a primary care approach to mental health and...

A primary care approach to mental health and wellbeing

Case study report on Sandwell

NHS reform and transition

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Contents

Executive summary 2 Introduction 3

Background 4

The drivers for change 6

The commissioning response 7

A collaborative primary care model for mental health and wellbeing 9

A stepped approach to provision 10

Learning points for implementation 17

Conclusion 19

Acknowledgements 20

References 21

A primary care approach to mental health and wellbeing02

Executive summary

The importance of mental health and wellbeing cannot be understated. It affects and influences the lives of individuals, families, communities and societies. There is growing evidence that positive mental health and wellbeing at a population level can reduce health inequalities and improve wider outcomes in relation to physical health, social cohesion and economic productivity.

This report presents a detailed case study of the journey Sandwell’s health commissioners (then Sandwell PCT, now Sandwell and West Birmingham Clinical Commissioning Group) went through to respond to a number of important health inequalities within its local population. It focuses on how its health service commissioners responded to specific health inequalities to develop a primary care-led approach to improving mental health and wellbeing. The specific health inequalities they sought to address included:

•poor levels of mental and physical health

•social deprivation

•poor access to low-intensity community mental health and wellbeing services

•heavy use of secondary care mental health services.

Sandwell’s primary care approach to mental health and wellbeing is a direct and practical response to stark health inequalities within its locality and challenges that many health service commissioners across England face. The approach, known as the collaborative primary care model for mental health and wellbeing, uses the principles of collaboration, co-location and integration to support its population to access low-intensity services and healthcare professionals when making referrals. The purpose of each low-intensity service is to empower the population to make decisions about their own care and improve emotional resilience and wellbeing.

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The approach also illustrates how early intervention and prevention, through a stepped approach to provision, can improve existing service infrastructure.

The Sandwell primary care approach to mental health and wellbeing has shown some promising early outcomes, with over 4,000 people completing prevention, wellbeing and health improvement programme, saving around £800,000 in prevention costs. In addition, over 3,000 people have accessed talking therapies, saving around £600,000. It provides some key learning points for wider commissioners to consider, namely:

•the continued need to align primary healthcare with key partners and stakeholders, including probation services, secondary care acute and mental health providers, schools, libraries and colleges

•the importance of investing in education and training for primary care and community care staff

•the importance of clinical and service user engagement.

Under new commissioning arrangements ushered in by the Health and Social Care Act (2012), the Sandwell example highlights the need to respond to strong evidence of local health inequalities. At a local level, clinical commissioning groups (CCGs) along with health and wellbeing boards may wish to utilise the evidence within joint strategic needs assessments to drive a primary care-led approach to mental health and wellbeing services. At a national level, the NHS Commissioning Board and Public Health England will need to work together to enable this type of local innovation and priority setting.

A primary care approach to mental health and wellbeing 0303

Introduction

There is growing evidence that positive mental health and wellbeing at a population level can reduce health inequalities and improve wider outcomes in relation to physical health, social cohesion and economic productivity. This case study report illustrates the vital role that health commissioners can play in ensuring mental health and wellbeing services are accessible, meet local needs and drive collaborative working.

It presents a detailed case study of the journey that Sandwell’s health commissioners (then Sandwell PCT, now Sandwell and West Birmingham Clinical Commissioning Group) went through to respond to a number of important health inequalities within its local population. These include poor levels of mental and physical health, social deprivation, poor access to low-intensity community mental health and wellbeing services and heavy use of secondary care mental health services. The report focuses on four specific aspects of Sandwell’s story:

1. The demographic context and drivers – the specific health inequalities that prompted the development of a primary care-led approach to mental health and wellbeing and its priorities.

2. The collaborative primary care model that Sandwell’s health service commissioners adopted to address the challenges.

3. The service infrastructure that has been developed to make the model a reality and work across a whole population while meeting individual needs.

4. The learning points from the implementation of the model for other commissioners.

‘There is growing evidence that positive mental health and wellbeing at a population level can reduce health inequalities and improve wider outcomes in relation to physical health, social cohesion and economic productivity.’


The Government’s mental health strategy, No health without mental health, describes mental wellbeing as “[a] positive state of mind and body, feeling safe and able to cope, with a sense of connection with people, communities and the wider environment.” It affects the lives of individuals, families, communities and societies, and influences individual behaviour, wider social cohesion, social inclusion and economic prosperity.1 Positive mental wellbeing also improves overall physical health, encourages recovery more rapidly and promotes higher levels of employment and productivity.2

Psychological wellbeing

A growing amount of research has explored the benefits of positive psychological states such as contentment and fulfilment,3 often collectively referred to as psychological wellbeing. Far from being associated with the absence of mental health difficulties, psychological wellbeing has distinct causes and significant implications across a range of wider outcome areas. For example, people who report higher levels of wellbeing tend to be more involved in social and civic life, are more likely to behave in environmentally responsible ways, have better family and social relationships at home and are more productive at work. In addition, a recent review of literature has found that wellbeing is positively associated with positive health outcomes.

