The Primary Care Wellbeing service is provided by Bradford District Care Foundation Trust (BDCFT) and has been developed in collaboration with GPs to support them with some of their most complex and vulnerable patients who have comorbid physical and mental health problems and often appear amongst the top 200 patients on the risk stratification tool due to their high use of primary and secondary care services.
What We Did
The Primary Care Wellbeing service is provided by Bradford District Care Foundation Trust (BDCFT) and has been developed in collaboration with GPs to support them with some of their most complex and vulnerable patients who have comorbid physical and mental health problems and often appear amongst the top 200 patients on the risk stratification tool due to their high use of primary and secondary care services. These patients tend to have a number of psychosocial difficulties linked to childhood abuse and socioeconomic deprivation in addition to struggling with long term conditions (LTC) and medically unexplained symptoms (MUS). The PCWBS serves a two pronged approach by supporting GPs directly through training, consultation and case formulation and by seeing patients directly for intensive MDT support.
The Primary Care Wellbeing Team takes a multi-disciplinary approach to working with people and their families. It is psychology led and driven by the team’s psychological formulation. In addition to clinical psychology, the team is supported by Physiotherapy, Occupational Therapy, Advanced Nurse Practitioner, Dietetics, CBT and EMDR therapy and support workers.
The service has made a significant difference both to the patient and to the practices concerned. We have undertaken regular reviews with service users and these are some of the comments from service users:
Been a good experience and I know that they are there to help me anytime. I have had many times that I have felt ending life, but wellbeing have been there to support me and encourage me to “Kick ass”. They talk to me, understand me, visit me in hospital. I feel they help me and listen to me. They don’t give me bullshit and are honest. They care for me….. They try to find me things to do to help me get out. I couldn’t leave the house with my anxiety and pain due to my tube, and I always said no whenever charlotte and Monika tried to take me out. Slowly, slowly, they kept coming and eventually got me out and helped me to be able to go out to a coffee shop and have a coffee like other people. I feel like I can do it now without having a panic attack
The team have found out that I’m an avoider and I laugh all the time, but they know I’m not going through a good time and have recognised that it’s my way of coping. They have helped me to identify that I avoid and I can’t cope with some things because it’s too painful for me to cope with. I worry that the wellbeing team will tell me soon that I’m doing well and they might kick me off. I feel that I need them.
This service is a team of people that I can talk to. I still don’t talk about some things because they’re too difficult, but it’s helping me to motivate myself to get through life. They’re helped to get me out, such as going to the library, doing job searches and doing things I would never have done before.
My overall experience has been pretty good. It’s more understanding and empathic than other services.
I feel this service is a more person-centred service and they’re there for me. I feel this service is not making me run and jump before I can crawl. They understand all the different parts of me, and I might be doing ok in some things, but not in all things……. I would say it’s a non-judgment service, they accept you for who you are. I am learning to be more comfortable, talking, and seeing different people. They have helped me to build my confidence and they have helped me to see that I am a person and I am worth something.
What do you think service users can bring to services generally? What can you do to help them be better?
Sometimes I can help by telling them how I feel and how my stoma works and my tube works. I tell the wellbeing girls about how the tube works and they learn from me about it. I tell them about how my bag works……
I can bring constructive criticism. I have lived experience, I know what can work and what won’t work when you’re feeling the way I do. For example, when someone doesn’t have motivation, some things won’t work and I’m able to tell the service that. The team recognise that there is no quick fix and I recognise that. Each individual has their own goals and the team recognise this and that’s something I say all the time. I feel exhausted often and as a service user, I need to have that trust. A lot of people come for a variety of reasons; people have lost trust and have been told things like, pull yourself together. They don’t understand what I’ve been through. The service understand this and support me. You can be empathic, without being in a quiet mode/vocal tone. I am able to give feedback to the team about what I prefer and what I don’t prefer.
We have also developed staff satisfaction measures which enable us to be as flexible with staff resource as possible and respond to any needs that arise. Any information we receive is then used to inform further service development. A recent quote from member of staff highlights that the service “identifies some of the most vulnerable people in society and focusses on improving their quality of life whilst reducing costs to the NHS. The Primary Care Wellbeing Team works creatively and flexibly whilst working with those from all walks of life”
In terms of benefits to the practices, GPs have been able to refer the patients that they feel require this different approach to care. The practices have identified a reduction in GP appointments and hospitalisation from the identified client group. Practices are able to draw on the expertise of the whole team and have seen improvements in physical and mental health, in addition to reductions in costly medical or surgical interventions.
Wider Active Support
The service is commissioned by Bradford Districts, Bradford City and Airedale, Wharfedale and Craven Clinical Commissioning Groups. The funding for the team was significantly increased and made recurrent in April 2017. The team works in an integrative way with four GP practices across Bradford and Airedale and works collaboratively with voluntary sector organisations including AGE UK and local agencies such as Healthy Lifestyles. The PCWB service provides liaison between primary care, mental health, voluntary sector and social care and supports patients throughout their physical and psychological journey. The team have developed robust links with the acute care setting which has resulted in positive outcomes for patients
This service is recognised in the Bradford Mental Health and Wellbeing Strategy as a core development and is subject to regular review from commissioners.
