described above,

ultimately means that a new and flexible workforce is required.

The following actions will need to be undertaken:

• Develop new job descriptions for CMHT Managers and Deputy Managers, Modern Matrons, Ward Managers and Deputy Ward Managers. The job descriptions would need to take account of the new responsibilities and accountabilities for the team.

• Describe the range and type of psychological therapies required in each CMHT, PCMHT and specialist service. This would then determine the numbers of staff and the levels of skill required in each team.

• Develop new job descriptions for the above workforce.

• Agree the relative numbers and skills of staff required at each band from Band 5 to Band 8C.

• Clarify which other members of the workforce, i.e. Community Mental Health Nurses and/or Occupational Therapists, have acquired other skills and qualifications such as CBT, CAT or Group/Family Therapy. With the clarification of the new job descriptions these staff would be able to work sessionally to provide these therapies, and be rewarded accordingly.

8. It is recognised that even if these changes were implemented, team capacities

may be too low to match the number of referrals and levels of need. However, by clarifying our capacity and organising our services more efficiently, we would be in a stronger position to discuss the real gaps in provision with Primary Care Trusts. Also, on this basis, we could realistically base contracts so that upper limits on the number of referrals and treatments per team could be agreed.

9. The scope of this exercise covers:

• All current psychological services staff from all localities at Bands 5 through to and including 8d (excluding locality Heads of Psychological Services as these posts were recently recruited in the Network Management restructure)

• All current Counsellor Manager or Lead posts from all localities, currently at Bands 8a and 8b

• All psychological service Operational Management posts currently at Bands 8c and 8d (excluding locality Heads of Psychological Services)

• Current Head of Speciality posts

• Integrated Team Managers and Deputy Team Managers.

10. It is proposed that where LCT provide primary care services the locality would

have at least one Clinical Lead for Counselling and Graduate Workers. Where counselling services are not commissioned with LCT, leadership capacity will not be required. The post holder would be managerially and professionally accountable to the Locality Professional Lead for Psychological Services. The post holder would not hold budgetary or operational service responsibility. Within a locality ongoing training, senior clinical support and supervision will need to be provided to the counselling workforce, it is proposed that a number of Band 7 posts will be required.

11. It is further proposed that a number of Consultant level (8c) posts would be

established in each locality to provide additional capacity for professional leadership and supervision for psychological services. These posts would cover primary care and secondary care services (including in-patient services).

12. These Consultant level post-holders would, in turn, be professionally managed

and supervised by the three Locality Professional Leads.

13. Figure 3 below aims to clarify the proposed network professional lead, clinical

and operational structures.

FIGURE 3

Professional Lead, Clinical and Operational Structures

14. Views are sought on the proposals to clarify professional leadership and

operational management arrangements for the provision of psychological therapies and treatments.

3. Specialist Psychotherapies Services

1. Mental health services in Lancashire provide a rich variety of psychological

services and have, over many years, built up considerable levels of expertise in the

provision of a number of specific therapeutic approaches including psychodynamic psychotherapy for individuals and groups, cognitive analytic therapy, systemic therapy and cognitive behaviour therapy (type C level). This service would aim to provide a range of agreed therapies at a tertiary level of expertise for service users with complex needs. This aim would be met through the provision of specialist therapy as well as consultation, supervision, training and support for colleagues in the primary and secondary mental health services. This consultation seeks views on the possible development of a Trust-wide specialist psychotherapies service, which would draw together the services currently provided in different geographical locations into a single managed service. Two possible options for the Clinical and Operational Leadership of SPS are outlined below:

1. SPS Option 1

This option assumes that SPS would be a Trust-wide service with components of the service based in the different localities. Under this option a new post of Consultant level Clinical and Professional Lead would be developed.

The Operational Management and Clinical Leadership for Option 1 would be:

• Overall operational responsibility – Adult Network Director via a designated Assistant Adult Network Director

• Overall Professional Lead responsibility – Network Professional Lead

• Day-to-day professional responsibility – Consultant level Clinical and Professional Lead for Specialist Psychotherapies Services.

• Day to day operational responsibilities – a new clinical service manager post for specialist psychotherapies.

