Abstract
Key message
IAPT will succeed or fail on the extent to which it enables partnerships.
Why this matters to me
For years I have been working to integrate mental health services in Ealing. Improving Access to Psychological Therapies (IAPT) offers the best chance I have ever known to achieve this, and to make a coordinated impact on the health of the people of Ealing.
IAPT is an exciting opportunity for us in Ealing and we have grabbed it with both hands. We are incorporating it into our beliefs, values and passion to produce a service that will reflect our vision for holistic primary care services. A service which is financially sound. A service which does not believe that there is one answer to everyone's mild to moderate mental health problems. A service which recognises that working in silos is detrimental to our patients' health. A service which is constantly striving to improve relationships with our partners. A service which is mindful about the people we see, and the staff who see them.
Keywords: mental health, partnership, psychological therapies
Background
Ealing Primary Care Trust (PCT) is the fifth largest in England. A population of over 315 000 is served by over 170 general practitioners (GPs) within 83 general practices. There are over 13 000 refugees in Ealing, a strong South Asian community and many economic migrants from the countries of central and Eastern Europe.
In 2007 primary care mental health services in Ealing were fragmented and we planned to integrate them. We intended to break down the barriers between disciplines and create a shared ethos of improving mental health and well-being within community settings for the population of Ealing.
At that time, Ealing PCT employed seven graduate workers, four gateway workers and a counselling service which included six whole time equivalent counsellors. This set of teams systematically developed partnerships with the voluntary sector, West London Mental Health Trust, GPs and other services within the provider arm of the PCT, including district nursing and health visiting. With them we have explored how extended multidisciplinary teams can provide culturally sensitive and appropriate psychological interventions, including support for work-related stress, debt, advocacy, and advice about healthy eating and healthy living. Our therapists and vocational workers regularly visited GP practices to develop relationships and clarify the best use of the services available.
New relationships with therapists from other services have greatly enhanced our reach. For example we now work so closely with the Mental Health Resource Centre (Southall; Norwood) that we consider ourselves to be part of the same team.
In September 2008 we became an IAPT expansion site. This provided us with new impetus to develop integrated community-based services for mental health.
Developing a larger more diverse service, incorporating IAPT
As an expansion site for IAPT our teams grew larger and in December 2008 we moved into a suite of offices and refurbished them into consultation rooms. This site includes a training centre for the trainees.
Our new offices are situated away from existing healthcare services on the Uxbridge Road. Since November 2008 we have employed 37 new trainees.
Our integrated service from February 2009 includes:
19 CBT trainees (high-intensity therapists)
18 well-being advisors (low-intensity therapists)
Seven Graduate Workers: help people with mild to moderate mental health problems focusing on anxiety, phobias and panic disorders, using a CBT approach and telephone support. Graduate workers signpost patients to local services.
Seven CBT Therapists: provide personal counselling using a CBT approach, for people with mild to moderate mental health problems in 12–18 sessions, focusing on anxiety, phobias and panic disorders.
Four Gateway Workers: provide help for people with moderate to severe mental health problems, frequently those who have complex needs and fall in the gap between primary and secondary care. They provide detailed assessments of need for patients and support them to develop personal care plans that might involve primary and secondary care and the voluntary sector.
Six whole time equivalent Counsellors: lead different services that help patients with long-term conditions, trauma and attachment disorders. Counsellors provide six to 12 weeks of one to one support. An example is the service that supports patients with multiple sclerosis.
Five Vocational Workers: help people to return to work or maintain employment. Vocational workers work with local employers, the voluntary sector, and partners such as Job Centres. They involve other members of the team when needed e.g. counselling.
Three Community Development Workers: work at a strategic level to support commissioners and provider services, making links with the voluntary sector, particularly Black and Minority Ethnic (BME) communities. These community development workers bring together partners such as the housing department, local refugee groups and GPs.
Business Manager: leads on operational protocols and procedures, premises, recruitment, finance, data activity and managing the administrative workforce within the service.
Three Team Leaders: the senior leadership of the service includes Head of CBT, a Clinical Lead, and a Head of Service.
We are also presently recruiting two mental health advocates and a physical health coordinator.
All staff have clinical and line-managerial supervision. To enhance mutual learning we have set up a ‘reflective practice group’. We encourage all staff to work in a collaborative way within the multidisciplinary teams, appreciative of all the disciplines that work within the service.
Working with local practitioners (GP pack)
A GP pack contains the referral form, a laminated sheet with contact details, and a booklet in both English and Punjabi, and a list of voluntary sector providers (developed in partnership with a service user).
