10. Conclusions

The Expert Advisory Group and Review Board considered the evidence summarised within this report, as a basis for discussion and the development of recommendations. Following consideration of this evidence, the review commended the Advanced Interventions Service’s progress to date and recommended that the service continues to be nationally designated, and continues in its robust audit programme.

10.1. Fit against National Services Advisory Group criteria

Every three to five years, National Services Division is required by the Scottish Government and NHS Boards to review whether each designated national specialist service continues to meet the criteria for national designation. This review considered the national Advanced Interventions Service against the criteria used by the National Services Advisory Group who recommend services for designation of national funding, or the de‐designation of existing services. To be recommended for designation services will be:

  • highly specialist;
  • of proven effectiveness;
  • incidence of the condition requiring diagnosis and/or treatment is rare and/or unpredictable;
  • meet a recognised need for all residents of Scotland within a clearly defined clinical area (i.e. service is national);
  • require a highly skilled multidisciplinary team and / or specialist equipment and facilities that can only be provided cost effectively in one, or very few, locations;
  • require concentration of expertise to achieve clinical effectiveness;
  • require close monitoring e.g. of a new clinical technique, and/ or designation to prevent inappropriate proliferation;
  • require scare clinical skills;
  • are at risk, and require stable, protected, funding to ensure sustainability.

The Advanced Interventions Service is highly specialised and is recognised as a UK service, as one of three UK centres providing neurosurgery for mental disorder. It was deemed by the Expert Advisory Group that the Advanced Interventions Service clearly fits the criteria for national designation.

10.2 Performance of the service

A safe and effective service

Safe service: “There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times.
Effective service: “The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.

Patients proceeding to anterior cingulotomy or vagus nerve stimulation have high‐reported levels of chronicity, severity, disability and treatment‐resistance relative to the levels reported in the literature. Despite these high levels of chronicity, disability and treatment resistance, it is apparent that the service has worked well and has reported on good, predominantly (and on average) positive outcomes, with the majority of service users experiencing improvements including response and remission. It was noted that in the small number of cases where depression scores were worse after treatment than they were prior to it, without the intervention, service users may have experienced a greater worsening in their condition. The Expert Advisory Group concluded that both ablative neurosurgery and vagus nerve stimulation should continue to be offered by the national service within the current governance framework.

The positive feedback from the psychiatric community was also highlighted, with 82% of respondents who had used the service noting that their overall experience of the service was either ‘good’ or ‘very good.’

The Expert Advisory Group praised the holistic multidisciplinary approach of the service, and joint working with the University of Dundee which has supported the development of the evidence‐base for treatments for chronic and severe treatment‐refractory depression. Of note was the service’s continued commitment to robustly assess patients and ensure that their condition is significantly and sufficiently chronic, severe and treatment‐resistant, prior to offering ablative neurosurgery or vagus nerve stimulation as a treatment option. The Advanced Interventions Service should be commended for its work in ensuring that both patients, who have not fully satisfied these robust criteria, and their referring clinicians, are provided with a set of ongoing treatment recommendations for additional psychological and pharmacological management strategies.

A person‐centred service

Person‐centred service: “Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision‐making.

The service has demonstrated a person‐centred approach through its assessments, treatment and follow‐up levels. The review of existing casenotes in addition to undertaking psychiatric and psychological reviews assist the service to better understanding the person’s illness, and the impact that this illness has on their life. The service’s feedback sessions allow for further discussion between the service user and members of the service, and support the development of a mutual understanding of the person’s illness which informs a shared decision‐making process for ongoing treatments.

The service has worked well to capture feedback from outpatients and inpatients, and to use this data to continue to develop the service. This data provides evidence from service users that the service is person‐centred. The high‐quality of the service has also been acknowledged and is supported by patient and clinical‐user feedback, in addition to feedback from the wider UK clinical community with expertise in areas of mood and affective disorders.

The service has worked well to report robustly to patients, the public, the clinical community and National Services Division through its annual and mid‐year reports that are published on its extensive website.

10.3 Areas for further development

10.3.1 Referral and conversion rates

In appraising the data collected for the review, it is clear that a number of NHS Boards have lower than expected referral rates into the service. On the other hand, the service’s host Board, NHS Tayside and NHS Fife have higher than expected referral levels into the service. The conversion rate to surgery of NHS Tayside patients indicates that there is a need to ensure that patients who would be part of regional specialist activity are accounted for separately to those who are part of the national specialist activity within the service.