FIGURE 4

Leadership and Management Arrangements for SPS – Option I

2. SPS Option 2

This option assumes that SPS would be a Trust-wide service with components of the service based within each locality.

Overall operational responsibility – Adult Network Director

Locality operational responsibility – Assistant Network Directors in East, Central and North Lancashire.

Overall Professional Lead responsibility – Network Professional Lead

Locality Professional Lead responsibility – Locality Professional Lead

FIGURE 5

Leadership and management Arrangements for SPS – Option II

2. Views are sought on the proposals to establish a specialist

psychotherapies service and the options regarding the organisational and management arrangements.

4. Eating Disorders Services

1. Eating disorder services are not provided uniformly across the Trust. Where

they are provided the services are usually multi-disciplinary. It is proposed that a single managed clinical network for these services is developed across LCT. This proposal allows for a more effective focus on the on-going development needs of this service area.

2. This network would have a designated Clinical Lead providing overall clinical and

professional direction for the service working together with a Clinical Services Manager who would have line and operational management responsibility for the staff involved.

3. The above postholders would have an overall operational management

accountability to a designated Assistant Network Director with the lead clinician having a professional accountability to the Network Professional Lead for psychological services.

FIGURE 6

Leadership and Management Arrangements for the Eating Disorders Services

4. Views are sought on the proposal to establish a managed clinical network

for eating disorders across the Trust.

5. Workforce Implications

1. Consistent with the proposals outlined above, there is the need to ensure that the

knowledge and skills required to undertake the duties and responsibilities of the post within these new arrangements are considered carefully.

2. Historical patterns of funding are likely to mean that there will be variations in the

number of posts within localities however, Appendix C provides outline information in the form of a number of draft job descriptions and person specifications, concerning the range of duties and responsibilities of post holders.

3. The draft job descriptions cover the following groupings:

Graduate Primary Mental Health Care Workers

Counsellors - Bands 5 – 7 plus Counselling Professional Leads

Psychological Therapists e.g. CBT, CAT therapist staff

Clinical Psychology staff – Bands 5 – 8C.

N.B. all draft job descriptions are subject to AfC banding.

Amended Team and Deputy Team Manager job descriptions will be developed following the outcomes of the consultation.

Job descriptions for Adult Psychotherapist staff will be developed after the consultation around the potential for Specialist Psychotherapies Teams.

Job descriptions for the Consultant level Clinical and Professional Leads and a new clinical service manager will be developed after the consultation around the potential for Specialist Psychotherapies and Eating Disorder Teams.

4. Views are sought on the workforce implementation of these proposals.

1. Next Steps

5. This paper raises a number of key issues and puts forward ambitious

proposals which would assist the Trust in meeting its stated aim of providing high quality evidence based psychological, social and medical models of mental health.

6. The paper outlines a clear, positive focus on the development of professional

leadership and operational management arrangements.

7. Service users will benefit from more timely access to psychological assessments,

formulation and interventions where:

• levels of knowledge, skill and expertise amongst staff are closely understood

• stepped care models are in place

• all staff have clear opportunities to provide psychological care and/or psychological therapy at a level of complexity consistent with their knowledge, skills and competence

• services provide protected time and appropriate supervision for staff providing psychological therapies

• the skills and expertise of specialist staff are carefully utilised.

8. The Trust now seeks views and opinions on the issues and proposals

identified. Are there other issues that should have been considered? Are the proposals reasonable? Will the vision deliver better outcomes for service users? Appendix D provides a summary of the key consultation questions.

9. In order to progress this consultation further the Trust would welcome feedback, by Monday 26th November 2007, e-mailed directly to me. My telephone number is 01282 657120. I am also organising Consultation discussion meetings in each locality with groups of staff directly affected by this Consultation. David Hodgetts, the Assistant Network Directors and I would be happy to meet staff who may be affected by the proposals and who would want to contribute to the Consultation. Dependant upon the responses received we would hope to complete the consultation by January 2008 and to begin the next stages of implementing changes that have been agreed.

Thank you.

John Keaveny, David Hodgetts and John Holland.

