BOROUGH OF POOLE
COMMUNITY SUPPORT OVERVIEW GROUP
22RD NOVEMBER 2005
POOLE PRIMARY MENTAL HEALTH SERVICES
1. PURPOSE AND POLICY CONTEXT
1.1 The purpose of this report is to inform members of the developments in primary
mental health services, in line with NICE (National Institute of Clinical Excellence) guidelines and the Mental Health NSF (National Service Framework). The redevelopment is also a priority of the Poole Mental health Local Implementation Team. The completion of a successful pilot would lead to the development of a long term primary mental health strategy.
2. RECOMMENDATIONS
2.1 Members are asked to note the contents of this report
3. BACKGROUND INFORMATION
3.1 In a general-practice surgery, every third or fourth patient seen has some form of mental disorder. Levels of mental health problems among primary care patients with such disorders are high; greater on average than disability among primary care patients with common chronic diseases such as hypertension, diabetes, arthritis and back pain.
3.2 Simple effective treatments are available for many mental disorders.
3.3 Changes in the way services are provided also emphasize the importance of primary care as a setting for mental health and social care. Over the past 30 years, the number of hospital beds available for people with mental illness has fallen, while the number of GPs and psychiatrists has risen. A direct result is that people in primary care need to work more closely with those in mental health services. Good care is a collaborative effort. The Primary Care Service includes practice nurses, district nurses, health visitors, counsellors, clinical psychologists and school nurses, as well as GPs, all of whom may have a role in mental healthcare. The Community Mental Health Team may include nurses, occupational therapists, clinical psychologists, social workers and support workers, as well as psychiatrists.
3.4 Families and friends, self-help and community groups also provide crucial support to people with a whole range of mental disorders: from transient distress to enduring psychotic illness. All these services need to talk to one another, respect each other's contribution and jointly agree who will provide which service to whom.
3.5 Over the last year several investments in Primary Mental Health Care services have already been achieved. These include the employment of two graduate workers who have in turn developed the self help pathway and are in charge of the Poole Book Prescription scheme as well as delivering “Beating the Blues” (A computer based Cognitive Behavioural therapy course). We have also employed a nurse into the Primary Mental Health Support Team, who will be responsible for liaising with health and social care staff regarding medications and nursing interventions. A new directory is now available to local health and social care staff detailing all the available services.
4. CURRENT LOCAL PROVISION
4.1 In Poole the two main providers of primary mental health are The Psychology and Counselling Service and The Primary mental health support team. (Poole PCT also employ four private counsellors in GP surgeries)
4.2 The Psychology and Counselling service recently (April 2005) moved to a locality based service. This had been agreed at board level within the PCT in the previous year. Poole residents are referred through GP’s and then screened for assessment. Psychologists and counsellors then provide interventions at a variety of practice based locations and at The Chines, Herbert day Hospital. This includes mainly one to one work. Development of group work and specialist intervention is ongoing.
4.3 Poole Primary Mental Heath Support Team receives referrals from a wide variety of sources including self referral. They provide one to one interventions, domiciliary visits, deliberate self harm service and various groups. The Poole Primary Mental Heath Support Team also houses the Poole PCT employed Graduate workers who provide self help.
5. WORK TO DATE
5.1 Dorset Health Care Trust (DHCT) have in the last year put a large amount of resource into reducing wait times for people needing a psychology service. They have successfully achieved a consistent wait time of below 9 weeks in line with the target.
5.2 The Borough of Poole, Primary Mental Health Support Team (PMHST) and Poole Primary Care Trust (PPCT) in February 2005, undertook a project to reduce counselling wait times and examine the referral pathway for those needing counselling. A summary of this project is in Appendix 1.
5.3 Poole PCT has been working closely with the private providers of counselling in Poole to engage them in a modernisation process.
5.4 A service improvement team including GP’s, health visitor, practice manager, pharmacist , service users, carers and representatives from secondary mental health services was convened in April 2005 in order to examine the current local provision.
