NCAP EIP Audit 2020/21 Report

Professor Jo Smith, NCAP Joint Clinical Advisor to the EIP Audit in England, Wales and Ireland, has commended the work of the England Early Intervention in Psychosis (EIP) teams in the latest NCAP EIP Audit 2020/21. Professor Smith’s report follows:

It has been a challenging year for healthcare, including EIP services, with many aspects of delivery impacted by COVID-19. Yet in spite of this, data from the 2020/2021 round of the EIP audit showed improvements or maintenance at the same levels as last year’s 2019/2020 audit findings for several audit standards. This was heartening in the context of the many challenges that COVID-19 has created for EIP staff, individuals with first-episode psychosis (FEP) and their families and EIP teams are commended for their efforts to preserve and improve EIP service quality during this difficult year.

A specific section of the report highlights some of the good practice and innovative work that EIP teams have been doing to support people with psychosis and carers during the COVID-19 pandemic. EIP teams have had to find ways to provide interventions while maintaining social distancing and have had to work more flexibly and creatively to do this. Services have had to adapt rapidly, often while facing pressures on staffing, to ensure continued quality of EIP service and comprehensive delivery of care standards for service users and carers throughout this time.

The biggest improvement observed this year was in outcome measurement recording. This is encouraging and reflects the efforts of EIP teams to improve practice in relation to this standard, year on year, where we have observed outcome measurement improvements from 9% to 55% of individuals with FEP over the last 3 years of the audit. Routine outcome measurement is critical in order to be able to confidently and robustly review clinical outcomes of individuals with FEP and evaluate the impact and experience of EIP services on recovery outcomes important to service users.

Take-up of family interventions (21%) and supported employment and education programmes (31%) remained the same as the previous year. Small reductions were seen in timely access (72%), provision of CBTp (46%) and those offered clozapine (50%).

Improvements were seen for six out of the seven physical health interventions including for cigarette smoking (92%), harmful alcohol use (95%), substance misuse (93%), BMI (85%), hypertension (70%) and abnormal glucose control (77%).

Conversely, physical health screening for all seven measures had dropped as had screening rates for the majority of the individual measures (cigarette smoking, alcohol, substance misuse, BMI, blood pressure, blood glucose and blood lipids).

The percentage of people offered all seven physical health screenings and relevant physical health interventions (a composite measure of standards 6 and 7) also had dropped (61%). Physical health intervention for dyslipidaemia (69%) showed one of the biggest drops. This may reflect an impact of COVID-19, particularly those measures and interventions that require face-to-face contact. However, physical health screening and intervention are important to maintain because of the increased risk of morbidity and mortality for this FEP group, related to cardiovascular disease, diabetes and smoking.

Of concern, is that carer-focused education and support programmes showed a marked drop from 58% to 53% for patients with an identified family member, friend or carer and from 61% to 55% when excluding those family, friends and carers whom patients did not wish to be involved. This may reflect changes made to the auditing of this standard this year which now only includes ‘take-up’ rather than ‘take-up and referral’ of carer-focused education and support programmes.

However, this finding is important, especially during times of COVID-19, as in order to ensure service users are adequately supported by their family, we need to ensure that carers continue to be supported too.

There was also a reduction in number of Trusts meeting the AWT standard and a marked increase in the care co-ordinator caseload range. It is unclear from the audit data whether these reflect local COVID-19-related pressures on EIP teams as it was not a universal finding across all EIP teams nationally. This needs to be reviewed at a local level for those Trusts where this is the case to understand, and problem-solve factors contributing to these changes and identifying ways to protect EIP care co-ordinator caseloads and capacity locally and ensuring adequate local investment in care co-ordinator capacity, in line with the NHS commitment to EIP delivery in the NHS Long Term Plan.

There was pervasive evidence of wide variations and inequities in provision suggesting there remains a ‘postcode lottery’ in terms of access and wait times, EIP, CYP under 18 and ARMS service provision across England. There are still many EIP teams reporting no ARMS provision and several areas with no EIP provision for under-18s with FEP, 18-35s and 35-65s. More needs to be done to ensure equitable and uniform commissioning and provision of evidence-based EIP care across England in line with NICE quality standards. There is also wide variation in offer, take-up and refusal rates of NICE interventions across EIP teams nationally. We need to understand what may be contributing to these variations in processes and outcomes and create opportunities for sharing good practice and successful quality improvement initiatives around uptake and refusal of interventions between EIP teams.

One nice addition to this year's report is the 'Foreword' written by Veenu Gupta, NCAP Service User Advisor. Veenu has used the opportunity of her 10-year anniversary since her first episode of psychosis to reflect on her personal progress, much of which she attributes to the EIP care she received 10 years ago. She also comments on the changes she has observed in EIP care over the years and the continuing challenges of racism and discrimination in society that can impact on peoples experiences of psychosis and the care they receive.

The audit data is also supported by a series of qualitative comments on the audit findings generated from focus groups of EIP service users and carers co-ordinated by Rethink Mental Illness. This adds a richness to the report findings where individuals comment on the value of interventions received and the quality of EIP care, informed by this year's audit findings.

The report was published on 8 July 2021. A copy of the national report and appendices for England can be found on the NCAP website. We hope you find this latest report useful.

Thank you to everyone involved with the audit for their hard work and diligence in completing the NCAP EIP audit 2020/21. If you have any questions on this year's report, please do contact:

The NCAP team
Royal College of Psychiatrists
21 Prescot Street, London, E1 8BB
Telephone: 0208 618 4268

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