September 2007

Appendix A - Types of psychological treatment as an integral component of mental health care

1. Type A: psychological treatment as an integral component of mental health

care.

1. This describes a wide range of psychological interventions offered within mental

health services alongside other types of care, e.g. nursing and medical care. In general practice, family doctors and primary care nurses may offer this, and community and hospitals services. Most mental health professionals in Community Mental Health Teams also offer it, e.g., a psychiatrist may offer a form of behavioural anxiety management whilst also attending to medication side effects during an outpatient appointment. Family interventions in schizophrenia, delivered by specially trained mental health nurses, are complemented by pharmacological management and are part of a wider care plan. Occupational Therapists may offer basic social skills training and counselling and, with the same service users, other group activities. A clinical psychologist in a multidisciplinary team may offer cognitive therapy to alleviate the delusions of a service user with schizophrenia whilst the service user is in hospital and also receiving medical and nursing care.

2. It is characteristic of this type of work that it is an integral component of other

mental health care activities (for example in a day hospital). It is part of a care programme offered by a team or service and is not offered separately

2. Type B: Eclectic psychological therapy and counselling.

1. In contrast to type A, types B and C are complete treatment interventions, offered

in the form of a series of set sessions, following an assessment which generates a therapeutic plan. The characteristic of type B provision is that it is informed by more that one theoretical framework. It includes both non-directive counselling and psychotherapeutic work which uses a range of techniques to address different facets of a service user’s problem.

2. Distinctions can be made between therapeutic counselling and eclectic

psychotherapy, but it is not easy to do empirically; counsellors and eclectic psychotherapists have many skills in common and few systematic differences in values or knowledge. Traditionally, counsellors worked with people who were less severely ill, people with situational or life adjustment problems rather then mental illness per se. In primary care within the NHS, the term ‘counsellor’ is often applied, irrespective of whether a counselling intervention is used, in preference to ‘psychotherapist’ as it is perceived as less stigmatising and off-putting to General Practice service users.

3. Although counselling tends to be skills-based, type B therapies may also be

driven by theory and carried out at an expert level; for example, clinical psychologists frequently work in this way, formulating complex problems from basic principles of human development, psychopathology and change, and taking a problem-focused, multi-modal approach to intervention. Some consultant psychiatrists use a variety of psychotherapeutic techniques in an informed way, without having formal specialist psychotherapy training or being designated psychotherapists.

4. Type B psychotherapists can claim research justification for the pragmatic use of

a range of techniques, in the findings that non-specific factors account for much of the variance in psychotherapeutic outcomes. There are potential advantages to a pantheoretical, pragmatic approach for service users with complex psychosocial difficulties, although these methods require formal evaluation.

5. Good practice within type B therapies should be distinguished from work which is

‘eclectic’ only in the sense that the individual is insufficiently skilled to articulate a clear rationale for the approach and carry through a therapeutic intervention based on this.

3. Type C: Formal psychotherapies.

1. Formal psychotherapies are practiced within particular models, well developed

bodies of theory and protocols for practice; eg, psychoanalytic, cognitive-behavioural, systemic. They are therefore undertaken by, or under the supervision of, a specialist practitioner, trained in a particular school of formal psychotherapeutic work, usually within a designated psychotherapy or psychology service. Specialists undertaking or supervising type C psychotherapy may work outside a designated department, although they will have the psychotherapeutic role in their job description. Some practitioners have trained and are competent in more that one formal model of psychotherapy.

2. Type C psychotherapy is delivered in the NHS by two kinds of people; a) those

whose training has included a range of psychological theories and who have specialised in formal psychotherapy after this broader training (this includes the training routes of clinical psychologists, and those psychiatrists and psychiatric nurses whose training has encompassed a broad spectrum of psychotherapies); b) those who have trained from the outset in a single theoretical framework and set of techniques (e.g. some of the trainings recognised by the United Kingdom Council for Psychotherapy and the British Confederation of Psychotherapists). The former type of training is more appropriate for those undertaking assessments to make informed recommendations on treatment of choice; a specialist training in a specific model is required to assess for that specific therapy, but does not necessarily equip people to act as brokers to other services and those undertaking such trainings should be aware of the limits of their competence in this regard.