The service works actively with patients at all levels of care. We value the contribution that service users are making and proactively seek to make changes in the light of feedback. For example, service users with a history of chronic pain identified the need to be able to work with and support other users with similar problems. Chronic pain groups have developed which are lead and driven by service users and supported by the GPs and PCWB team members. We are developing a scheme to employ ‘expert patients by experience’. We have identified volunteers and working with them to create support packages for service users. Service users were involved in the development of outcome measures and after discussion and agreement, were signed off by them. Service users co-present with members of the team at conferences and teaching sessions.
We continue proactively to seek patients’ opinions of the service with a view to further developing the service to meet their needs.
Looking Back/Challenges Faced
There are a number of things which have caused some difficulty to the team during its development. The recruitment process is a lengthy and highly structured to suit the needs of the BDCFT. With the support of BDCFT we have been able to be creative in recruiting staff in different ways, for example, establishing Service Level Agreements with other Trusts to recruit people on secondment, internal secondments, fixed term appointments, we have been able to use the staff bank flexibly which allows the service to ‘try out’ roles to ensure they are appropriate for the needs of service users. BDCFT also supports employing patients by experience which enables users to provide valuable insights and support for other users.
The team faced challenges in developing necessary links with local community organisations required for their rehabilitation, we have been able to forge robust links with local voluntary sector groups and organisations and are now able to provide support for service users. The use of the ‘patients by experience’ approach has improved engagement significantly and in some cases we have seen behaviour changes.
A particular challenge was developing links and liaison with other care providers involved with clients, eg surgeons. The team identified this issue at an early stage as being crucial to the patients’ recovery journey. The team have been able to forge links with other providers and attend appointments with service users. This joint approach to care has resulted in some cases for example of by-passing scheduled surgical intervention and agreeing an alternative approach to recovery.
In April 2017, commissioners confirmed continued funding on a permanent basis. Additional funding was secured to build team capacity and expand the service to other practices. We are creating capacity in the team and embedding the service firmly into the BDCFTstructure. We also have agreements in place with other BDCFT services as part of the pathway, for example, fast track to psychological therapies. Service Users have access to other BDCFT support services, such as First Response in case of emergency.
We are also developing a programmatic research pathway within the service to include auditing, surveys, service evaluation and PROMS. We are aiming for this to eventually lead to the opportunity of conducting RCT’s to collect gold standard evidence of our approach including training packages for GPs and targeted courses and manuals for patients which will be replicable. We are currently in talks with leading professionals in their field who will serve as our academic partners.
Evaluation (Peer or Academic)
Professor Alan House (Leeds University) provided an advisory role in the evaluation that was undertaken after the first year of the service. This was commissioned and delivered by Clinical Support Unit in Bradford. The evaluation framework was derived from two main sources: The Framework for Routine Outcomes Measurement in Liaison Psychiatry (FROM-LP) developed by the RCPsych Liaison Psychiatry Executive; and Professor Allan House’s advice, University of Leeds and Chief Investigator for the NIHR funded project Liaison Psychiatry: Measurement and Evaluation of Service Types, Referral Patterns and Outcomes (LP-MAESTRO. The evaluation reported measurable costs changes. It predicted longer term savings around patient care and demonstrated specific examples. For example, the intervention of a support package of the team halted an expensive ‘out of district’ Learning Disability placement at a potential saving of £18k per week
By providing patients with integrated care the team have been able to provide a shared bio psycho-social occupational formulation between the patient, GPs, and other health professional involved in care. This has provided a more effective understanding of the issues and also treatment plan. For example working with somebody with undiagnosed autism and borderline LD, enabling GPs and police and the Criminal Justice System to ensure that there is a clear understanding of behaviour and safeguarding issues meant that the most effective service was put in place which resulted in the individual not receiving a custodial sentence.
Staff are able to work more holistically, and not being constrained by organisational frameworks, have been able to provide the most appropriate interventions. This is more fulfilling for staff and achieves successful outcomes for service users.
Some Early findings:
• Identified at risk patients offered range of evidence based therapies in a non-stigmatising programme based in primary care.
• Focus on wellbeing, with success defined in terms of meeting a person’s self-defined emotional and social needs as well as in terms of clinical symptoms and definitions.
• Early indicators suggest potentially large savings, albeit for small number of patients, but will consider what this could look like at scale
• Clear evidence of reduce primary care, A+E, prescriptions, admissions and operations that have been cancelled after discussion with the team and the surgeon.
The service has developed a protocol which can be shared nationally to replicate the model. Members of the team have presented at national and local conferences and there has been significant interest in the service. GPs in Airedale are replicating the pain service set up by PCWB to roll out to the rest of Airedale using their Enhanced Primary Care funding programmes.
The team is committed to sharing this model of working and is regularly asked to share the learning.
Is there any other information you would like to add?
This is a new approach to providing care in collaboration with GPs using an innovative approach led by psychological formulation. The service provides treatment and care for those vulnerable groups that are difficult to reach or for whom the usual routes of care has been exhausted. It works on a multi-agency basis with General practice, Voluntary sector, social care and acute setting colleagues. A key success of the service so far has been is partnership with service users who actively participate as expert patients and contribute to service development.
The service has demonstrated significant cost savings to the health system by avoiding for example costly surgery.
The service has improved access for patients, providing the service in a setting of their choice. The service facilitates access to other services where required and enables patients to be proactive in this. As demonstrated above, patient experience and outcomes have improved through the development of patient-led groups, eg chronic pain. Staff report increased satisfaction through working within this team. They are able to realise alternative ways of working and can see some measured success with patients.