HOW DO I START TO SET UP EARLY INTERVENTION SERVICES IN MY AREA?

An audit of current incidence and service provision for young people with psychosis will help to establish a baseline of what is currently available and local development needs.

There are examples of different service models depending on resources and demographic area in the section EI services.

Developing a project group of local champions may help to focus and promote the process - representatives from different backgrounds, service users and family members, will give the group a broad focus.

Incremental steps may include setting targets for key areas initially e.g. every service user should have a relapse plan, every young person will have a case co-ordinator for 3 years, duration of untreated psychosis will be routinely monitored. The Clinical Guidelines provide useful starting points.

Tackling Early Detection at primary care and community level as well as improving mental health services' response at the same time may prove overwhelming. Depending on audit findings, it may prove beneficial to focus on improving service provision first before "casting the net" wider and increase referral.




WHAT DO I NEED TO AUDIT TO ESTABLISH CURRENT PRACTICE?

In the Tool Kit section there are examples of audit tools to measure service provision and the experience of young people accessing services for the first time. Examples include a thorough assessment involving interviewing service users, family members and service providers as well as tools for auditing case notes. A thorough audit may be time consuming but will provide rich information on the experiences of young people and may also serve to raise the profile of Early Intervention in the area.

In auditing services and the experience of first episode of psychosis, it is easy to sink in a sea of data. Consideration of what information you need, who it is for, and how it will be useful may provide the right balance in collating qualitative and quantitative information. Incidence and quantitative data is necessary for commissioners. Clinicians may be better engaged by presenting case vignettes and real stories.

Key considerations may be service user demographics and also service response e.g.
ethnicity, comorbidity, living status, number of children, employment, academic qualifications, family involvement, past medication prescribed, duration of untreated psychosis (DUP), number of pathway players (and who was the critical pathway player), risk prior to admission (self harm, self neglect, aggression), key factor that led to concern/help seeking, use of Mental Health Act (1983), police/forensic involvement.

Follow up data at 6 months could include e.g. sustained engagement, re-admissions/relapses, medication prescribed, compliancy, risk, CPA level, care planning alongside IRIS guidelines e.g. any evidence of addressing comorbidity, evidence of relapse planning etc.




WHAT TRAINING DO STAFF REQUIRE TO BE EFFECTIVE IN EARLY INTERVENTION?

The most important skill is the ability to engage young people, without which no other intervention may be provided. Engaging young people requires flexibility, warmth, persistence, communication skills, patience and a positive outlook. A belief in the treatability of psychosis and adopting a recovery model within a supportive team will sustain enthusiasm.

Care co-ordinator skills include assessment of symptomology, comorbidity and risk, conveying information to service users about aspects of their illness, supporting service users and their families and promoting coping strategies. Specialist skills within a team should include the management of positive symptoms using a cognitive behavioural framework, management of complex substance misuse and family therapy skills.

A five-day IRIS training course is available in the West Midlands to serve as a taster for basic knowledge and skills in early intervention - see Training Courses.

WHAT IS THE ROLE OF RESPITE AND HOSPITAL ADMISSION IN EARLY PSYCHOSIS?

One of the IRIS guiding principles is to stream young people away from traditional mental health services and to provide treatment in the least restrictive setting. Occasionally it may be necessary or beneficial to treat someone in hospital for a short period during an acute phase (see Medication Protocol under Tool Kit). However, community based respite facilities for young people should be accessed as soon as possible. For an example of service provision, see under EI services - North Birmingham EIS.




HOW DOES EARLY INTERVENTION FIT WITH OTHER SERVICES?

This, of course, will vary between services especially with developments to provide services across the Adult/CAMHS overlap. For examples see under EI services.

Other useful links may be with Early Detection teams, Primary Care teams and Home Treatment. Specialist services may be utilised for some service users to enhance services within an Early Intervention service e.g. specialist substance misuse teams, teams providing services for a particular ethnic group. Care should be taken to maintain continuity by joint working and liaison and each service user specifying a preference to how and where their needs are met.

See under Service Development for DoH Project Implementation Group literature on Early Intervention.

WHO SHOULD MANAGE AN EARLY INTERVENTION TEAM?

The person with the necessary skills! A Service Director may manage the strategic development of the service whilst the day to day management may be best delivered by an Outreach Manager or Respite Manager. Individuals within a team may be given specific responsibility for key areas e.g. CPA co-ordination, family work supervision. The Manager should be an experienced clinician who feels comfortable managing crisis as well as promoting recovery and a positive ethos within the team, and managing staff from other disciplines.

HOW LONG SHOULD YOUNG PEOPLE BE MANAGED BY AN EARLY INTERVENTION SERVICE?

In order to continue to provide a prompt and efficient service to all those who need it in the area, an exit strategy needs to be adopted. Services should be developed in line with research suggesting that the "critical period" is the first 3 to 5 years following onset. Interventions targeted within the critical period maximise recovery. Planning for discharge from a specialist service and lowering or changing the input should be a gradual and collaborative process. Arrangements should be made for young people who require sustained intervention as well as those who are largely independent from services.

HOW DO I KNOW IF MY EARLY INTERVENTION SERVICE IS EFFECTIVE?

Service evaluation may be simple or highly complex. Obvious initial key indicators may be - sustained engagement, suicide reduction and lowering of the duration of untreated psychosis (DUP). More advance measures may include symptomology rating scales measuring positive psychotic symptoms, depression, anxiety and relapse. Quality of Life scales and measurement of vocation and service user and family satisfaction are at least as important.