In response to the growing body of evidence in the area, the Department of Health launched the coalition Government’s mental health outcomes strategy, No health without mental health (2011). The strategy emphasised an important shift in policy, giving considerable attention to promoting positive and more preventative approaches for mental health and wellbeing across populations. The strategy also made mental wellbeing a priority for public mental health.4

Sandwell’s socio-economic landscape

A metropolitan borough located within the West Midlands, Sandwell is comprised of six towns; Oldbury, Rowley Regis, Smethwick, Tipton, Wednesbury and West Bromwich. It is also the 14th most deprived local authority in England with 53 per cent of its wards described as “very deprived” (as of 2011).

The borough has some important socio-economic contexts in its population, such as:

•around 23 per cent of residents are from black and minority ethnic (BME) groups, specifically of South Asian origin (Indian, Pakistani backgrounds)5

•the area has a high unemployment figure at 4.5 per cent, compared to the England average of 3 per cent (as of 2010) – this is due to the decline in manufacturing in the past decade, which saw the number of jobs in the region fall by 13 per cent, compared with a 7 per cent fall nationally

•it has higher-than-average Job Seeker Allowance (JSA) claimants rates in comparison with regional and national levels – this includes higher overall unemployment (including those not claiming benefit) and lower economic activity rates

•the borough has higher than average levels of ‘non-decent’ homes and 7.4 people per 1,000 households receive statutory homeless status (as of 2010).

Background


Physical health

The physical health of people in Sandwell is also generally worse than the England average.6

•Life expectancy for both men and women is

lower than the England average. In the most deprived areas of Sandwell, life expectancy for men is 10.1 years lower than in the least deprived areas. For women, it is 5.9 years lower.

•Over the last ten years, all-cause mortality rates have fallen. Early death rates from cancer, heart disease and stroke have fallen, but remain worse than the England average.

•23.5 per cent of year 6 children are classified as obese.

•A lower percentage than average of pupils in Sandwell spend at least three hours each week on school sport.

•Levels of teenage pregnancy and GCSE attainment are worse than the England average.

•Estimated levels of adult ‘healthy eating’, smoking and obesity are worse than the England average.

•Rates of smoking-related deaths and hospital stays for alcohol-related harm are higher than average.

Gathering the evidence for change

In 2006, Sandwell Primary Care Trust, currently in transition to Sandwell and West Birmingham Clinical Commissioning Group, undertook a mental health GP profiling assessment. This identified that Sandwell had high levels of mental ill health in wards that are socially deprived and have high unemployment. A gap analysis also showed that the diversity of needs in the borough were not being met, leading to

higher-than-average representation of BME groups within acute services and generally low uptake of community lifestyle services.

Part of this was due to fragmentation, as primary care services were not sufficiently connected to secondary care mental health services. Sasha Gelpi, mental health promotion lead, said “at that time, the system was close to collapse, GPs were not referring patients to the right services due to a lack of awareness and unresponsive services. Community services were very disconnected or had 18-month waiting lists – something had to change.”

The GP profiling assessment also highlighted that there were correlations between people diagnosed with depression and other long-term conditions, particularly cardiovascular disease and diabetes. Of people attending GP surgeries, nearly one-third have mental health problems. In addition, 15 per cent of GP consultations, and a staggering 50 per cent of hospital outpatient consultations, arise from a high cost group with medically unexplained symptoms.

The GP profiling assessment report suggested that there was an immediate need to prioritise and make adequate provision and prevention for depression, which represented the highest prevalent disorder, with high numbers of people not receiving therapy but receiving anti-depressants.


The socio-economic, service provision and access challenges in Sandwell translated into three drivers for creating a radically different approach to mental health and wellbeing provision within Sandwell.

1. The need to tackle the low aspirations and emotional distress associated with severe deprivation at a population level.

This concerned establishing a preventative and early detection integrated primary care and mental health model that would pick up individuals in the population that may fall under the radar of acute services. Examples include people who feel lonely, isolated or have low self-esteem and have associated physical health problems.

2. Improving access to and the infrastructure for referrals to low-intensity mental health and wellbeing services.

The drivers for change

This was about developing a primary and community care delivery model which included signposting, and building within that capacity to respond to individuals and their families, including those who have complex needs. This also incorporated those who are socially excluded, including the homeless, alcoholics, and also those presenting with medically unexplained symptoms, frequent and persistent attendees.

3. Improving the engagement of primary care and creating more integrated models for provision.

This included challenging the more dominant psychiatric disease model through the development of a bio-psychosocial approach that was more holistic and person-centred.


The commissioning response

The PCT’s director of commissioning and chief executive appointed a primary care mental health and wellbeing lead at Sandwell PCT (Lisa Hill) who, working in partnership with the PCT Professional Executive Committee (PEC) chair and mental health lead (Dr Ian Walton GP), started to develop a more collaborative and primary care-led approach to mental health and wellbeing.

