A pioneering commissioning organisation in Bedfordshire has brought together a unique GP provider company, a primary care trust provider arm and the mental health charity Mind to take mental health care into the community. Alison Fisher, CEO of Bedfordshire and Luton Mind explains how the three partners work together.
We had a head start in Bedfordshire when it came to collaborating over the provision of mental health care. In 2006, we were one of 20 Improvement Foundation sites chosen to form a Primary Care Mental Health Collaborative with the aim of improving the care and management of common mental health problems in primary care. The steering group overseeing this was made up of a wide range of stakeholders, including GPs and the Third Sector.
Out of that the Collaborative, a project entitled 'Equal Partners' evolved where myself and a member of staff from Bedfordshire PCT (now NHS Bedfordshire) worked together on developing models and initiating pilots for the integration of the third sector in to primary care. So when Bedfordshire won their bid in 2008 to be part of the second wave of the national Improving Access to Psychological Therapies (IAPT) pilot scheme, everything was already in place for an integrated approach involving all three agencies.
The preparatory work we'd done meant we'd already begun to understand each others' perspectives which is one of the concerns with collaborations such as this. There is still a long way to go, but working together under IAPT has changed things significantly. Mind has been around for 32 years in Bedfordshire, but never before has the approach to mental health been so joined up.
Improving Access to Psychological Therapies
The IAPT scheme was launched by the Department of Health in October 2007 with £170 million nationwide funding and the aim of training 3,600 therapists, treating 900,000 patients and allowing open access to GP referral for mental health patients with the aim of supporting PCTs in meeting NICE guidelines.
Broadly, patients are offered an initial assessment and are recommended a course of treatment based on their needs and the pre-determined pathways defined by NICE .
The programme began in 2006 with demonstration sites in Doncaster and Newham. A year later, 11 pathfinder PCTs began to offer services to vulnerable groups. Bedfordshire were part of the second wave of 30 or so PCTs to join the scheme.
In Bedfordshire, IAPT runs in five localities - Bedford, Leighton Buzzard, Dunstable, Ivel Valley and West Mid-Bedfordshire. These fit in with the five PBC groups in the county and mean we can provide a really local, community-based service to patients in partnership with Bedfordshire Community Health Services (BCHS) and the GP provider company Horizon Health Choices Ltd.
The provider company Horizon was launched in May 2006, simultaneously with Horizon Health Commissioning, covering a combined patient list size of over 160,000. The company is owned equally by 26 GP practices which together represent about 40-45 per cent of the PCT.
The locality-based approach means that people don't have to travel far. Although first contact is always face to face, a lot of the work is telephone-based - another factor that makes it easy for patients to benefit.
In mental health terms, not everyone needs huge psychological input - perhaps just some support or information. The care Mind contributes tends to be around step 2 of the stepped care model (see table below).
Table 1: Basic stepped care model
1. Recognition and diagnosis
2. Treatment in primary care
3. Review and consideration of alternative treatments
4. Review and referral to specialist mental health services
5. Care in specialist mental health services
The basic idea of IAPT is to manage steps 1-3. Before the IAPT programme started, GPs often said they were forced to go straight to steps 4 and 5 because little or nothing else was available.
The way it divides up is that Mind oversees referrals at Step 2 withHorizon Health Choices Ltd - the GP-led provider group in North Bedfordshire and BCHS providing Step 3 interventions.
We are all commissioned by the commissioning arm of the PCT, NHS Bedfordshire, and have separate contracts channelling the central NHS and PCT funding streams. We signed a partnership agreement at the start which sets out basic rules allowing us to work together.
In terms of Mind's role, county-wide, we employ 15 'Psychological Wellbeing Workers' - PWPs. These are non-clinicians who are trained to provide high volume, low intensity interventions for clients with mild to moderate depression, based on a cognitive behaviour model. One of these specialises in diverse cultures, covering the black and minority ethnic community which in our case also includes travellers. Depending on the needs of patients the PWPs can offer them one or more of a range of services such as
- giving out information about conditions, 'how to' guides etc
- computerised cognitive behavioural therapy (CBT) courses which patients can do from home
- guided self-help via books or leaflets
- signposting to other services
Signposting involves pointing the patient towards community groups including ourselves and other support organisations, offering them e.g. a mentor access to wellbeing groups, telling them about exercise or books on prescription. The latter are all evidence-based and are available in every library in Bedfordshire.
What we bring to the table is that we are one of the largest Mind organisations in the country and have over 30 years of experience in mental health in our locality.
We're affiliated to National Mind with 58 staff of our own and 120 volunteers including volunteer mentors. We have contracts with the local authorities and PCTs as well as a range of project funding. Through our normal activities we already have links with community organisations, job centres, colleges as well as community information points in Ampthill and (opening soon)Bedford.
Our PWPs follow up all patients. Every time they speak to someone they take a minimum data set on how they are getting on, so we have plenty of outcome data. The PWPs are also now starting to do group work with people.
Our figures are monitored every month by the PCT and ultimately by the SHA. This is done via the dedicated computer programme PCMIS
Some sample outcomes for the county-wide service can be seen in the table below:
Table 3: Step two outcomes in Bedfordshire
October 2008 to end of January 2010
Patients referred: 1,930
Patients who entered the service: 1,554 (80%)
Patients who completed treatment: 1,033 (67%)
Patients moving to recovery: 470 (45%)
Patients who completed treatment who did not meet caseness: 189 (18%)
Patients in employment during treatment: 541 (52%)
Patients who moved off sick pay and benefits during the reporting period: 58 (6%)
Making it work:
In terms of organising the collaboration, we have partners' meetings every six weeks with the commissioners. The operational managers of the three partners also meet together regularly.
Being a charity, we - Mind- know we represent good value for money and we are happy about that. The IAPT pilot scheme has been a great success and was due to be extended for another three years. However, we learned toward the end of last year that IAPT funding is being cut substantially on a national basis, so we will have to cut our cloth accordingly going forward. The PCT were about to tender to take over the service permanently, but they have had to reassess things in the light of the funding cut so for now, the pilot scheme will be extended for a few months.
In creating this service, the PBC groups, Horizon in particular, contributed great knowledge of what GPs want for their patients. Horizon have offered a fresh approach, looking to do things in a different way by being innovators and risk-takers in a the best possible sense. They are a good advert for practice-based commissioning. What we have learned from our collaboration will help both us and Horizon going forward.
Helen Hardy Mental Health Commissioner for primary care mental health and psychological therapies. NHS Bedfordshire.
'What we've learned from this is that the partnership has to work together very strongly. It's not a hands-off type thing. The third sector are very good at partnership working. It's one of their skills.
We do have to performance-manage each of the partners quite carefully. I have a monthly meeting with each of the partners separately, they meet independently and we have a semi-formal partnership meeting all together on a monthly basis. The priorities of practice based commissioners, third sector and NHS are all very different and all need to be kept in the loop operationally and strategically.
In retrospect, I think a three-way split is too many. Two providers would have been better. Over-complications can arise and it can become top heavy. In the future we'll be looking to slim down to two providers.
Mind have been extremely dedicated and hard working - a very important part of the consortium. They represent great value for money and are able to be responsive and flexible, delivering about 75 per cent of completed treatments.
Alison Fisher (left) and Helen Hardy