GPs in Leicestershire are pioneering an integrated primary care mental health service in collaboration with both the private and voluntary sectors. Dr Theresa Eynon describes the lessons learned so far
In 2008, a group of Leicestershire GPs – led by Melton Mowbray GP Dr Ron Thew and funded by our PCT – came together to look at how PBC could enable them to take over responsibility for providing a primary care mental health service.
The Improving Access to Psychological Therapies (IAPT) rollout was beginning. IAPT strictly specified the types and the numbers of therapies provided, as well as outcome monitoring and national benchmarking. We saw this both as a challenge and an opportunity.
It was clear to us that setting up an IAPT scheme would not be a cornershop business. Without a well-organised bid with GPs at the heart, there was a risk of the service being provided from outside primary care.
We decided we did not want it to be fragmented by separating off anxiety and depression and leaving much of the real clinical work untouched, so we set about getting advice from all available sources. Above all, we did not want something imposed on GPs from above.
The Leicestershire locality that had the most drive in terms of PBC was Hinckley. It had just formed a GP provider company called Assura Leicestershire LLP, a partnership between 22 local practices and health provider Assura Medical.
Assura Leicestershire paid for my clinical time and for a manager to support the process. The GP company now acts as landlord for our main base in Loughborough and premises in Narborough.
Assura suggested a partnership with mental health charity Rethink Mental Illness as a body with previous IAPT experience, and so with Assura Leicestershire LLP and the community health Leicestershire Partnership Trust on board, the Good Thinking partnership – originally conceived by GPs in a Coalville coffee shop – was born.
To avoid conflicts of interest, the GPs involved in providing the service had to remove themselves from the tender process. The bid was led by Rethink Mental Illness.
What the scheme does
Good Thinking, as well as tackling anxiety and depression via IAPT, also addresses the needs of patients with nonpsychotic and chaotic and challenging disorders (care cluster 8) – who are often unreachable by secondary care but present frequently to their GP – and the general care needs of stable individuals on the Severe and Enduring Mental Illness (SEMI) register who are being managed in primary care (care cluster 11).
Rather than acting as a service to which GPs can refer, Good Thinking sees itself as integral to each practice, enabling primary care to take up the productivity challenge in mental health. At the centre of the model are mental health facilitators (MHFs), who are primarily there to work with patients with serious mental illness who have been stepped down from secondary care.
They come from a mental health background, having often worked as community psychiatric nurses or occupational therapists, which makes them good at signposting. Practices either have their own MHF or share one between several depending on their size. This negates the need to refer via Choose and Book, which is one of the reasons why GPs like it so much. Rethink Mental Illness supplies the counselling services that the MHFs may refer patients to. The MHFs' role can include :
• individual work with patients
• work with practice nurses to help SEMI-registered patients receive generalist care
• work on mental health reviews
• supporting GPs with chaotic patients unsuitable for secondary care
• supporting patients awaiting a community mental health team assessment.
Patients referred to the service are given a named MHF that they meet with to discuss what the problems are and agree together the next steps.
Staff are employed both by Rethink Mental Illness and Leicestershire Partnership – it's about a 50:50 split at the moment.
Data on cost per treatment also shows NHS Leicestershire County and Rutland had the lowest costs among PCTs in the region. Good Thinking not only works as an affordable IAPT scheme, it is also in the national top five schemes for getting people back to work.
Comparative SHA data shows that for its first year of operation, 2009/10, Good Thinking's ‘moving towards recovery' rates were consistently comparable with those of the successful Newham and Doncaster IAPT demonstrator sites and – despite a relatively low financial investment of £2,727,000 per year – better than some of its neighbours (see box).
In the year after the implementation of the MHF service (2009/10), NHS Leicestershire County and Rutland was the highest-performing PCT across the region for indicator MH09 – the percentage of patients with schizophrenia and bipolar affective disorder and other psychoses with a review recorded in the previous 15 months.
In the review, there is evidence that the patient has participated in routine health promotion and prevention advice appropriate to their age and health status.
Good Thinking works closely with GPs and provides training in the Five Areas model of cognitive behaviour therapy. The training itself is proven to be effective, and was chosen by the RCGP for a workshop at their forthcoming conference in Liverpool.
Lessons so far
In common with many IAPT services, Good Thinking had problems with waiting times in its early phase. This was due to taking over the historical waiting lists of the previous psychodynamically oriented service at a time when most of our CBT therapists were still untrained
As an evidence-based service, we take a rigorous approach to GP satisfaction data. Recognising that the response rate to ‘round robin' feedback forms is notoriously poor, we use protected learning time sessions to obtain reliable results.
Despite the waits, after only one year of operation, 63% of GPs in the Hinckley area were satisfied – of which 20% were very satisfied – with the service. Responses in Blaby and Lutterworth however, six months later, showed 65% were dissatisfied. This locality had not taken much interest in the original specification, and many GPs were still unhappy at the loss of the previous service.
Wide variations in waiting times and GP satisfaction have persisted. However, a recent review has suggested that the service works best where good and informal lines of communication exist. This is clear from recent data showing that practices managing referrals in-house are achieving one- to two-week waits, while others that have not allowed therapists to enter their premises struggle with the 18-week target.
Our vision was that primary mental healthcare should be seen as integral to primary care. Now the first cohort of therapists is trained, the service is actively working to change hearts and minds. Recent improvements include cross-referral management with a sister service, Leicestershire's Fit4Work, which helps employed and self-employed people get back to work more quickly when they are signed off sick.
We're rolling out more GP training in the Five Areas model of CBT. We are also working with the local mental health trust to take over the care of stable patients with enduring psychotic illnesses (care cluster 11).
The economic case for primary care mental healthcare is strong, with evidence that it can reduce the cost of welfare dependency and improve the management of chronic diseases.
The current contract for the service runs until August next year. When reviewing the contract, clinical commissioning groups could, for example, consider more investment in medically unexplained symptoms, using the Five Areas models to enable GPs to identify and manage these patients without recourse to over-investigation and referral.
Dr Theresa Eynon is a sessional GP and GP engagement lead for Good Thinking