The PCT commissioners used the evidence of poor service provision and access to work with local stakeholders to develop a business case for change. This work took into account the GP profiling work and the outcomes from a series of hearts and minds events in which local service users expressed their dissatisfaction with current services. They explained that “one size does not fit all.”

In order to respond to the challenges, the commissioners ensured that time and resources were put into listening to the needs of the local population, mapping best practice evidence and scoping its options for partnership working. As such, the PCT then did the following:

Listened

They set up a number of further listening exercises with the residents and GPs of Sandwell to gather a frontline view of problems and what needed to change. Key to this was understanding how GPs navigated existing services. Lisa Hill explained: “We started from scratch, had little GP engagement and no service user or public engagement, we set up some hearts and minds events for them to tell us their frustrations and stories. We took a bottom-up approach, that was to ask how the patient perspective could inform the care pathway, and what would work for GPs.”

Analysed

They undertook a further local needs analysis, where individual general practice profiles were developed to establish the prevalence of patients that were presenting mental health issues and the implications for resource usage and savings that could be met under the Quality and Outcomes Framework (QOF). The team also assessed a broad range of ‘human needs’ and piloted the use of an emotional needs audit form to assess requirements. Dr Ian Walton explained: “The key themes that came out from our emotional needs audit were around security, safety, emotional connectedness, self-esteem and compassion – you have to look at emotional health before you can tackle physical health.”

Mapped

They used asset mapping, identifying which existing community services could be used more effectively such as local libraries and children and family centres. This was also about the PCT garnering a better understanding of which local services/approaches worked well among the Sandwell population and its various communities.

‘In order to respond to the challenges, the commissioners ensured that time and resources were put into listening to the needs of the local population, mapping best practice evidence and scoping its options for partnership working.’


Sourced funding and partnerships

They sourced funding and partnerships opportunities, by adopting a starfish (i.e. networking with all potential partners – like a starfish ‘fusing’ and keeping the connection by ‘growing another limb’) methodology to partnership working. The PCT looked for opportunities where its organisational policy objectives and strategic visions aligned to national policy in order to access internal and external funding.

Modelled

Both the demand and capacity of the workforce were modelled building on earlier innovative work profiling the local primary and secondary care workforce, which resulted in a Health Service Journal (HSJ) award.

Measured

They identified a system to collect pre and post-outcome measures. They knew that in order to prove that a new primary care-led model for mental health and wellbeing would work, they would need to have a robust evidence base. Sandwell PCT decided to purchase the COREIMS system (Clinical Outcomes in Routine Evaluation Information Management System).7 They used CORE-10 from the system, a ten-question clinical outcome measure that monitors an individual’s level of mental wellbeing and level of risk. The system also links well to primary care indicators within the QOF.

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‘They identified a system to collect pre and post-outcome measures. They knew that in order to prove that a new primary care-led model for mental health and wellbeing would work, they would need to have a robust evidence base.’


Following a number of local pilot initiatives to test delivery approaches, a commissioning approach was developed by Sandwell to align mental and physical wellbeing, called a collaborative primary care model for wellbeing. The approach works on the principles of co-location, integration and collaboration.

Co-location

The approach uses co-located services, as these are proven to improve access to care and offer a more effective service for people with mild depression. Those with mild to moderate mental health needs, commonly seen in primary care, can be treated alongside those with psychiatric conditions. Managing patients in a primary care setting also reduces stigma and improves adherence to treatment.

Integration

The approach ensures the integration of services at a local level, especially the link between acute, primary and secondary healthcare, wellbeing and social care services. The PCT streamlined its primary care mental health budgets and planning cycles under one role – the primary care mental health and wellbeing lead. This lead has oversight and responsibility for commissioning all the services that come under the population and primary care level (i.e. all low-intensity mental health and wellbeing services).

Collaboration

A collaborative care model incorporating case management shows benefits, particularly with older adults and people with persistent or

A collaborative primary care model for mental health and wellbeing

recurrent mild to moderate problems, including stable severe psychiatric disorders. The key areas for collaboration for more complex cases with multi-agency working are:

•mental health, alcohol, dementia and wellbeing assessment tools

•gateway workers

•maternal mental health

•involvement of carers

•patient registry

•psychiatric consultation

•shared care protocols and integrated care pathways with agencies such as maternal mental health, probation and maternity services.

Flexibility

The approach also emphasises flexibility. The PCT’s local needs analysis identified that there were some specific populations who were not having their mental health needs met at a low-intensity level. These were identified as the lesbian, gay, bisexual and transsexual population, those with hearing disability, young people (under 16s), carers and South Asian populations (i.e. men of Pakistani origin). Lisa Hill said that “this is where co-location is important. We do not want to create new services for diverse populations, it is more about those populations having access to existing resources. So for those people with hearing disabilities, we hire/train staff in sign language. To reach Pakistani men, we would hire community development workers, or to locate services in the local faith community.”


