Integrating mental health therapy in primary care

The following very encouraging case study, of how our Calderdale team has integrated mental health therapy in primary care, has been published on the NHS England website. Congratulations to the whole team for this recognition for the work they have done!

Introduction

Commissioned alongside Calderdale IAPT, a primary care talking therapy service run by South West Yorkshire Partnership Foundation NHS Trust (SWYPFT), Everyturn works within a stepped-care model, offering assessments, step 2 low intensity interventions, step 3 and counselling for depression. In 2017/18 IHC aimed to ensure 16.8 per cent of adults (4,367 people) were able to access the service and by the end of March 2018 it achieved 5,105 (19.6 per cent) access. There are 230,470 people registered at 40 GP practices across Calderdale and the prevalence of adults with mental health problems is 25,992. IHC works in 14 of the 40 GP surgeries and two community venues.

IHC felt it important to become a wave 1 pilot site for the IAPT-LTC (Long Term Conditions) pathway, in 2016, as managers could see the need to integrate physical and mental healthcare and raise awareness in physical health services of the impact health conditions have on a person’s wellbeing. Calderdale CCG was keen to link with the expectations in the Five Year Forward View which show a commitment to expanding services for people with LTCs. IHC managers felt that by embedding the IAPT input in GP surgeries, patients would see it as part of the management of their condition rather than being ‘passed on’ to another service.

How it works in practice

It was important to work closely with Calderdale CCG and SWYPFT to ensure the service was established quickly and focused on what it sought to achieve. A steering group set up in January 2017 created a monthly plan of activity and by the end of March a pattern was established in which SWYPFT practitioners worked with musculoskeletal disorders, and IHC practitioners would integrate into GP practices. The service approached four local surgeries to start as pilot sites. It was important to highlight to practice managers the potential to reduce unnecessary appointments and free up some of the GPs’ time.

For the practitioners to be fully integrated into the surgeries it was important they had access to the GPs’ database via a SMART card, while patients had the same experience booking appointments as they would for any other practitioner clinic. Practice staff could book patients directly into the co-located therapist’s clinic during their appointment or during a triage call. The practitioner can type relevant notes around risk, medication issues and health concerns onto the patient’s notes and send tasks and alerts to the GP. It has been helpful for the practitioner to see the patient’s notes relevant to their mental health before their appointment.

IHC agreed to offer one Psychological Wellbeing Practitioner (PWP) clinic for assessments and step 2 treatment, and one high-intensity therapist for a cognitive behavioural therapy (CBT) clinic. Both practitioners are based at the surgery, offering assessment and treatment for patients as well as providing clinical consultation for practice staff. Practitioners were introduced to the team at their regular meetings, the new service explained and leaflets and posters produced inviting patients to ask their health professional about wellbeing assessments. Following assessment, the patient would be offered step 2 treatment by the same practitioner or passed onto the step 3 CBT practitioner within the practice. Separate waiting lists were created on an internal database to ensure practitioners knew who was waiting and the administration team was given additional training in the new pathway.

Challenges and solutions

A number of challenges emerged and these are outlined together with the solutions developed:

• Some practices were keen to secure a monthly charge for the use of the room and struggled to see the mental health practitioners as part of the practice. The message from the CCG about the need for this pathway has been important to ensure GPs are aware this is a joint venture for the greater good of patients. Persistence and open communication between the practitioner and staff at the practice have been key,
• The clinic diary can only be seen by the practitioner when they are at the practice and IHC practitioners could struggle to see in advance empty slots and be proactive in filling them. The solution was for practitioners to note how many empty slots or did-not-attends occurred and feedback to the practices on a quarterly basis, together with recovery and patient suitability rates,
• There is a risk GPs and nurses book wellbeing assessments with patients who don’t have a LTC or whose needs are more appropriate for secondary care. It is important practice staff feel able to have open clinical discussions with the practitioner about patients they are unsure of before booking them into an appointment that could be better used by another patient,
• Training has helped practice staff understand the stepped care model and what difficulties are suitable for primary and for secondary care. Previously, training was informal at team meetings; 2018 sees a planned training programme for GPs on the IAPT-LTC pathway and IAPT in general.

Impact of integrated healthcare

In 2017/18 the pathway expanded from four surgeries to 12 with varying degrees of success in terms of patient numbers. With regular communications IHC management were proactive in looking at the individual needs of each practice. Some surgeries only needed wellbeing assessments, with treatment sessions carried out at IHC’s base; some surgeries needed only half-day clinics.

By the end of March 2018, 809 patients had been assessed and 375 had completed treatment with IHC. Fifty-four per cent reached recovery. According to feedback from the surgeries, in 2017/18 there was a 20 per cent reduction in GP appointments and a 38 per cent reduction in nurse appointments for those patients who came through the IAPT-LTC pathway. Feedback suggested patients felt the benefit of a holistic approach to their medical condition which incorporated their psychological wellbeing, and being seen initially at their local practice helped them engage with talking therapies.

The next step will see IHC focus on education and training for local practices on the stepped-care model, local mental health services and their criteria, as well as basic training on what the therapies involve. Being part of the pilot has helped raise the awareness to IHC managers of the needs of this patient group while the training received by IAPT-LTC practitioners has been rolled out to all staff through in-house training.