3. Formal psychotherapy is sometimes offered in primary care; more usually the

role of the ‘formal’ psychotherapist in primary care is to offer assessment services, advice, consultancy and supervision. Formal psychotherapists also have an important role in supervising those offering these therapies at less specialist levels.

4. All three types of psychological therapy services are offered to individuals,

couples, families and groups.

Taken from: NHS psychotherapy services in England - a review of strategic policy September 1996

Appendix B - Proposed Range of Psychological Therapies/Treatments to be provided.

Within Primary Care Services:

a) Counselling (brief) – usually person centred/humanistic

b) Cognitive Behaviour Therapy (CBT)

c) Cognitive Analytic Therapy (CAT)

d) Interpersonal Therapy (IPT) usually psycho-dynamically derived

e) Brief Solution Focused therapy

f) Systemic Therapy - individual as well as family

g) EMDR (eye movement desensitization and reprocessing)

h) Mindfulness approaches

i) Psycho-educational group approaches.

Within Secondary Care Services:

a) CBT/Cognitive therapy/Schema-focused Cognitive Therapy

b) CAT

c) Brief focal Psychodynamic Psychotherapy/IPT

d) Integrative Psychotherapy (sometimes described as generic clinical psychology

in that it is what most Clinical Psychologists routinely do, drawing on a range of theoretical models to design an individually tailored therapy)

e) CBT/family approaches for Psychosis

f) Mindfulness

g) Dialectical Behaviour Therapy (DBT) for service users identified as having borderline personality traits.

Within Specialist Psychotherapy Services:

a) Individual Psychodynamic Psychotherapy

b) Group Psychodynamic Psychotherapy

c) Cognitive Analytic Psychotherapy

d) Systemic Therapy

e) Cognitive Behaviour Therapy

Appendix C - Sample Job descriptions and Person Speciation

for Proposed Job Families

Attached with Consultation Document on the intranet.

Appendix D - Key Consideration Questions

1. Views are therefore sought on how to improve the provision of psychological

therapies within inpatient settings.

2. Views are sought on the proposal to implement a stepped care approach across

all primary and secondary mental health teams.

3. Views are sought on the development of an agreed range and menu of therapies and treatments that should be available within the Trust.

4. Views are sought on the proposal to develop effective governance arrangements

for the agreed range of therapies and treatments within the Adult Network.

5. Views are sought on the proposals to clarify professional leadership and

operational management arrangements for the provision of psychological therapies and treatments.

6. Views are sought on the proposals to establish a specialist psychotherapies

service and the options regarding the organisational and management arrangements.

7. Views are sought on the proposal to establish a managed clinical network for

eating disorders across the Trust.

8. Views are sought on the workforce implementation of these proposals

-----------------------

OUTPUTS ATT

Treatment is completed and service user is discharged to Primary Care.

OUTPUTS CTT

Treatment is completed, further recovery support is needed, so service user care pathway moves to LTCT or to Primary Care.

Assessment & Treatment Teams. ATT.

CBT Therapist

CAT Therapist

Psychologist

OT

CMHN

Social Worker

Long Term Conditions Team. LTCT.

CMHN

Social Worker

Volunteer or other Support Workers from MIND/MAKING SPACE

OUTPUTS LTCT

Service user has reached optimum level of recovery – can be discharged to Primary Care, or supported partly by Primary Care & LTCT, or discharged from services & is able to access other services from the wider community.

Whole team managed by Team Manager and Deputy Team Manager

Complex Treament Team

Psychiatrist

CMHN

OT

Social worker

Referral from Single Point of Access (PCMHT) (Inputs)

Severe mental illness

High risk

Requires in-patient care

Prepare for discharge planning

Severe depression

Daily functioning: sig. impairment

Higher risk

Severe PHQ-9/HDAS score

Moderate depression

Daily functioning: mod. impairment

Increasing risk

Mod to severe PHQ-9/HDAS score

Mild to moderate depression

Daily functioning: mild impairment

Low risk

Mild to moderate PHQ-9/HADS score

Sub-clinical - primary care clinician alerted to service user’s state of mind.

Mild symptoms present for ................
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