A stepped approach to provision

The Sandwell approach combines positive self-help, psycho-education, condition management, talking therapies and access to specialist support, all of which have been developed with service users who are ‘expert by experience’, to ensure that the primary care mental health needs of the patient are reflected throughout the model.

Sandwell adopted a stepped approach to primary care mental health, which uses different levels of care to ensure the consistent flow of service users between the steps, resulting in no waiting lists. The steps are graduated from low to high intensity and are non-exclusive. The care pathway is integrated to reflect that recovery is built into each step, so that people can be referred back to primary care at any point. The approach assesses patients using COREIMS and allocates them to stepped

levels of service. Service users are offered a range of evidence-based approved interventions available, to give people a choice of services, with different interventions offered within each step (see Figures 1 and 2).

Lisa Hill explained that “the smooth transition between steps ensures that the patient experience is not disjointed and the population’s range of needs is met. We want to ensure that a person is referred appropriately so we unclog the secondary care system.”

The population is offered the most straightforward treatment that is likely to benefit them. As progress will be closely monitored through COREIMS, those not improving in low-intensity services will be quickly picked up and offered alternative care.

Wellbeing

Emotional

resilience

Prevention

Figure 1. Stepped approach to mental healthcare in Sandwell

Self-help

Information

Education

Community settings

Wellbeing

Emotional resilience

Prevention

Promoting wellbeing

Self-care, conditions management

Step0

Step

1

Step

2Step

3Step

4Step

5Guided self-help

Education

Advice

Triage available in community and health settings

Range of 1:1 low-intensity supported interventions

Pathways to work

Improving access to psychological therapies (IAPT)

Low-intensity service

Primary care resource

High-intensity psychological interventions

Psychological interventions for people with long-term conditions

High-intensity service

Access to psycho-therapeutic interventions from integrated child and adult mental health teams

Early intervention, psychiatric liaison service within primary care

Centralised resources to provide specialist care and support – secondary care services


Figure 2. Integrated primary care and wellbeing model

This diagram depicts the Sandwell primary care mental health and wellbeing model. Within the model, people can step up or step down according to need.

Wellbeing is a theme at all levels through the model and access to programmes incorporating wellbeing and positive psychology is offered in a range of settings including faith, schools, children and family centres, health and community venues.

High volume Minor, self-limiting and longer-term conditions

Graduate workersCommunity

development workersMIND community

wellbeing serviceConfidence and wellbeing team

Faith networksSchools

Community

Low intensity Mainly minor/mild

(anxiety and depression)Improving access to psychological

therapies (IAPT)Counselling services

GP leadsPsychology

Medium/high-intensity therapiesMixed presentations (moderate/complex)

Esteem team, probation, youth offending team

Gateway workersCommunity matrons

Health trainers and health visitors, maternity services

Link workers

Severe illness(Urgent/Crisis)

Single point access for crisis all agesRapid, Assessment, Interface

and Discharge (RAID)

Outreach, self-help and guided self-helpMental wellbeing promotion

Targeted and universal lifestyle servicesEmployment, accommodation

EducationSelf-careHealth improvement programmes

PersonalisationPt education – co-produced programmes

Access to talking therapies and consultationNHS independent/voluntary sector/chaplains for wellbeingLow-intensity service integrated counselling and

therapy service

Primary care workforceCommunity primary care services

Early detection/interventionAccess to crisis prevention services

Ongoing management of long-term conditions including physical and psychological needsService users and carers

High-intensity servicePsychiatric liaisonShared protocols and assessment

Integrated/shared careMental health, alcohol, dementia and wellbeing screening

Gateway workersPatient register audit and management across long-term conditions Home treatment

Effective medicines management more consideredAmbulatory pathway from A&E

Co-morbidities

Assessment beds, respite beds, crisis bedsHospital liaison Consultation

Booked day case inpatientBooked discharge

Specialised inpatient services

Step 4 Hospital and community

bedsPopulation:

3.3 per 1000

Step 3 Collaborative/

shared carePopulation:

20.8 per 1000

Step 2 Practice-based

primary carePopulation:

101–105 per 1000

Step 1 Access to talking

therapiesPopulation:

230 per 1000

Step 0 Local community

prevention, advice, prevention

Whole population


The service infrastructure

The broad range of wellbeing services put in place reflects a stepped approach to care. The purpose of each low-intensity service is to empower the population to make decisions about their own care and improve emotional resilience and wellbeing. The collaborative care model has a number of key service features to enable this to happen.

Confidence and wellbeing service – prevention and self-help (Step 0–1)

The confidence and wellbeing service is open to all but is targeted for those identified by the needs analysis, and provides low-level interventions in the form of programmes/courses that aim to help people at Step 0-1 cope with conditions including mild depression, obesity, medically unexplained symptoms and anxiety. In January 2012, Sandwell PCT tendered this service to the Health for Living consortium (Sandwell Mind, the Accord Housing Group, Murray Hall Community Trust and Black Country Housing Group), which was awarded a £1.2 million three-year deal. This move was a further example of the desire to integrate and work on an inter-agency basis.

The service has core staffing, which includes five self-help coaches, two community development workers and a management lead.

Service users and carers have access and signposting to a variety of group activities, courses and programmes that support positive mental health and wellbeing and provide the resources of self-help coaches. Terry Rutter, a self-help coach, explained: “We know that group work supports people to become less reliant on NHS services. We are here to lift the mood of the population, empower Sandwell residents to seek support, have choice and help themselves to feel positive. Our aim is to respond to low-level issues before they go to primary care.”

To support integration and co-location, the confidence and wellbeing team are encouraged to work with existing service providers, such as local authorities, social care and voluntary sector partners, to build capacity through training and development. The team also works with GPs and social workers on a regular basis to highlight their ‘offer’ in relation to emotional support and the process for referring to them. The team provide a mix of conditions management and wellbeing programmes, detailed in Figure 3.

The Hub – a single referral point

Since February 2011, Sandwell residents and health and social care professionals have had the same access routes to confidence and wellbeing services via the Hub, either online or via a single phone number. They all speak to a wellbeing coordinator who acts as a gateway between services, but more than that, the Hub takes on responsibility for low-intensity referrals, ensuring there is follow up and no-one is left waiting.

When a referral is made to the team, they aim to respond within three days (with Step 2 referrals they respond as soon as possible). Following a phone assessment, the outcome is always to refer them into a service on the same or following day. Louise Perkins, wellbeing coordinator, said: “I came to the Hub from a customer service background. To me the Hub is no different, we have a commitment to respond to referrals and provide the best service we can.”

The service model has a dedicated website and directory (www.confidenceandwellbeing.co.uk), which holds current information of local services and events and links to community activities and is kept updated by the local service user group.

http://www.confidenceandwellbeing.co.uk

http://www.confidenceandwellbeing.co.uk


Figure 3. Conditions management and wellbeing programmes

One-off workshop

Stress and relaxation workshop (group/approximately 1.5 hours)A course to learn some simple techniques to help manage stress and relax including a simple relaxation exercise.

Group programmes

Health improvement programme (group/eight weeks/1.5 hour sessions)A six to eight-week programme designed to help manage stress and anxiety, build confidence and develop communication skills. As well as including tips to help boost your mood and improve sleep, this programme includes a variety of relaxation techniques.

Food and mood programme (group/three weeks/two-hour sessions)A three-week programme designed to help build positive relationships with your food, including food savouring exercises, learning about how foods can help improve your wellbeing, and access to a selection of healthy recipes.

Long-term conditions programme (group/six weeks/1.5 hour sessions)A six-week programme which teaches ways to cope with condition management, including learning ways to manage stress, increase self-confidence, independence and become aware of your emotions.

Chin up (group/eight weeks/two-hour sessions)A fun interactive wellbeing programme for young people (11–18) looking at the core emotions. Targeted at those most likely to offend, seeks to prevent teenage pregnancy.

Internet-based self-help (one to one/requires internet access)An initial face-to-face appointment with a self-help coach to discuss the programme followed by regular telephone support throughout. Suitable if you have mild anxiety or depression.

Positive mental health training (one to one)This programme encourages self-development via the acquisition of life skills through relaxation and visualisation techniques. The programme involves working through a series of CDs.

Breathing space (one to one/six weeks/one-hour sessions)When stressed we tend to overbreathe which can impact us emotionally and physiologically. This is a breathing awareness programme that helps you reduce feelings of stress and anxiety through regulating and harnessing mindful breathing techniques.

Emotional freedom technique (EFT)Known as the tapping technique, EFT is useful for a variety of conditions including emotional stress, trauma, insomnia. Sessions are one to one.

Other group support

Flourish: a self-care programmeDelivered by service users with first-hand experience of the mental health system in Sandwell. A group programme over a few weeks or bite-size chunks, delivered from doctors’ surgeries. It is a self-help support group designed to help people cope with their mental health and recover.

Welfare rights support – benefits adviceIncludes home visits, offering proactive assistance in accessing benefits, assisting with debt issues and financial advice.


For referrals with more complex needs, there are two clinical supervisors on hand to support the wellbeing coordinators to refer clients to the right services. This is important as Sandwell Psychiatric Liaison services (Step 3–4) also refer clients to the confidence and wellbeing services for recovery/additional emotional support (the Flourish programme). The key to the Hub is the use of a single primary care mental health and wellbeing referral form, developed by Sandwell PCT in partnership with the Hub and GPs. It is designed to support GPs and primary care health professionals to know which services are available and identify any risks with their patient. A similar form has also been developed for referral to the secondary care psychiatric liaison service, which has a single point of access.

Therapy services (Step 2–3)

To support slightly more intense needs around emotional wellbeing, Sandwell has a range of low-intensity therapy services, which are also referred to via the Hub. These range from: •Counselling services – for residents suffering

from bereavement, confidence issues, and relationship difficulties (these are also tailored to the needs of BME communities).