A local GP – Dr Hemant Patel – supports a rolling programme of training. He works with other GPs throughout Ealing to increase their knowledge and awareness of mental health issues. Dr Patel also represents us at regional and national meetings.
Three mental health leads relate to three Practice-Based-Commissioning Groups. We also work closely with a local nurse-led general practice. This has become an ‘expert practice’ for us, supporting and working very closely with our service and its evaluation, and promoting our services to other practices.
Referring into the service
One of the most common criticisms of mental health services was that the referral process was different for each discipline, making the process unclear and complex. We responded to this by creating a single referral form that we piloted in Southall and are now rolling out to the other areas. This form was put together with guidance from GPs and other practitioners, including the voluntary sector and users. It includes a brief explanation of the roles of each team member.
We have introduced self-referral into the Service (January 2009). Information about this has been sent out to our voluntary sector colleagues and all GP practices. A publicity drive about our new services is about to start, including TV commercials within surgeries in local community languages.
Exploring new ways of working
We constantly strive to explore new ways of working that will benefit our local population, particularly socially deprived/excluded groups. The following new services have recently started, in response to expressed need (Box 1).
Box 1.
| Food to Feed your Mind | Classes which teach people how to cook healthily on a budget. |
| Self-Esteem | A self-esteem group started in October 2008, to include healthy eating and exercise sessions. |
| Group Work | Patients with mild to moderate depression receive support in a group setting – a maximum of 10 patients for 12 weeks (in partnership with Asian Family Counselling) |
| Fear Fighter | This is a web-based CBT package for anxiety and phobias. Training for staff is complete and training of GPs began in Acton and Central Ealing (PBC group training) in October 2008. |
| Beating the Blues | “Beating the Blues”, a web-based CBT intervention for depression, is available at some GP surgeries, including Hillcrest in Acton and the Southall Broadway Community Clinic. |
| Translating material | The Well-being Service has piloted a translated booklet in Punjabi detailing the different psychological therapies available. We have also recruited seven staff within the past year from Black and Minority Ethnic communities, five of whom speak community languages. |
| Gay and Bisexual Support Group | The Well-being Service is working in partnership with Anchor who have set up a support group which is being run from a voluntary group setting. |
| Smoking Cessation Service | In November 2008 we incorporated the smoking cessation service into the Well-being Service working with local pharmacists and GPs. |
Where are we now and challenges ahead?
We now have a full complement of staff with a shared vision for holistic care. We have a well equipped and central site as our headquarters.
The challenges now are to get the referral process fully understood by local partners, to clarify with primary and secondary care our communication systems and complementary roles, and to embed evaluation.
We want to assess patient flow, practitioner and patient satisfaction, and clinical outcomes. We also want to evaluate ways in which we can operate as a learning organisation, embedding feedback mechanisms that help everyone to learn from the service as a whole.
We want to develop a team approach with primary care practitioners. For example some GPs may want to do initial work with patients before referral, or continue to work with them afterwards. Similarly, team-working with secondary care mental health practitioners will help to bring together a full range of skills and resources for the benefit of the system as a whole.
In the future we want to focus more on improving social inclusion and local community development. IAPT has been conceived largely as a treatment for individuals. We are well aware that relationships within families and communities are immensely important for good mental health. When we have consolidated this stage of development we will find realistic ways to address the social interface.
One big question hovers – is it all worthwhile? Certainly patients like it. So do practitioners and politicians. But will IAPT actually increase the number of people who are productively employed, and who are role models within families and communities to develop and sustain a mentally healthy society? I believe that IAPT can contribute to these higher aims, but they cannot be achieved without broad and active participation of everyone else. IAPT will succeed or fail on the extent to which it enables partnerships.
Conclusion
The past year and a half has been full of activity. I can't say that this has been an easy journey. I can say that we are getting there. Our strength at forming partnerships has been recognised at local and national levels. A representative from our service was recently invited to the signing of the IAPT consensus agreement between psychological therapy providers and other partners at the Royal College of General Practitioners. Our Well-being Service has been showcased at national, regional and local conferences.
We feel we have built the networks from which to support and change people's lives, to let in ‘some light’. We have developed partnerships for future collaboration throughout primary and secondary care. We have listened to patients and staff and brought together a strong and innovative primary care mental health service. We have not budged, however unpopular, from our beliefs and values for what a ‘Holistic Primary Care Service’ constitutes.