10.3.2 Retention and development of existing links with referrers

It is acknowledged that people with chronic and severe treatment‐refractory depression and OCD have long and complex treatment pathways that can last many years. The anterior cingulotomy and vagus nerve stimulation provided by the Advanced Interventions Service should be seen to compliment and act as treatment augmentation to other treatments. Indeed, referring Consultant Psychiatrists retain clinical responsibility for the patient during the assessment process by the Advanced Interventions Service, and in implementing the service’s treatment recommendations.

The efficacy of treatment by the national service will be affected by the psychological, psychiatric and pharmacological treatments administered by the team retaining responsibility for the ongoing care of the patient following discharge by the national service. As this is the case, there is a need to continue to ensure close liaison between the national service and the team retaining responsibility for the ongoing care of the patient to ensure that approved treatment recommendations are followed.

10.3.3 Benchmarking

It is noted that the Advanced Interventions Service is one of a low number of specialised centres in the UK for mood and affective disorders. Indeed the services provided by the Advanced Interventions Service place it at the top end of stepped care, making it a provider of a quaternary level service. The review’s Expert Advisory Group noted the service’s existing commitment to report transparently, and highlighted that it is important to continue to share data and benchmark with other units across the UK and internationally. Links between commissioners in National Services Division and their counterparts in England should be developed to support benchmarking and patient pathways across the UK.

10.3.4 Non‐surgical service activity

The review has recognised that the vast majority of the activity within the service currently and legitimately focuses on undertaking comprehensive assessments and developing detailed treatment recommendations for patients and referring clinical teams. It is important that in the future, the service, National Services Division and referrers formally recognise this existing activity.

10.3.5 Deep brain stimulation

The national service is currently participating in a multi‐centre trial of deep brain stimulation (DBS) for chronic, treatment‐refractory depression. It was noted that there is currently an insufficient evidence‐base to support the inclusion of deep brain stimulation as a treatment for chronic and treatment‐refractory obsessive‐compulsive disorder or depression by the Advanced Intervention Service.

10.4 Provision of tertiary level OCD services in Scotland

Both the Expert Advisory Group and the Advanced Interventions Service have highlighted the inequity in provision of OCD services across NHS Scotland which has an impact on the quality of referrals into the service, the ongoing management of the patient postintervention, and a low conversion rate to surgery. Whilst some clinicians in Scotland provide a tertiary level OCD service, there are a lack of consistently supported centres of expertise in Scotland.

The illness characteristics of patients being referred to the Advanced Interventions Service, and the proportion of patients identified as not having received all necessary treatments in full adequacy prior to referral, supports the view that there are structural issues regarding the provision of tertiary level OCD services in Scotland.

The high‐level mapping of services for people with conditions covered by the AIS found that a large number of units (38 units) across Scotland discharged low numbers of patients with classifications of Obsessive Compulsive Disorder covered by the Advanced Interventions Service. The units with the highest annual level of discharges on average discharged only 6 patients per year. The three units who were noted as discharging patients with OCD who had an inpatient length of stay of 3 years or over, all discharged on average, less than two patients a year with OCD, regardless of their length of stay. This indicates that these units are not formally recognised as tertiary inpatient OCD services.

When asked what tertiary services patients had been referred to for treatment‐refractory OCD, members of the Royal College of Psychiatrists in Scotland predominantly responded the AIS, with one respondent noting the Southern General Hospital. The low volume of patients and high number of units support the view of the Expert Advisory Group and the Advanced Interventions Service that it is unlikely that whilst some clinicians provide specialist services for OCD, there are no formally recognised tertiary OCD units in Scotland providing tertiary OCD services.

10.5 Provision of quaternary psychopharmacological and psychiatric OCD services

Scottish residents with OCD who currently require access to quaternary level psychopharmalogical and psychiatric services have access to NHS England services through a NHS Scotland risk‐sharing agreement. However, it has become apparent that there is the expertise to provide this level of service in NHS Scotland.

The level of psychological assessments and therapies currently provided at a quaternary level in Scotland needs to be explored further by services across Scotland. If capacity is available in NHS Scotland, there could potentially be a more enhanced role in providing quaternary specialised psychopharmacological, psychiatric and other treatments for OCD that are currently being provided in the English Springfield Unit. This would help to develop capacity of quaternary services in Scotland, reducing travel distances for patients, in addition to yielding significant savings to NHS Scotland.

Last Updated on Wednesday, 28 August 2013 10:10

National Services Scotland

Advanced Interventions Service
Area 7, Level 6
South Block
Ninewells Hospital and Medical School
Dundee, DD1 9SY. UK.
Tel: +44 (0)1382 496233

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