•Fit for work – a service to support employed people who are finding it difficult to manage their health condition at work or have long periods of absence. This service provides support to return to work.

•Listening and guidance – chaplains for wellbeing offer a one-to-one listening service for stress and bereavement.

•Trauma/post-traumatic stress disorder – a service that can work with post-traumatic stress disorder, trauma, emotional distress and depression.

•Cognitive behavioural therapy (CBT) or talking therapies (improving access to psychological therapies) – providing psychological wellbeing practitioners (PWP) and high-intensity therapists, offering CBT for mild to moderate anxiety and depression, in online and face-to-face format.

•An esteem team for complex needs and maternal mental health (MMH) – these are gateway and link workers who can undertake home visits, assess clients in primary care and pre/post-natal women with complex needs, ensuring clients look after their mental and physical health.

Access to talking therapies is co-located and integrated in Sandwell, with the flexibility to respond to individual needs. For example, the PCT commissioned the improving access to psychological therapies (IAPT) service from Sandwell Mind, a well-connected voluntary and community sector provider and Black Country Partnership Foundation Trust. This was to reach whole populations that were not presenting themselves at GP surgeries.

The service has recruited a team of full-time low-intensity and high-intensity psychological wellbeing practitioners (PWP) who cover the six towns in the borough. Sue Vincent, IAPT manager at Sandwell Mind, said: “As a non-NHS provider, we have much broader reach and can see clients in different venues in the community. We are also trusted. This means our PWPs are more person-centred, we have face-to-face listening sessions and can make links to wellbeing services more generally through our networks.”

Sandwell Mind is also well connected to the Hub and has been receiving referrals since February 2012. Sue Vincent said: “Referrals are increasing slowly. What is reassuring is that they come to us from GPs and Step 3 services such as the psychiatric liaison services. What is important is that we can refer too; the voluntary sector referring to the statutory sector, it feels positive and joined up.”


The esteem team

The esteem team is another distinctive service that targets more complex needs, such as those residents in Sandwell with medically unexplained symptoms, have diagnosed mental illness but do not attend GP practices for their physical health/medication, and those with maternal mental health problems. As such, the team has been recruited to be able to undertake home visits, accompany clients to medical appointments and have the ability to bypass GP receptions if needed. They are also culturally diverse to reflect Sandwell’s diverse population. Dr Pauline Naughton, GP and clinical lead, explained that: “The esteem team fulfil a vital role, they fill the gaps in primary care, they befriend and build trust with their clients, they also have a duty to ensure physical health is addressed alongside mental health.”

Psychotherapy and chaplains for wellbeing services

In a similar way, the Sandwell model for mental health and wellbeing includes therapies that can be delivered at primary care venues such as walk-in centres and GP practices. A good example is the psychotherapy service, developed to respond to residents with cases of post-traumatic stress or psychological trauma, which can receive direct referrals or those via the Hub. The psychotherapists are supported by GPs and are capable of delivering therapies from Step 2 to 3 through a primary care setting.

Another example is the chaplains for wellbeing service, which is available at selected GP practices/drop-in centres in Sandwell. It serves patients, carers and health service staff who present emotional issues and who would benefit from simply talking to an understanding person. Chaplains for wellbeing address the spiritual and/or religious needs which influence health, in order to:

•encourage faith and hope

•restore significance and worth

•develop a sense of belonging

•provide support

•promote healthy life choices.

Fiona Collins, chaplain for wellbeing, explained: “My role is to listen, offer spiritual support if they want it and help the emotional side of a person to be released. I support individuals to understand that the resources within them are sufficient for recovery.”

Collaborative/shared care (Step 3–4)

At Step 3, the collaborative model demonstrates close multi-agency working to support individuals with mental health needs as a result of a physical

How does it feel to work in an integrated way?

Sandwell’s approach to collaborative care is not only beneficial to patients, it also empowers and develops staff in their roles. Key to this is working in a joined-up and integrated way.

“ It feels liberating to work this way, to feel part of something that is so good, compared to the old system. We feel like there is more choice for patients and carers, and referrals are so much smoother. It feels so much quicker and more helpful.” (Louise Perkins, wellbeing coordinator)

“ Coming from the voluntary sector, it really is a good way to work, very collaborative, it feels like one organisation. We all want the same thing, to improve the mental health and wellbeing of Sandwell.” (Sue Vincent, IAPT manager, Sandwell MIND)


condition and/or complex social difficulty. These include people who have dementia, drug and alcohol addiction, those within the criminal justice system, and the homeless.

This step supports both the individuals and their families. The Sandwell mental health and wellbeing model works with existing agencies to join up care, working with their care arrangements to ensure patients have access to not only confidence and wellbeing services and therapies, but also services that meet their wider needs such as housing, benefits advice and employment support.

The workforce consists of gateway and link workers who stay with people until they have their needs met or are signposted accordingly through primary care. For example, staff recently worked with two patients who were frequent attendees in A&E. Both patients were ex-offenders, on probation and had drink and drug addiction. By supporting probation services with the health and wellbeing offer, which included family therapy, addiction services and appropriate accommodation, both patients are on the road to recovery, registered with a GP and are no longer attending medical services.

Governance to support improvement

The collaborative care model in Sandwell also upholds strong values around co-production and continuous improvement. Dr Ian Walton, Sandwell PCT PEC chair and lead on mental health, explained: “The model is also representative of a set of values; these are pragmatism, always asking what works best, listening to others such as patients, professionals, clinicians and feedback, and always seeking to improve what we have established.”

The approach has two governance arrangements to support meaningful clinical and service user involvement.

1. The primary care mental health clinical steering group, formed in 2007, was set up to lead the development and implementation of the model and make recommendations to the PCT board. It had representation from a variety of clinicians and local authority stakeholders with various interests; public health, dementia, primary care (GPs), drug and alcohol services, pharmacy, adult mental health and child and adolescent mental health. This group is critical for engaging GPs within the collaborative care model.

Rita Gupta, mental health project development manager, explained that “the group plays a key role in steering the development of Sandwell mental health and wellbeing services, ensuring the referral processes are working and talking to their peers about the services. The relationship we have with the GPs is co-productive, they know we are filling a huge gap in services.”

2. Unique People was set up by a group of mental health service users to ensure commissioners responded to the concerns of those who had been through the mental health system. Unique People sits within the resources of the PCT service user network but is a voluntary group with 12 core members, who hold specialist knowledge about services and provide support and expertise to wider service users. They are involved in educating GPs about service user perspectives, lobby for patient rights locally, have access to PCT (and so CCG) governance structures and have co-produced a self-help support group programme called Flourish. Debbie Elwell, a former member of the network, said: “We believe no-one should have to fight the system to get well. We are here to support and advise, and we are now very well known as a point of contact. In fact a lot of the people in Sandwell think Unique People is human, honest and..... best of all, ‘bostin’ (good).”


Learning points for implementation The Sandwell primary care approach to mental health and wellbeing has shown some promising early outcomes. According to Dr Ian Walton, “since the mental health and wellbeing services started in Sandwell, over 4,000 people have completed prevention, wellbeing and health improvement programmes. For commissioners, this equates to a saving of around £800,000 in prevention costs. In addition, over 3,000 people have accessed talking therapies, which using the same formulae, suggests a saving of around £600,000.”

In terms of outcomes, initial results show reductions in lengths of stay and hospital episodes alongside clinical improvements and a rise in wellbeing. Sandwell is currently having further outcomes evaluated as part of a study on integrated care for complex needs being undertaken by the King’s Fund.

For new commissioners wishing to adopt a similar approach in their localities, there are some important learning points to consider from the Sandwell example.

The influence of primary care in relation to secondary care in mental health is still to be addressed

While the team have made considerable progress on primary care-led provision and referral, there is more work to be done to ensure a consistent primary and secondary care interface. In particular, this concerns aligning the care models in secondary care (psychiatry) with the holistic primary care model, to ensure both approaches lead to smooth referrals and are patient-centred.

The importance of consistent education and training

The Sandwell model trains and educates staff that provide services, service users and the primary care workforce to work in a bio-psychosocial manner. Commissioners responded to specific skills needs among the workforce in order to ensure smarter referrals and increased motivation.

For example, two academic courses were developed with local universities, Royal College of General Practitioners and primhe (Primary Care Mental Health and Education). The first was an advanced diploma to meet the needs of GPs, the second was a certificate in primary care mental health and wellbeing for the primary care workforce, which included nurses, therapists, independent domestic violence advisers and link workers. Around 20 per cent of the GPs that attended the diploma course increased their confidence and decreased referrals by up to 50 per cent from these GPs into secondary care.

‘Commissioners responded to specific skills needs among the workforce in order to ensure smarter referrals and increased motivation.’


Securing clinical and service user engagement

The example illustrates through its set-up phase (listening events) and governances structures that clinical and patient involvement are essential for a collaborative care model to work. This is to ensure legitimacy for service approaches and to support quality implementation.

Creating an environment that makes change possible

The Sandwell wellbeing team is an example of the importance of having champions on the ground who make new models of care possible. Many staff, clinical leads and service users from the Sandwell example, highlighted the importance of having a team that support creative thinking, listen and act on feedback.

Robust evidence and data collection

The Sandwell approach started with little or no evidence base to support their commission of low-intensity services. To build the evidence base, they have been collecting individual outcome data and analysing it. The interpretation of this data will be vital for the sustainability of the approach in the new commissioning system.

‘Clinical and patient involvement are essential for a collaborative model to work.’

