NHS appointments

Centre for Anxiety Disorders (CADAT)

There are various referral routes to the service, which depend on your GP’s registered address or whether you are under a Community Mental Health Team.

For local areas we can receive a referral from the IAPT – Increasing Access to Psychological Services service after they have screened you. People in Lambeth, Southwark or Lewisham can be referred through the specific referral routes as below:

Lambeth:  If you reside, and have a GP registered in, Lambeth you can self-refer, or ask your GP to refer you to the Lambeth IAPT Service.  This referral will then be triaged to decide the most appropriate type of assessment and treatment and where this can be carried out (which will include our Centre). You will need to ask for a referral to us. For more details, please contact the Lambeth office on 020 3228 6747.

Lewisham: As above but you should contact the Lewisham office on 020 3049 2000 for more information.

Southwark:  As above but you should contact the Southwark office on 020 3228 2194 or 2195 for more information.

The last coalition Government introduced the legal right for GPs and patients to choose who provides their out-patients’ mental health care, just as they can when a patient is suffering from a physical illness. This is outlined in the document Choice in Mental Health published by NHS Improvement who are responsible for regulation of patient choice.

The only funding requests that legitimately cannot be referred by a GP are:

1. those that do not follow a typical package of care (e.g. require in-patient care), and
2. those that are not clinically appropriate (e.g. require patient to be under the care of a local CMHT or social services, due to e.g. risk of suicide, self-neglect).

In these cases, it is not clinically appropriate for a GP to refer that patient to our service. In this case the patient is likely to require a CMHT and a Funding Panel to approve funding for assessment or treatment. Our outpatient clinic offers primary, secondary and tertiary care interventions. Primary care interventions are eligible for patient choice.

This offers CBT as an outpatient and no consultant involvement. This is the equivalent of IAPT and does not include severe or complex cases. Such referrals are allowed under Patient Choice and a GP referral with automatic funding. A GP and patient may decide they wish to go to a different provider even if a Clinical Commissioning Group (CCG) has a block contract with a local IAPT service. No medical advice is provided at this level.

As an alternative, you can ask your GP to refer you to your local Improving Access to Psychological Therapies Service (IAPT) or in many cases you can self-refer to that service. To find your nearest IAPT service please visit www.iapt.nhs.uk. The IAPT programme offers Cognitive Behaviour Therapy for less complex cases of all anxiety disorders.

This involves a patient with more severe symptoms may require a more experienced therapist and medication advice. Such patients must be under a Community Mental Health Team (CMHT) who have to request an Individual Funding Request to the Clinical Commissioning Group (CCG) (or some CCGs have a block contract). This is suitable for patients with severe and complex symptoms of anxiety disorder who need to remain under the care of their local CMHT whilst receiving treatment through our clinic. To access your CMHT, you can seek a referral from your GP.  If you need treatment then your local CMHT may seek funding from your local Clinical Commissioning Group. This does necessarily mean that funding will be successful as there many competing priorities within the NHS and they have a limited budget.

There are two funding schemes for the national specialist services in OCD and BDD and other anxiety disorders. The first is local funding (e.g Clinical Commissioning Group) and the second is the Highly Specialised Service  funded by NHS England.

The Highly Specialised Service (HSS) is a national funding stream for treating NHS patients only from England with severe OCD and BDD. This means that you may be eligible for referral to one of the OCD/ BDD specialist centres – for example

1. To myself at  Anxiety Disorders Residential Unit (ADRU) at the Bethlem. It is not staffed at night and requires a higher level of independence. It cannot for example take patients who are at risk of suicide or need nursing care.
2. To myself for out-patient treatment at the Centre for Anxiety Disorders and Trauma (CADAT) at the Maudsley;
3. Dr Ilena Pampaloni at Seacole Ward, Springfield Hospital, Tooting. This is a 24 hour nursing staffed ward, which is for people with such severe OCD/BDD who need nursing care. They also do home treatment.
4. Professor Naomi Fineberg at QE2 Hospital, Welwyn Harden City.
5. Dr Bruce Clark for young people at the Michael Rutter Centre at the Maudsley Hospital.

To be eligible for HSS funding you must be referred by your Community Mental Health Team (CMHT) (or young person in a CAMHS) and have a care co-ordinator and the patient must meet certain clinical criteria. This usually requires a patient to have:

• Severe symptoms of OCD or BDD using the Yale Brown Obsessive Compulsive Scale (YBOCS). This will be done at an assessment.
• Two adequate trials of CBT involving exposure and response prevention. The CBT can be completed in either the NHS or the private sector. (Young people require only one trial)
• Two trials of a serotonin re-uptake inhibitor (SSRI) (for example fluoxetine, sertraline, citalopram, escitalopram, paroxetine or fluvoxamine) or of clomipramine at the maximum tolerated dose for at least 12 weeks (Young people only require 1 trial).
• Augmentation of  the SSRI with an anti-psychotic at a low dose for at least 4 weeks (for example aripiprazole, or risperidone). This is not required for BDD or for young people with OCD or BDD. If a patient is not able to take medications due to a medical condition or because of the OCD, then the medication criteria might be relaxed. Remember that the HSS is just a funding stream. It does not mean that you have to have to fulfil the criteria above to be treated at our own unit.

All services have a wait list (you will need to check current situation). They cannot be used for an emergency.

If a patient from England does not meet the HSS criteria, or he/she has another anxiety disorder (eg PTSD) they can still be referred to me but they will have to get local funding approval.

HSS funding scheme covers England only. People from Wales, Scotland, or Channel Islands may still be referred but funded by their Health Board.

