A federated approach that goes beyond IAPT
GPs across three clinical commissioning groups (CCGs) in the West Midlands have joined together to create an innovative whole-system approach to mental health. Dr Ian Walton sets out what they’ve achieved so far
GPs across three clinical commissioning groups (CCGs) in the West Midlands have joined together to create an innovative whole-system approach to mental health. Dr Ian Walton sets out what they've achieved so far
Our three CCGs had a very clear idea of what we wanted – a truly primary care mental health service built around GPs. And we wanted a whole-system approach that started with prevention.
That vision in some ways held us back from getting on board with the Improving Access to Psychological Therapies (IAPT) rollout at first. We made ourselves slightly unpopular over it because we didn't want it in the form that it was ‘dictated'.
As GPs, we were clear that mental health was linked to people's social situations. IAPT has some benefits – but in our view, it's a lot more beneficial if you can sort out all of people's problems at once rather than one at a time.
Sandwell, in the West Midlands, has high levels of mental ill health in areas that are socially deprived with high unemployment.
Our needs analysis showed we needed to prioritise and make adequate provision for depression – the highest-prevalence disorder, with high numbers of people not receiving therapy but being in receipt of anti-depressants. Levels of depression were higher than England as a whole – Sandwell is at 7.3% compared with 6.5% for England.
Our assessments also showed a rise in complex needs in primary care and highlighted equality of access issues that we resolved to sort out.
The CCGs involved in the initiative are pan-Sandwell: the 19-practice Black Country CCG, the 30-practice Sandwell Health Alliance and the 19-practice Healthworks CCG.
They were brought together by our primary care mental health lead Lisa Hill, who established a mental health steering group with lead GPs from each.
The steering group works out the needs analysis and prioritises any gaps highlighted, then undertakes business plans to develop relevant areas and services, pilots and evaluates them, and then commissions them and makes sure they work in an integrated care pathway.
One of the things we've done to help knit all the available services together and give patients easy access is to set up a wellbeing hub, accessed by a single phone number that both the public and GPs can call.
It's a bit like a call centre, and is based at the Spires Health Centre in Wednesbury, funded by NHS Sandwell and manned by PCT wellbeing co-ordinators. We operate a call-back facility and a website.
Patients who can benefit from self-help are directed to this network of education, health, employment, mental health and social providers. Patients who need a higher level of support, such as talking therapies, can be directed to their GPs. They can then assess them using the CORE Net system (Clinical Outcomes in Routine Evaluation clinical audit and evaluation system – see box, right) and refer them in the normal way. GPs can also contact the hub directly to refer patients.
How IAPT integrateswith the system
To make all the elements work together, we've adopted a stratified approach using the CORE Net system to allocate patients to a stepped level of service that helps ensure flow and helps prevent waiting lists.
• PCT confidence and wellbeing team covering step zero and step one
• IAPT service covering step two and step three
• Collaborative care covering step four
• Specialised service covering step five
The steps are non-exclusive and the care pathway for each step is integrated to reflect that. Recovery is built in so people can be referred back to primary care at any point. The diagram at the bottom of p31 shows a step one pathway. Other pathways can be accessed in the online version of this article.
Appropriate integrated care pathways combined with psychological therapies and other mental health services ensure a smooth transition between steps, so that the patient experience is not disjointed and the population's range of needs is met.
With the right support and information, people are the best managers of their and their family's mental health needs. We see the patient as being ‘expert by experience'. We're now one of the top IAPTs in the country with a 66.7% success rate, according to recent NHS Information Centre statistics.
Our workforce requirement was worked out through systems modelling based on a breakdown of need. We calculated that the total staffing needs would be 18 low-intensity and 21 high-intensity workers . All the workers we take on need further training to meet the competence levels we aspire to. Currently, the low-intensity workers are employed by Sandwell MIND.
The existing workforce is diverse and representative of the local population. The IAPT service links into the existing NHS counselling service and primary care psychology service to ensure therapists can get support from other local health services.
The hub engenders a snowball effect, in that the more you have in it, the more organisations want to join. Patients can also take a wide range of other routes to psychological therapy services.
• Libraries offer access to wellbeing, befriending, self-help, advice, psychoeducational groups, bibliotherapy and talking therapies.
• Schools offer confidence building, help manage psychosomatic symptoms and tackle addictions, teenage pregnancy and other issues linked to self-esteem.
• Self-help services are running health improvement and lifestyle programmes integrated with talking therapies, Fit for Work and access-to-employment schemes.
• Wellbeing projects are under way for NHS, ambulance, fire, police and other statutory sector staff.
Our website and service directory (www.confidenceandwellbeing.co.uk) hold up-to-date information on local services
and events, and have links to community activities based in neutral settings such as libraries, and children and family centres. Faith communities have agreed that they will facilitate training for black and minority ethnic advice and link workers, who will then be able to offer appropriate low-level interventions.
We've established a confidence and happiness steering group that has a main theme of inclusivity. Sitting on this group are the PCT mental health lead, diversity and race equality leads across the voluntary sector, secondary care, LINKS and public health and GP leads from the three CCGs.
The group lobbies and runs events to highlight issues. An example is a recent homeless event for 200 people – including the homeless – that resulted in changes in policy and direction for Sandwell. A similar event for forces veterans is planned.
The total cost is about £3.4m a year, of which £1.4m is IAPT. Part of the reason we've been able to do this is because I'm still the professional executive committee chair, and as such I can keep making sure that money for primary care mental health is protected. It is a long, hard fight. In most cases the trust sees mental health money as theirs.
Overall we can demonstrate a 1.0 to 2.5 standard deviation increase in people's wellbeing, and the latest results are showing even higher improvements.
Our Fit for Work pilot scheme across Birmingham, Coventry and Sandwell had 317 referrals of which 242 were case-managed – 106 were mental health issues. At three months, 60% had returned to work, 29% were still off work and 17% were no longer employed. High levels of user satisfaction were reported.
The IAPT service went live in February. Referrals so far are 568 across whole IAPT service model, including referrals into psycho-education programmes and computerised cognitive behavioural therapy.
Up to 45% of people on GP lists have a mental illness that hasn't been identified. Some of those end up in A&E, costing the NHS a lot of money. That's what you want to avoid. What we're doing goes against the grain of the NHS, but we've had 7,000 people through the service so far and we have lots of evidence that it's working.
Dr Ian Walton is a GPSI in mental health, PEC chair and current chair of Primary Care Mental Health and Education.
This case study has been shortlisted for a 2011 Vision Award. To find out more go to www.napcannual.co.uk/awards.