A note on transitional arrangements

The integrated model remains a priority as the PCT cluster is in transition to new commissioning arrangements. The existing relationships with GP clinical leads has meant that Sandwell and West Birmingham Clinical Commissioning Group is working with Sandwell’s primary care mental health and wellbeing lead to develop the model in the new system, and is supporting the development of new pathways with links to acute services, the first of which is cancer.

Under new commissioning arrangements, the Sandwell example highlights the need to respond to strong evidence of local health inequalities. At a local level, CCGs along with health and wellbeing boards may wish to utilise the evidence within joint strategic needs assessments to drive a primary care-led approach to mental health and wellbeing services. At a national level, the NHS Commissioning Board and Public Health England will need to work together to enable this type of local innovation and priority setting.

For more information about the Sandwell collaborative primary care model, please contact Lisa Hill, primary care mental health and wellbeing lead, Sandwell and West Birmingham Clinical Commissioning Group, at [email protected]

For more information on the issues covered in this report, contact [email protected]


The NHS Confederation supports the view that the social and economic determinants of health, such as employment, housing, education and environment, as well as lifestyle, play a key part in influencing health and wellbeing. Poor socio-economic circumstances can affect health and wellbeing throughout life, producing health inequalities.

Sandwell’s primary care approach to mental health and wellbeing is a direct and practical response to stark health inequalities within its locality – challenges that many health service commissioners across England face. The case study shows that collaborative and co-located services for mental health and wellbeing can ensure organised referrals, allowing clinicians to spend more time delivering high-quality preventative, clinical and specialist care. This is about restructuring services to a primary care-led model based on need and the adoption of an integrated, holistic lifestyle and person-centred approach.

Conclusion




Acknowledgements

We would like to give special thanks to the team we interviewed at Sandwell:

•Lisa Hill – Primary Care Mental Health and Wellbeing Lead – Sandwell and West Birmingham Clinical Commissioning Group

•Terri Rutter – Self-Help Coach, Confidence and Wellbeing Team, Health for Living

•Dr Ian Walton – GP, Mental Health Lead, Sandwell and West Birmingham Clinical Commissioning Group

•Debbie Elwell and members of Unique People – Service User Network

•Sasha Gelpi - Mental Health Promotion Lead – Sandwell and West Birmingham Clinical Commissioning Group

•Louise Perkins – Wellbeing Coordinator

•Sue Vincent – IAPT Manager Sandwell MIND

•Rita Gupta – Mental Health Project Development Manager – Sandwell and West Birmingham Clinical Commissioning Group

•Dr Pauline Naughton – GP and Clinical Lead for Esteem Team

•Primary Care Mental Health GP Steering Group – Sandwell and West Birmingham Clinical Commissioning Group

•Malcolm Hanson – Psychotherapist

•Fiona Collins – Wellbeing Chaplain

•Report author – Julie Das, Policy Manager (Commissioning), NHS Confederation


References

1. NHS Confederation (2011) Public mental health and wellbeing – the local perspective.

2. Huppert, F.A and Whittington. J.E (2003) ‘Evidence for the independence of positive and negative wellbeing: implications for quality of life assessment’ in British Journal of Psychology, 8, 107–122.

3. New Economics Foundation (2011) Five ways to wellbeing: new applications, new ways of thinking.

4. Friedli L (2009) Mental health resilience and inequalities. WHO Europe.

5. Sandwell Trends website (2010): www.sandwelltrends.info

6. Sandwell health profile (2011) Network of Public Health Observatories.

7. Clinical Outcomes Routine Evaluation Information Management System.

Further information

Mental Health Network (2012) Defining mental health services: promoting effective commissioning and supporting QIPP.

Mental Health Network (2012) Mental health and homelessness: planning and delivering mental health services for homeless people. Mental Health Network (2012) No health without mental health: implementation framework.

Mental Health Network (2011) Developing an outcomes-based approach in mental health.

Mental Health Network (2011) Housing and mental health.

Mental Health Network (2011) Key facts and trends in mental health.

Mental Health Network (2011) Investing in emotional and psychological wellbeing for patients with long-term conditions.

Mental Health Network (2011) No health without mental health: the new strategy for mental health in England.

New Economics Foundation (2011) Five ways to wellbeing.

NHS Confederation (2011) Public mental health and well-being – the local perspective.

Mental Health Network (2008) Delivering race equality in mental health.

http://www.sandwelltrends.info

The importance of mental health and wellbeing cannot be understated. It affects and influences the lives of individuals, families, communities and societies. There is growing evidence that positive mental health and wellbeing at a population level can reduce health inequalities and improve wider outcomes in relation to physical health, social cohesion and economic productivity.

This report presents a detailed case study of the journey that health service commissioners, located in Sandwell in the West Midlands, went through

to respond to a number of important health inequalities within its local population. It focuses on how its health service commissioners responded to specific health inequalities to develop a primary care-led approach to improving mental and physical wellbeing. The specific health inequalities the trust sought to address included poor levels of mental and physical health, social deprivation, poor access to low-intensity community mental health and wellbeing services, and heavy use of secondary care mental health services.


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