5.5 Since the latter part of 2004, the Psychology and Counselling service provided by DHCT, the PMHST and PPCT have been examining the services provided to people presenting with common mental health problems in Poole. This has resulted in a several meetings between the teams. The main aim of these meetings was to develop a streamlined service that worked effectively and efficiently in Poole.
5.6 There is a recognition that at present demand outweighs capacity and therefore pooled resources and partnership working would enable better outcomes for service users. This culminated in a recent development day facilitated externally where a pilot project was discussed and working parties formed to progress this work. An action plan has been developed that will be thought through within the working parties. The memberships of these working parties are multi-disciplinary and have service user representation.
6. THE PILOT
6.1 This Pilot is a single point of access for service users to a “gateway” that then signposts to the appropriate service through screening and assessment. The pilot will adopt a model of care that introduces different interventions dependent on the severity of need called the Stepped Care Model and with both teams in Poole working together provide a more comprehensive treatment package for service users.
6.2 Staffing consists of Psychologists, counsellors, social workers, social work assistants, a mental health nurse and primary mental health graduate workers. The skills throughout the teams are varied and include, (not exhaustively) Cognitive Behavioural Therapy and Brief Intervention Therapy
6.3 Service users may be assessed as needing more than one service and treatment plans will reflect this. Joint planning and treatment will enable comprehensive care packages for service users. Regular case review within a multi-disciplinary setting also allows for consultation and professional development.
6.4 Various treatment options are on offer within the joint team approach. These include intensive psychological therapies, both one to one and group work; psychoeducational groups and workshops, brief interventions and self help.
6.5 Self help materials will be accessible directly (access through the gateway not needed) by service users through the Cardiff book prescription scheme and Computer Cognitive Behavioural Therapy. (Beating the Blues) Primary mental health graduate workers will provide guided self help and mental health promotion in primary care.
7. EXPECTED OUTCOMES
7.1 Equity of access for services users requiring primary mental health services.
7.2 Better choice of treatments for service users.
7.3 Reduced waiting times for assessment.
7.4 Appropriate signposting – clearer referral pathways.
7.5 More efficient use of resources.
7.6 Recommendations for further development of primary mental health services.
8. EVALUATION
8.1 Evaluation will be undertaken by members of staff overseen and aided by the Poole Hospital Research and Development department headed by Professor Roger Baker.
8.2 The outcomes will be measured using data collected and a series of questionnaires designed from previously validated surveys. (See Appendix 2)
8.3 Evaluation will take place over a period of eighteen months, with interim reports available.
9. CONCLUSION
9.1 It has to be acknowledged that currently demand for primary mental health services outweighs the capacity available in Poole. As a result it is necessary to reconfigure current services to provide a more efficient use of resources.
9.2 The main aim is to provide equity and faster access to Primary mental health care, a better choice of treatment for Poole residents and to implement national guidelines.
9.3 Through partnership working, a joint assessment team with expertise in signposting will operate in the Poole area. Using a stepped care model utilising best practice within service provision, the service user can look forward to a variety of choice in treatment modalities. Primary Care practitioners will be able to clearly refer using the gateway and have assistance in referral to self help with the aid of primary care graduate workers.
9.4 The service will be run in locality settings coterminous with the Poole Community Mental Health Teams.
9.5 Consultation has taken place through the PCT, DHCT and Local Authority process as well as eliciting the views of Users and Carers through the Primary Care Service Improvement Group. Primary care mental health service users sit on the working parties used to develop the detail of the pilot.
JOHN DERMODY
Head of Adult Social Services Commissioning
01202 261132
Contact Officer: JOANNE LABROW
Development Manager
Mental Health/ Substance Misuse
Adult Social Services commissioning & Poole Primary Care Trust
01202 633385
10 November 2005
Appendix 1:
Poole Primary Care Trust/Borough of Poole Counselling Assessment Project
14th – 25th February 2005
Introduction
The aims of this project were to:
Reduce the counselling waiting list.