Anxiety Disorders Residential Unit (ADRU)

ADRU is a service, where patients with more complex and severe symptoms of anxiety come to stay with us for 3 to 4 months.  As this is a specialist tertiary care service, you can only be referred by your Community Mental Health Team (CMHT)

Funding is described above under CADAT Secondary and Tertiary care. It is either:

1. locally by an Individual Funding Request to the local Clinical Commissioning Group CCG or local Health Board (Scotland, Wales or Northern Ireland). This is suitable for patients with severe and complex symptoms of any anxiety disorder (for example specific phobia, PTSD, OCD, BDD) who must be under the care of their local CMHT after receiving treatment through our unit.
2. nationally by the Highly Specialised Service for severe treatment resistant Obsessive Compulsive Disorder (OCD) and Body Dysmorphic Disorder (BDD). This is a national service funded by NHS England (and does not require CCG funding) for eligible patients with severe, treatment resistant OCD and BDD. The criteria are described above under CADAT.

For either route, you need to be referred by your Community Mental Health Team. Please do not hesitate to contact our service manager, Ms Lisa Williams here or on 020 3228 4146 should you wish to discuss a referral to our service under any of these options.

In theory, we can admit patients funded by your health commissioner in the European Economic Area.  You will need to obtain a S2 form (or old name E112), which entitles you to treatment in the state-funded sector in another European Economic Area (EEA) country. Treatment will be provided under the same conditions of care and payment as residents of the UK. In the UK, care is free at the point of delivery, so you are not required to pay any treatment costs upfront.

To obtain an S2 form, you will need to apply to your local health commissioner for their written agreement to recommend funding for treatment. In making this decision, your local commissioner will need to be satisfied that your mental health team has recommended that you are treated at our service, and that a full clinical assessment has been carried out to demonstrate that the treatment will meet your specific needs. It may be helpful for you to have a screening assessment with our service for us to provide our recommendation as we will need to be satisfied that you need treatment and that we can provide it. It may help funding if you have failed treatment locally or that your local services cannot provide such a service. The commissioner will also want to know the costs of sending you abroad for treatment are justified against their responsibilities for spending money efficiently and fairly, in the interest of all the patients in your area.

If your commissioner agrees that you should come to us for treatment, they will advise you on the issuing of the S2 form. You will need to take this form with you to our service in order for us to claim fees for treatment.

Procedure for CADAT or ADRU

Once we have received the referral for an assessment, we will write to you and the referrer to advise you that you have been placed on our waiting list. We will write to you again in due course inviting you to contact the Centre so that we can offer you a choice of appointment dates.

Specialist services such as ours may have a waiting list, but we do endeavour to offer you a choice of appointment within 11 weeks of the date of the authorised referral. You are likely to be assessed by a member of my team, who will discuss the outcome of the assessment with me and the rest of the team. We will discuss with you any research trials that we are conducting.

Once you have accepted an appointment you will be sent out some rather lengthy, but very important questionnaires covering different aspects of your problem. It is essential that you complete these prior to the assessment and bring them with you. You will also of course receive a map and directions to the Maudsley or the Bethlem Royal Hospital. We do expect that if for any reason you are unable to attend on the day you let us know, preferably in advance. If you miss the appointment, but require another, there may be a lengthy delay as you will go back to the end of the list.

When you come for the assessment appointment this is a rather tiring and lengthy process and usually takes about 2 hours. Sometimes it can take longer in which case we may need to ask you to come back. You will be asked very detailed questions about your problems. It is important that we get a very clear understanding of your problems in order to establish what kind of help you may need. We prefer to video or audiotape our assessments, which is good practice as it means we can be sure we all carry out our assessments to a high standard. It also means that other members of the team can be involved in discussion about your care. However, a video or audiotape can only be done with your consent.

We will not make a decision about what is the best way to proceed on the day. We will consider your case and discuss it with the team and aim to let you know within a couple of weeks.

We will write back to your referrer after we have completed the assessment and made decisions about your care. We have a policy whereby if you wish to be copied in on letters, we are happy to do so with your signed consent.

If we feel we are able to help you with your problems, there is normally a wait of 1-3 months in the outpatients and 9-12 months in the residential unit before we are able to start your therapy (either as an out-patient or at the residential unit). This is due to the high national demand for this service.

We would offer suggestions to your referrers about your care in the meantime, if this is appropriate.

If, at assessment, we do not feel we are able to help you then we tell you the reasons for this and make suggestions as to what would seem more helpful ways for you to proceed towards getting help with your problems.

Written or electronic referrals can be made to me at either CADAT (outpatients) at the Maudsley or ADRU (Residential unit) at the Bethlem

SCOTLAND, WALES AND THE ISLANDS

SCOTLAND

Scotland have their own Care Pathway for adults with severe treatment resistant OCD and depression in Dundee (Advanced Interventions Service, Ninewells Hospital and Medical School. Tel: 01382 496233) http://www.advancedinterventions.org.uk

Referrals can only be made by a Consultant Psychiatrist to Dr David Christmas and cannot be made by a GP. They do not take private patients. They are also not commissioned to offer treatment for adolescents or for related disorders such as Body Dysmorphic Disorder, hoarding, emetophobia or health anxiety when this is the main problem. Therefore, if you are severe and have failed local treatments for BDD or emetophobia, then you may be able to get a referral to my team at the Maudsley (out-patient adult) or the Bethlem (adult residential unit). Referrals can only be made by your Community Mental Health Team and cannot be made by your GP.

WALES, ISLES OF MAN, JERSEY and GUERNSEY

Wales and the Islands do not have a specialist care pathway for adults or adolescents with severe OCD, BDD, health anxiety or emetophobia. Therefore, if you are severe and have failed local treatments, then you may be able to get a referral to my team at the Maudsley (out-patient adult) or the Bethlem (adult residential unit). Referrals can only be made by your Community Mental Health Team and cannot be made by your GP.