The London Mental Health Fact Book Innovation in primary care: helping those who fall through the care gap By Dr Julian Stern, Consultant Psychiatrist in Psychotherapy & Head of Psychiatry in the Adult and Forensic Services Unit, The Tavistock and Portman NHS Foundation Trust Innovation is key to providing relevant and effective mental health services that reflect the needs of London’s population and changes to how NHS care is delivered. The Tavistock and Portman NHS Foundation Trust’s award-winning City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS) is a new model of working in primary care and has also inspired the recently commissioned service in Camden – the new Team Around the Practice (TAP) service – developed in partnership with the charity Mind. What PCPCS does The service in City and Hackney focuses on patients who traditionally fall between the gaps in care provision. They include those with medically unexplained or complex psychiatric symptoms, long term conditions, personality disorders and other difficulties whose needs are below the threshold to receive secondary care, or have not previously engaged with secondary care services. The service works with GPs and patients alike and uses both external partners to monitor and audit the services and internal models of reflective practice and supervision. The evidence-based model can make dramatic improvements to people’s lives and reduces pressures on GPs and hospitals which, in turn, result in financial savings to the system equivalent to about a third of the cost of the service, and which may be even larger as time goes on. According to a review conducted by the Centre for Mental Health, the PCPCS also achieves very high satisfaction ratings among local GPs and has won many accolades – most recently it was voted 2015 Mental Health Team of the Year by the British Medical Journal. Crucially, the service has improved the mental health in 75% of its patients and helps more than half to recover significantly. It helps to reduce the number of GP consultations, A&E visits, outpatient appointments and hospital admissions among its patients. How PCPCS works Working in GP practices, primary care psychotherapy practitioners see patients for an assessment. They are highly skilled clinicians, who not only have a core health qualification, but are also trained in therapies approved by the National Institute of Clinical Excellence. After the initial assessment, up to 16 sessions of therapy can be offered in the GP practice itself or linking up with voluntary sector organisations such as Mind, or black and minority ethnic groups. GPs are invited to join in the initial consultations, especially where a patient’s existing treatment is not working, or where they have not previously engaged in it. To improve their own ability to help their patients, GPs are also offered bespoke training in psychological and psychiatric work and clinicians regularly attend GP mental health review sessions throughout Hackney. Supervision of staff is a crucial component of the service’s success. The patients are often difficult to engage with, suffering from multiple traumas and social difficulties, and make considerable emotional and time demands on staff. Mindful of this, senior staff members pay close attention to clinical excellence, supervising their colleagues closely and attending to areas of potential burn out, clinician frustration and therapeutic impasses, resulting in a very coherent team with low staff turnover. The main features of the model in City and Hackney have now been commissioned in Camden. However, in Camden, the service will offer a key additional feature. Embedded in the service are three workers from Mind in Camden who will provide a ‘social prescribing’ element to the service, and help with the integration of psychological and social needs. Through social prescribing, patients can be offered short term support from a voluntary link worker to help them identify and access the community resources that can help them meet their personal needs. This is particularly important to people who may be isolated and lack social support, a sense of purpose or a healthy daily routine. Rapid and enduring improvements While some of the patients seen in both services will have a significant history of mental ill-health, most have no history of engagement with mental health services. Early intervention for such people aims to prevent their conditions becoming chronic and reduces their risk of becoming dependent on A&Es and referrals to traditional secondary care services. It is with initiatives and models such as these, based in primary care with the aim of intervening early, that we can make rapid, significant and enduring improvements in people’s mental health. 24
London Mental Health Fact Bbook
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