Improving access to primary mental health services: are link workers the answer?

Key messages

• Mental health link workers placed in general practices improve access to talking therapies for black and minority ethnic communities.

• Collaborative networks in healthcare involving primary care can support and facilitate quality improvements in mental health care for people from black and minority ethnic communities.

Why this matters to me

I know from both professional and personal experience the debilitating effects of depression and anxiety on individuals, their families and friends. I also know that there are effective and evidencebased therapies available that can help people to help themselves manage and recover from depression and anxiety. Making these therapies as accessible and available as possible to all members of the community is something worth striving for.

Abstract

Background The incidences of common mental disorders such as anxiety, depression and low-level post-traumatic stress are associated with deprivation. Since 2007, the Improving Access to Psychological Therapy (IAPT) programme in Ealing has made it easier for primary care practitioners to refer patients with common mental disorders for treatment. However, fewer patients of a black and minority ethnic (BME) background were referred than expected.

Setting Southall, Ealing, is a diverse ethnic community; over 70% of the population is classified as having a BME background.

Aim To evaluate the effect of locating mental health link workers in general practitioners' (GP) surgeries on referral of BME patients to IAPT services.

Methods In 2009, an initiative in Southall helped practitioners and managers that served geographic areas to work with many different agencies to improve whole systems of care. One strand of this work led to mental health link workers being placed in 6 of the 23 GP practices. They provided psychological therapy and raised awareness of common mental disorders in BME groups and what mental health services can do to improve these. Referrals to the service were monitored and assessed using statistical process control.

Results The mean referral rate of BME patients for GP practices without a link worker was 0.35 per week per 10 000 patients and was unchanged throughout the period of the study. The referral rates for the six practices with a link worker increased from 0.65 to 1.37 referrals per week per 10 000 patients.

Conclusions Link workers located in GP practices, as part of a collaborative network of healthcare, show promise as one way to improve the care of patients with anxiety and depression from BME communities.

Introduction

Common mental disorders (CMDs), including anxiety and depression are a significant cause of health impairment globally.¹ In England, a large-scale programme for improving CMDs was initiated in 2007 – the Improving Access to Psychological Therapies (IAPT) services. IAPT provides community-based talking therapies, including cognitive behavioural therapy (CBT), using a stepped-care approach.²

Many people who have CMDs do not seek treatment and under-diagnosis remains a problem at the primary care level for all groups.³ Higher incidences of CMDs are associated with deprivation and other factors that contribute to social inequalities, including being from a black and minority ethnic (BME) background.⁴ However, evidence indicates that although use of primary care is high amongst BME groups, under-recognition of depression and consequent poor access to treatment of CMDs in BME communities is a significant problem.⁵ This translates into, among other things, poor access to IAPT services, and a need for interventions and pathway development that improve access for people from socially excluded groups, including BME communities.^6,7

The London borough of Ealing is in West London and has a population of over 330 000 from diverse ethnic and social backgrounds. Southall, a district within Ealing, has a population of around 65 000 and is one of the largest ethnic communities in the UK, with over 70% of the population classified as BME. Southall is served by 23 general practices.

The Ealing Mental Health and Wellbeing Service (MHWBS) hosted the IAPT service from 2008. Be-tween 2009 and 2012, the MHWBS undertook out-reach work with Southall communities and faith groups, and translated publicity and service-related material into languages spoken within the local community. At the same time, it undertook outreach to all of Ealing's 79 general practices.

Background to the Southall link worker project – the Southall Initiative for Integrated Care

The Southall Initiative for Integrated Care (‘the Southall Initiative’) operated between 2009 and 2012 (see Box 1).⁸ It helped practitioners and managers that served geographic areas to work with many different agencies, including primary care providers, to improve whole systems of care. The mental health stream within the Southall Initiative analysed referrals to Ealing's MHWBS. It concluded that the proportion of referrals received from BME patients was considerably less than expected. At a Southall Initiative event, stakeholders considered possible reasons for this disparity and concluded that cultural barriers, stigma around mental health, and low levels of awareness of CMD and available therapy services amongst Southall general practitioners (GPs) were the most likely causes. This led to the development of the Southall link worker project, intended to increase awareness of these issues within primary care.

Box 1. The Southall Initiative for Integrated Care.

The Southall Initiative for Integrated Care operated between 2009 and 2012.⁸ It included five mechanisms designed to enable multiple-way collaboration for ongoing system-wide improvements:

1. An annual cycle of collective reflection and co-ordinated action. A sequence of events, scheduled long in advance, allowed stakeholders from different organisations to agree shared vision and priorities for improvement, devise co-ordinated improvement projects and learn from these projects by putting into place synchronised improvements.

2. Interorganisational shared leadership teams engaged people from their own organisations and disciplines in the improvement projects that emerged from the annual cycle of activity.

3. Overt expectation that membership of shared leadership teams would change each year but four main sectors would continue to contribute to ongoing annual cycles of collective reflection and co-ordinated action – mental health, acute care, social care and community care.

4. Clustering of general practices into convenient geographical groupings, with different practices leading development in different areas on behalf of the whole cluster.

5. Routinely gathered data about cost and quality of care within the GP clusters, to observe in real-time the impact of the collaborative activity.

The Southall Initiative therefore provided a systematic way for practitioners and managers that served the same geographic area to work with many different agencies to improve whole systems of care. The link worker project was one of the projects that emerged from the Southall Initiative.