Compare referral reason with presenting problem
Gain an insight into the variety of problems presenting to primary care mental health services within the Poole area.
Method
Contact was made by an initial letter to all the individuals currently on the waiting list asking them to call the office to arrange an assessment with the team. After contacting the office, an appointment was made at a location closest to their GP. Individuals who opted out at this point were then taken off the waiting list.
The assessments were carried out by Social workers within the Primary Mental health Support Team, using an assessment tool that had been specifically formulated for this project.
Each individual assessment lasted 45-60 minutes; the assessment covered a multitude of areas including looking at past history, current problems and symptoms. A joint decision was made between the individual and the social worker to determine the most appropriate service to meet the individual needs, from the categories below.
Prior to the assessments the services available had been categorised as follows;
Remain on counselling list
Psychology
1:1 work through Primary Mental Health Support Team
Group work Primary Mental Health Support Team
Supported Self Help, Primary Mental Health Support Team
Signposting
Relate
We have time to listen
Redlands
Cruise
And others where appropriate
Information giving/no service required
After all assessments a referral was immediately made by the social worker if necessary.
On completion of the project a letter was sent back to the GP’s informing them of who was to be removed from the counselling waiting list and which alternative services they had been referred to.
Results
The primary list for counselling consisted of 152 people, after letters had been sent 75 people opted in. Following 8 “Did Not Attends” during the project, 67 were assessed.
Of the 67 assessed 12 individuals remained on the counselling list, this was 7% of the initial 152 individuals.
The waiting time from the initial referral for counselling by the GP to the point of our assessment varied across different localities. The shortest was 7.5 weeks and the longest was 42.71 weeks. The overall average waits 18.58 weeks.
The range of presenting problems seen in the project includes;
Life event problems (relationship/bereavement/loss/employment/financial)
Anxiety/Panic
Depression including Post Natal Depression
Post Traumatic Stress Disorder
Self Harm
Physical/Sexual abuse
Substance misuse
33% of the individuals seen, presented with different problems than were originally stated in the GP referral.
Of the individuals removed from the counselling list;
22% Supported Self Help
19% Signposted
19% Group work
9% 1:1 work
7% Psychology
6% Information giving/ No service
Conclusions
Looking at the above results it was apparent that alternative services were suitable for many of the individuals that had been originally referred for counselling.
It was also apparent that the referral problem and the presenting problem at the time of assessment were different in a number of cases.
Through signposting to alternative services, we were able to significantly reduce the waiting times for counselling in primary care.
Through this process we were able to eliminate inappropriate referrals to ensure that the counsellors would see individuals that were most suited to their service.
Scripted by Lydia Smith and Louise Naylor (Graduate Primary Mental Health Workers – Poole)
APPENDIX 2
EVALUATION OF PRIMARY MENTAL HEALTH PILOT
The data collected will include:
Signposting:
· What numbers of people are referred to the Primary Care Mental Health Service?
· What percentage can be signposted on the basis of the information in the referral letter and to which service?
· What percentage of people opt-in?
· What services were people signposted to?
· What percentage were clinician led signposting [a referral to the service was made] vs. Client led [self referral required]
· What percentages of people engage with the service that they were directed to? [Compare Referrals made vs. self referral]
Assessment:
· How many people fail to attend [DNA] their assessment session and are discharged?
· Length of time from referral/acceptance of referral to assessment?
· How many people CNC their assessment appointment and request a further appointment?
· What percentages of people were signposted to other services as a result of the assessment?
· What percentage of clients were discharged following assessment and considered either:
o Not in need of a service
o Unlikely to benefit from a service
· What were the treatment recommendations? How many were recommended for multiple treatment interventions?
Treatment:
· How many people do not attend for treatment at all?
· What is the average length of wait for treatment?
· What percentages of people go on to have a second course of treatment?
· Length of treatment? How many people are seen within: