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Finding new roads to wellbeing 

Dr Amit Sharma, clinical director of Earley+ PCN in West Berkshire, explains why his network is focusing attention on providing quality mental health support  

The rising demand from patients for mental health support, much of which GPs did not have the time or training to address, led our PCN on the outskirts of Reading to focus on this issue.  

We are located in an affluent area with low unemployment and good schools, which is attractive to families and those wanting to live outside London where housing is more affordable. 

Our demographics show an even split between men and women. The population is largely white British but with many other ethnic groups well represented – Indian, Pakistani, and Chinese. Our average age is 38 years, which means that as a practice we are not funded as well by the GP contract.

We looked at population health management data, which identified us as a practice with the highest proportion of adult mental health patients compared with others locally – approximately 16% of our adult population. A significant proportion of the working population has a depression or anxiety diagnosis, or both. A large part of our work has been to demedicalise the issue. By partnering with One Front Door (OFD), part of Citizens Advice, we began helping patients to address their social, emotional, physical and practical needs instead of giving a prescription.  

Our approach came from the sense that much of the poor mental health we saw was from lifestyle and non-medical causes. Patients wanted to get better, but did not know how to go about it. So we referred our patients to OFD, which signposted them to local organisations and charities. 

Also, we employed three health and wellbeing advisers (HWAs) to help patients to engage in their own wellbeing with a holistic  approach, providing strategies and choices to help them avoid the need for medication in the first place, or to reduce their need for it over time. 

Our HWAs have completed mental health first-aid training, social prescriber-plus training and a health coaching course. 

Between October 2020 and April 2021, 475 of our patients were helped by OFD. They were largely aged between 30 and 54. The majority needed help with health and community care support, which includes support specific to Covid guidance. They also needed help with finance (benefits and debt), employment and housing.

We also have a full time MIND wellbeing worker seconded to the practice who has become an integral part of the team. And we have two physician associates who specialise in mental health, who conduct mental health reviews with patients who are on regular medication and those with severe mental illness. 

We offer coaching sessions for our patients with the same HWA for a duration of three to six months. The frequency of appointments is agreed between the patient and the HWA. In addition to this, our team has also conducted educational webinars in partnership with NHS talking therapies about managing anxiety.

Help for anxious parents
We identified that a significant proportion of our on-the-day and emergency demand was from anxious parents who were not confident about where to go or what to do when they were concerned about their children’s health. So we created a live virtual group consultation for anxious postnatal mums to educate and give them confidence about where and when to access healthcare support. 

Taking help to the community
As part of a community approach, our HWA team ran a health and wellbeing fair to bring together patients and local organisations and charities who wanted to support people’s wellbeing. There were 15 organisations including Link & The Friendship Alliance, Christians Against Poverty, Involve, Healthwatch, Earley Community Centre, Reading Men’s Shed and, of course, OFD. About 70 patients attended and discovered what was on their doorstep to help them improve their mental health and overall wellbeing.

How it’s working
Our HWAs are providing 90 hours of HWA work for the PCN’s patients. We also have a full-time wellbeing worker from MIND. 

Between July 2021 and January 2022 we have had 391 new patient referrals. There are more than 1,000 patient contacts per month. The approximate case load per HWA per month is 50-60 patients.

Very few of our GPs are now seeing patients with mental health or emotional wellbeing issues. We can ensure our patients are being seen by the most appropriate members of our team.

Looking to the future
We hope that in the future, more patients will find the help they need outside the GP practice, through self-care, connection and engagement with community and non-medical support, or through counselling and wellbeing coaching. 

We hope there will be fewer patients who need medication to manage anxiety and depression and that there will be better support for patients who are in need. 

We want to improve the sharing of information and collaboration with secondary care for more complex patients. 

We are also looking to expand into working with children, young people and their families. And we are aiming to improve links with social workers, health visitors and community nursing along with exploring, identifying and addressing key health inequalities in our community by working with population health and by collaborating with key local organisations. 

To achieve all this, we will need the right funding and personnel, investment in our practice sites and greater collaboration with other local organisations. 

We are committed to doing this for our patients as we know they value the service, and it has helped our PCN practices function better by getting the appropriate care to these patients and freeing up valuable GP time. 

Patient feedback about the service

  • ‘The service is a lifeline for people who don’t necessarily
    know where to turn. I appreciate the way you dealt with me,
    you listened, were empathetic and took the time. I am still worried about the future, but I don’t feel quite as frantic, scared and despairing.’
  • ‘I wish I had accessed support like this 15 years ago. It feels like I have been on a hamster wheel that was never ending and now I’m free.’
  • ‘Alongside the talking therapies and self-help guides, these sessions helped my mental health enormously.’
  • ‘Now that I have been doing the right exercises for a while, I can see the difference they have made in reducing my back pain. That has not only helped my physical wellbeing but also my mental state as I feel I am finally doing something that is taking me in the right direction and has given me a lot of hope.’
  • ‘These sessions have given me options for how to deal with my health anxiety in a more proactive way, which in turn has helped my emotional and physical wellbeing.’
  • ‘I felt I genuinely mattered during the sessions. From the much-appreciated information you provided, I obtained very useful tips on jobhunting techniques that ultimately led to me getting a job. The fact that the job is something I love doing is a great bonus too.’

Profile: Dr Amit Sharma

Clinical director  Dr Amit Sharma

Practice  Brookside Group Practice

PCN Earley+ PCN

Location  West Berkshire

Number of practices in PCN  2

Number of patients in PCN  30,500

PCN hires (ARRS employed)  

  • 3 health and wellbeing advisers/coaches 
  • 1 pharmacy technician 
  • 2 clinical pharmacists 
  • 2 physician associates 
  • 1 first-contact physiotherapist 
  • 1 advanced practitioner

Recruiting  (ARRS roles still to fill) 
Mental health practitioner (adult and child), nurse associate, two to three more physician associates this year