Southall link worker project

In January 2009 the MHWBS located one of its staff in a Southall GP practice to pilot the role that later became known as a ‘link worker’. A link worker became defined as a wellbeing advisor or CBT therapist, from the MHWBS team, who provided psychological therapy within a GP practice, and also raised awareness among the practice staff of CMDs and how to deal with them. They raised awareness through everyday team discussions and practice meetings in which they discussed clients and mental health policy. Over the next 18 months, five more GP surgeries had a link worker placed with them (in April 2010, September 2010, September 2011 and two in December 2011).

Supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care for Northwest London (CLAHRC NWL) (see Box 2) the team used a set of quality improvement tools. One aspect of this was the gathering of weekly measures of behaviour change (termed ‘improvement measures’) to track change and motivate those involved to ongoing improvements. The improvement measure selected for this project was the number of patients from BME communities referred to the IAPT service. Referral data were collected weekly for each Southall GP practice; this provided a data set with which to evaluate the impact of the Southall link workers on referrals to the IAPT service. Data were compared between practices that had or did not have a link worker, and analysed using the CLAHRC NWL webbased Improvement Support tool and a statistical approach called statistical process control.⁹

Box 2. NIHR CLAHRC for northwest London.

Quality improvement methodology

The Southall MHWBS worked in partnership with the NIHR CLAHRC for northwest London to increase referrals to their service between April 2010 and September 2011. NIHR CLAHRC for northwest London provides frontline clinical teams and support staff with training and mentoring to utilise a package of tools to deliver the implementation of evidence-based interventions. The use of quality improvement tools facilitated the collection and analysis of data to demonstrate the success of the interventions in delivering outcomes. Specifically, statistical process control is used by clinical teams to monitor the impact of specific interventions on various clinical processes or outcomes using improvement measures.⁹

Results

Figure 1 shows that the 17 practices that did not have link workers showed substantial variation in the referrals of BME patients, but did not demonstrate a change overall in the number of BME referrals made over the period of the study (April 2010–September 2011) from their base referral rate (January–March 2010). The average (mean) referral rate for BME patients (standardised to the size of the population served by practices) of these 17 practices was 0.35 BME referrals per week per 10 000 patients, and remained at this level over the whole period of the study.

Figure 1.

Referral rates (per 10 000 practice population) of BME referrals from 17 practices without a link worker, January 2010 to March 2012

Figure 2 shows that the six practices with link workers had a higher base referral rate of 0.65 BME referrals per week per 10 000 patients. The statistical process control method used to analyse the data revealed an increase in referral rates from July 2010 (week 26 from data gathering) – 18 months after the first pilot link worker, 13 weeks after the second, five weeks before the third and over a year before the last three were in place. This was an increase from 0.65 to 1.37 BME referrals per week per 10 000. This improvement was sustained to the end of the study period.

Figure 2.

Referral rates (per 10 000 practice population) of BME referrals from six practices with a link worker, January 2010 to March 2012

Figure 3 shows the improvement associated with link workers. It analyses referrals by quarter, comparing practices with a link worker against those without.

Figure 3.

Standardised mean referrals per quarter in link worker versus no link worker practices, January 2010 to March 2012

Discussion

There is national recognition of the need to provide effective, low-cost treatments for CMDs in people of an ethnic minority background,¹⁰ and to support GPs to manage the mental health needs of patients in alignment with National Institute for Health and Care Excellence (NICE) guidelines.⁵ Mental health link workers within GP practices, introduced as part of an associated initiative to facilitate multiple organisation collaboration for ongoing improvements, offer one model to achieve this.

Data generated in this project show a clear association between placing mental health link workers in GP practices and improved referral to IAPT services in patients of a BME background with CDM such as anxiety and depression. The effect of the last three link workers is debatable because data gathering stopped within weeks of their start.

One conclusion might be that link workers are effective because they raise awareness in their practices of CMD in BME populations and what can be done to improve these – causing GPs and practice teams to recognise such problems more often and refer more often. This conclusion is supported by the fact that practices with a link worker increased referrals and those without did not.

A different conclusion could be that the link workers provided merely one element in a complex process for culture change within the Southall community that raised awareness of mental health problems in BME populations in multiple, more subtle ways. This conclusion is supported by the fact that the practices that had link workers had higher referral rates at the outset. It is likely that they were more engaged in the Southall Initiative that revealed the original problem and gave birth to the link worker project in the first instance. The value of setting targeted projects such as the link workers within ownership-creating mechanisms is a question that we explore in a sister paper (Improving patient and project outcomes using inter-organisational innovation, collaboration and co-design). In our sister paper, we compare BME referrals from Southall practices into the IAPT service with referrals from practices in other parts of Ealing that did not benefit from the collaborative approach used in Southall.

AUTHORS' CONTRIBUTION

KS led the quality improvement work; LE, SG and PT conceived the study; SG and FM performed the analysis. SG and LE wrote the first draft; all authors contributed to the revision of the manuscript.

ETHICAL APPROVAL

NHS Ealing provided overview of the project and considered ethical issues. Research Ethics Committee approval was not required as this was part of a locally led evaluated service improvement project.

FUNDING

The quality improvement work was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Northwest London and NHS Ealing.

CONFLICT OF INTEREST

The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR, the HS&DR programme, or the Department of Health.