Case study summary
Inspired by successful interventions in other Improving Access to Psychological Therapies (IAPT) services, iCope set about implementing their own approach, which they termed ‘recovery consultations’. Recovery consultations were born out of the idea that this was to neither take up already overburdened supervision time nor to be a target driven approach from line management. Instead recovery consultation was put forward as an invitation to a supportive and curious professional learning environment, focussed on development in the quality of the therapy delivered by individual clinicians.
The Islington IAPT Service, named ‘iCope’ by service users, is dedicated to the provision of high quality Cognitive Behavioural Therapy and other NICE guideline adherent psychological approaches to the treatment of anxiety and depression for adults living in or with a GP in the London Borough of Islington. iCope serves a population of 206,100 people (according to the 2011 Census) , and referral rates are increasing, from 2033 referrals in 2011 and 8194 in 2015.
Using the stepped care approach, the service is staffed with a larger force of step 2 workers (psychological wellbeing practitioners) offering guided self-help, low intensity behavioural activation, psychoeducational groups and workshops, computerised CBT, and community linking. Step 3 workers see clients who are looking for more support following step 2 interventions as well as offering more in depth assessment and treatment for clients of higher need though still within the primary care IAPT remit.
Working in GP surgeries and out of community settings enables close working with GP colleagues, and makes the service accessible to the local population. The service pride themselves on service user involvement and innovations and have received several awards (including the Innovation in Mental Health and Primary Care Award from the Positive Practice Collaborative 2015, and the Promoting Healthy Living Through Education and Training award from Health Education England, 2015).
They sought to balance the potentially conflicting demands of KPIs around numbers entering treatment (that is, quantity) and KPIs for recovery rates (that is, quality of therapy work in terms of symptom reduction). In 2014 a working group was formed within iCope with a passion to bring recovery firmly to the foreground so as to ensure they can meet (and with hopes to surpass) the national target of 50% of patients recovered, not just averaged across the service overall, but also on an individual clinician basis. Inspired by successful interventions in other IAPT services, they set about implementing their own approach, which they termed ‘recovery consultations’.
Recovery consultations were born out of the idea that this was to neither take up already overburdened supervision time nor to be a target driven approach from line management. Instead recovery consultation was put forward as an invitation to a supportive and curious professional learning environment, focussed on development in the quality of the therapy delivered by individual clinicians. For example, where a clinician’s recovery rate was low, the approach was to be mindful that this can be in part owing to a higher proportion of clients being more complex than expected for an IAPT setting, or inconsistencies in coding of data on patient record systems, and a number of other factors, rather than reflecting a deficiency in the quality of their clinical work. This opened up the possibility for the recovery rates discussed in the consultation to be viewed as a baseline from which an improvement were to be sought via open-minded, problem solving exploration, and agreement on specific learning points and targets to be reviewed post-consultation.
The members of the Islington iCope Recovery Working Group started by inviting all step 2 clinicians who had completed their training to have an hour long recovery consultation at a time of their convenience, in a quiet and confidential space. Later this was extended to include all qualified step 3 staff, and then remaining clinicians identified as having lower than average recovery rates were specifically invited.
Before the recovery consultation, the following data were gathered in preparation:
- A list of 5-10 non-recovered and 5-10 recovered clients that were recently discharged.
- Missed (DNA or cancelled) session rates, and how this rate compares to the rate for the whole service.
- Number of treatment sessions completed for non-recovered and recovered cases.
- Drop-out rates and a comparison of this to the rate for the whole service.
- Whether follow-up appointments (before or after discharge) were offered.
- Recovery rates overall for different GP surgeries, and different levels of complexity.
- Having a diagnosis to describe the focus of the work and the treatment approach and the rate of use of matching anxiety disorder specific measures where appropriate.
- Using (minimum data set and specific ) questionnaires to support tracking change throughout therapy.
- The number of review sessions offered for clients that did and did not recover.
The consultations then explored these data and compared and contrasted recovered and non-recovered cases to collaboratively discuss:
- how treatment decisions were made
- supporting a good match of client and clinician’s expectations
- helpful use of the stepped-care model
- appropriate coding of data
- how to track recovery using goals and questionnaires
- when to consider discharging a client with recovery rates in mind.
This opportunity to reflect in depth then led to individually tailored learning points (presented as a written summary) for each clinician to act upon as their recovery focussed professional development goals, both independently and with the support of their supervisor.
Clinicians consistently fed back that they valued this new experience as refreshing and insightful.
One clinician said: “I found it very helpful. It involved finding out my recovery rate, then discussing cases, both those who had reached recovery and those who had not, to discuss the difference and think about any changes I could make to my practise to improve my recovery rate.”
Another said: “I thought that the meeting would be airing on the side of punitive and driven by service demands, however, it was more personal to me and not punitive in the slightest. I felt it was very thoughtful and I did not feel as though I was being told off for low recovery rates, but instead problem solving what could be helpful for me and my clients.”
Looking at the service outcomes overall for the time period during and following these recovery consultations across the team, data has shown a successful increase in recovery rates from 40.9% in September 2015 to surpassing the 50% national target for IAPT services and reaching an average of 51% for the last six months for both step 2 and 3 combined (or 53% for step 3 only), as calculated for March 2016- September 2016.
An audit of these consultations is still underway. Initial results from the first 12 clinicians that had recovery consultations and stayed with the service for at least three months afterwards, showed that their recovery rates three months prior to the consultation compared to three months after the consultation improved markedly for 9 of the 12. Improvements ranged from an increase in recovery rate of 2.25% to 44.45%, with the mean increase in recovery rate pre-to-post consultation for those that showed any improvements of 12.58%.
Even though they had made great strides to complete as many as over 20 recovery consultations across the team, it is clear from this feedback that there is more to do to ensure that the recovery focus continues to thrive.
“I see it as an ongoing piece of work for me and would welcome further discussion as it sparks ideas of how we can improve. …I would welcome discussing this with the recovery team so that we are doing all we can to ‘push’ up the rates incrementally service-wide. ”
“I think they should happen more regularly. I have only had one and I have been here for two years. I think it would be helpful to have them at least once a year, if not every six months.”
The management team in Islington iCope have been recently trained in how to offer recovery consultations, the Recovery Working Group is now passing the torch to managers. The hope is for all clinical staff to have this opportunity to reflect and learn from clinical work on a regular basis, and for recovery to be the cornerstone of working culture.
With thanks to the Islington iCope Working Group: Drs Isabella Foustanos, Jessica Willner-Reid, Joshua Buckman, Judy Leibowitz, (formerly) Alastair Bailey, and James Gray.
For further information please contact:
Dr Isabella Foustanos
Clinical Psychologist & High Intensity Worker
Islington iCope Psychological Therapies Service Camden & Islington
NHS Foundation Trust Service
Telephone: 0203 317 7252