Long Term Conditionsin an

IAPT / Primary Care Psychology Service

Dr Jon Freeman (Clinical Psychologist – Lead for LTCs)

jon.freeman@nhs.net

Facts and Figures

15m in England (>30%)

condition that cannot be cured but can be managed

through medication and/or therapy

chronic pain – 20%arthritis – 14%asthma – 5% obesity – 30% diabetes – 4%IBS – 10%CFS – 3%COPD – 2%

1/3 significant levels of distress chronic pain (50% dep 30% anx) diabetes (40% dep 40% anx)

impacts on self-care and physical health

nearly doubles cost70% of H&S care spend 15-20% of the pop. who have 3+ LTCs

Where does Psychology fit?

Aim:

improve health, reduce distress (and cost!)

How?

Cognitive Behaviour Therapy (CBT)

good, developing evidence base

Feelings

LTC Thoughts

Behaviours

Common Traps

hopeless & scared

diabetes “What’s the point?!” “It’s going to get me in the

end”

make no lifestyle changes pretend it’s not really

happening

anxious & frustrated

pain “Pain means damage” “I will press on on a good

day”

do less & less over time boom & bust

low & guilty

“I’ve let my family down” stroke “I’m not the person I used to be” “I’ll never do XYZ again”

withdraw from others, ruminate

not engage in rehab

• psycho-education (e.g. monitoring symptoms, identifying patterns, understanding condition & mind/body link, stress)

• behavioural change (e.g. goal setting, pacing, communication, sleep hygiene, relaxation, stress management)

• cognitive change(e.g. modifying and/or relating to unhelpful cognitions mindfully)

ALWAYS WITH A ‘MOTIVATIONAL INTERVIEWING’ HAT ON

COPD (Howard et al., 2010)↑mood, ↓A&E attendance, ↓bed days, ↓meds Every £1 Ψ input, saved £3 in admissions

Refractory Angina (Moore et al., 2007)↑mood, ↓emergency admissions (33%, saving £1337/pt/yr), ↑health

Cancer (Simpson et al., 2001) ↑mood, ↓expenditure by 23% - 2yrs post-Ψ

Diabetes, hypertension, asthma (Spurgeon et al., 2005) ↑mood, ↓admissions, secondary care referrals

Arthritis, stroke, lung disease, heart disease (Lorig et al., 1999)↑mood, ↓admissions, ↓bed days

Rheumatoid arthritis (Sharpe et al., 2001)↓admissions, ↓injections, ↓physio referrals

Low back pain (Lamb et al., 2010)↓resources, costs less than half of other interventions (e.g. physiotherapy)

What does the legislation say?

Joined-up, holistic workingProvide earlier helpSelf-management approach (CBT based)EmpoweringIAPT

Healthy Lives, Healthy PeopleNo Health Without Mental Health

Talking Therapies: a 4-year plan of action NICE

LIFT Psychology Service

developed 1993

opt-in service

community based

stepped-care

1st wave IAPT site

dh pathfinder site

The past 4 years…

- 0.4wte clinical health psychologist- small ‘core team’ built up over time - developing self-management courses- training and supervision to all LIFT staff (MI & CBT skills for physical health – individual and group-based interventions)- building bridges with physical health services- promotion & education to all, including GPs,

nurses, hospital staff, etc

Our self-management courses

2 hours, 1 day/week, 5 weeks, in community venues, opt-in

2 staff (usually assts, b4 or b5) facilitating group discussion

CBT-based techniques: - rationale for CBT - common traps - stress and relaxation - mindfulness - goal setting - activity management (prioritising, planning, pacing) - thoughts - communication - setbacks

chronic painchronic fatiguefibromyalgiairritable bowel syndrometype 2 diabetestype 1 diabetes strokemultiple sclerosis cardiac stressobesity non-epileptic attacks

plus, input on rehab programmes for acute back pain and pulmonary disease

This is about improving and complimenting existing service provision

and

improving accessibility

2% of people with chronic pain actually get to a specialist pain service……

Outcomes

- Minimum Data Set Questionnaires (mood, anxiety, work and social adjustment)

- Additional Questionnaires (specific LTC, QoL, service-use, subjective outcome)

- Qualitative Feedback Questionnaires

Stroke course n=31

Caseness -15

Post data 7/12 made CS changes for phq & gad

68% engaged

Positive shift on SSQOL & EQ-5D

CGIS: Much better (42.9%), Little better (42.9%),

No change (14.2%)

Cardiac course n=22

Completers – 19

Caseness – 9

Of which, 6 made CS changes

17 positive changes on the CAQ, most of which

huge shift

- “It has really helped me be more aware of my thoughts and actions and their implications and

given me the tools to try to change and see there is a way forward little by little” (pain)

- “Until this course started I had never spoken to another stroke patient. It helped tremendously with thoughts and how to mange / defuse them and how

to recognise and use the 3 P’s” (stroke)

- “I have found it to be very helpful.  The sessions were well run, the leaders certainly "knew their

subject" and ran the course extremely well. They hardly used any notes which was really refreshing -

they were really pleasant and friendly and made everyone feel at home” (fatigue)

Cardiac course attendee

phq – pre 4 post 3

gad – pre 3 post 4

wasa – pre 32 post 10

caq – pre 29 post 16

Lots of avoidance and seeking reassurance

By the end of the course, theatre, driving

independently, and joined local walking group

Step 3 Individual Work – diabetes

Pre (phq 16, gad 20, wasa 21, PAIDS 29)

Not going out by self, not driving, sick leave,

monitoring sugar levels++,

9 appts

Post (phq 2, gad 5, wasa 10, PAIDS 2)

Back at work full-time, driving, walking, monitoring s

sugar levels more helpful frequency)

The importance of wide engagement…

- talk to our wider colleagues and services- get ‘buy-in’ - need for clear understanding (see the benefit & signpost patients appropriately)- self-management, non-stigmatising focus- understood within the wider context (e.g. specialist teams, support groups) - create / capitalise on opportunities for joint working - get it in local care pathways

Challenges along the way…

Capturing meaningful data, in an appropriate way

Access for some courses / areas

Understanding it and keeping it in the awareness of wider colleagues (so they can signpost appropriately)

The old chestnut of stigma

Sense of threat from other services

Thank you for listening