Primary Care Wellbeing Service – Bradford District Care Foundation Trust – HC – #MHAwards19

The PCWBS is unique in supporting GPs with their most complex and vulnerable patients who are frequent attenders at primary, secondary and emergency services, who often appear amongst the top 20 patients on the risk stratification tool, where a psychological component is confounding their help seeking behaviour or symptoms/condition. Contact with the team has been shown to reduce primary, secondary & emergency care usage amongst frequent attenders, reduce medication whilst improving quality of life. This supports GPs in delivering evidence based and evidence generated practice and reduces the demands and pressures on their time to manage unnecessary ‘crises’.

Highly Commended - #MHAwards18 and #MHAwards19


  • From start: No
  • During process: Yes
  • In evaluation: Yes


  • Peer: No
  • Academic: Yes
  • PP Collaborative: Yes

Find out more

Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.

Over 4 ½ million people in England have co-morbid mental and physical health conditions, and 70% of NHS expenditure is spent on people with Long Term Health conditions. A significant proportion of patients with long term conditions and persistent physical symptoms become frequent users of services in both primary and secondary care. Many of these people fall through gaps in service provision as they have a range of comorbidities, do not respond to first line treatments and are passed from one service to another. The PCWBS is an MDT including clinical psychologists, occupational therapy, physiotherapy, dietetics, counselling and personal support navigation (Voluntary Sector Organisation). The focus of the team is to work collaboratively with GPs, patients and the wider health care system to reduce unnecessary interventions, medications etc and improve quality of life for service users. The service holds patients and GP goals central to its care. Patients benefit from a range of evidence-based interventions with a patient-centered, flexible approach. A collaborative biopsychosocial formulation enables a shared understanding of all presenting physical and psychological issues, informs current and future needs and treatment plans. It is individualised and shared ensuring that goals are productive, valued and meaningful to all.


What makes your service stand out from others? Please provide an example of this.

The PCWBS is unique in supporting GPs with their most complex and vulnerable patients who are frequent attenders at primary, secondary and emergency services, who often appear amongst the top 20 patients on the risk stratification tool, where a psychological component is confounding their help seeking behaviour or symptoms/condition. Contact with the team has been shown to reduce primary, secondary & emergency care usage amongst frequent attenders, reduce medication whilst improving quality of life. This supports GPs in delivering evidence based and evidence generated practice and reduces the demands and pressures on their time to manage unnecessary ‘crises’. The difference in methodology of this service, using the psychological formulation-led continues to provide an alternative route where traditional provision 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 is its attitude to finding new ways to work with patients through partnerships with other agencies is a key enabling factor. The pain program is unique because the team is embedded in primary care and work alongside GPs. They are working with patients with complex physical and psychological difficulties and this takes place in their general practice with their GPs. This provides ‘joined up’ thinking, consultations and interventions. Many training programs happen externally, there is little follow up or evaluation.

The GP training program is being externally evaluated by some 4th year medical students. What also makes this unique is that all the GPs in the practice are attending the training and aware of the alternative approach to medication or re- referral for injections etc. This provides consistency in approach and care for the patients and the psycho-educational group provides additional support for patients based in their general practice. Access to GPs is available, but generally not requested. Noel is one of Patients by Experience and he has had significant back surgery leaving most of spine supported by a metal frame. He has suffered with persistent pain and had taken 45 tablets a day to help manage. He struggled with mobility, mood and had a poor quality of life. Noel is off all his medication and occasionally takes paracetamol, he is back working voluntarily but looking for paid employment. Noel is helping facilitate the patient psycho –educational groups.


How do you ensure an effective, safe, compassionate and sustainable workforce?

The Trust provides a robust framework of training and development and HR programmes to support staff. All members of the team have access to training opportunities and are enabled to carry out their professional development in their own discipline. Whilst the clinicians function as a member of the team, each are involved in their own professional development and supervision programmes provided by the professional leads in the Trust.

The Trust has a variety of support packages and wellbeing initiatives for staff which the team are aware of and encouraged to use where necessary. Bradford District Care NHS Foundation Trust is committed to ensuring that all health and social care staff, registered or non-registered, engage in protected time for clinical supervision. For registered staff with a professional qualification this shall be in accordance with national guidance from their respective regulatory, accreditation or professional organisation. The Trust holds a central database for clinical supervision which is completed by all staff. Supervision in the team is robust and varied. Each member of the team receives regular (weekly/bi-weekly) supervision from their chosen supervisor. Line management supervision is provided to each member of the team by the team manager on a two-weekly or monthly basis. Clinical supervision for the team aims to: • Support them to reflect on and review their practice • Discuss individual cases in depth • Change or modify their practice and identify training and continuing development needs • Develop knowledge and competence and assume responsibility for their own practice • Enhance consumer protection and safety of care in complex situations The team have regular weekly ‘huddles’ which provide a supportive framework for sharing experience, reflecting on difficult cases and agreeing approaches for dealing with issues raised. The huddle has proved to be invaluable for team discussion and team building and developing relationships.


Who is in your team?

Consultant Clinical Psychologist 8c 0.6wte Clinical Psychologist 8a 1.2wte Specialist Dietitian 8c 0.2wte Occupational Therapist 7 0.81wte Physiotherapist 7 1wte Physiotherapy Assistant 3 0.8wte Assistant Psychologist 4 1wte Personal Support Navigator 4 1wte Team Manager 8a 0.5wte Student Interns 3 Volunteer Counsellors 2 Dietetics Postgrad student 1


How do you work with the wider system?

Working in accordance with agreed Standard Operating Procedures, 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. A crucial element and a key success factor of the service is the AGEUK relationship who are able to support patients with grant applications, ESA appeals, PIP appeals, housing applications etc. 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 Pain Program for GPs and patients was established with close collaboration with the team, GPs and patient by experience this has been adapted and presented at local multi-agency events. The team regularly meet with other services/professionals, eg, Care Co-ordinators, Social Workers, Consultant Surgeons, Local Authority personnel to discuss individual cases, to share team developments etc.


Do you use co-production approaches?

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 persistent pain identified the need to be able to work with and support other users with similar problems. The psych-educational 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. We are currently undertaking a service evaluation which involves in-depth discussions with patients to obtain qualitative data on patient experience. The service has developed a Pain focus group at one of the practices and this has been a direct result of patient feedback. This has been a very positive development for the team and has enabled us to explore different ways of working.


Do you share your work with others? If so, please tell us how.

The team work collaboratively with anyone else who is involved in the patients care. This means joint appointments, joint care plans and sharing formulations. The team’s first publication was Dec 2017 (see below). Members of the team have presented the work of the team at local and national events. The two Leeds University student interns represented the service at a national British Psychological Society with a service poster (see attached). The lead psychologists had a paper about the new model of care, accepted at a national BPS event in Cardiff 2018. The team have represented the service at regional networking meetings, eg Mental health in Primary Care Research Conference in Leeds. At the recent NHS Improvement event “70 years of the NHS”, the team held a stall in the market place and represented the service. Working with our GP colleagues, we have presented at a number of local commissioning events to raise awareness of the service and highlight the advantages of this way of working, specifically the cost savings that can be achieved.


We have had interest both from the Centre for Mental Health and following a visit by Graham Duncan who put us in touch with other national sites. We are also currently part of a BPS bid writing a paper on psychology led services in general practice (Lawrence Moulin Lead). Other practices (via GP Home) have heard positively about the pain program and invited us to discuss further whether this is something that they might benefit from. We are also working collaboratively with the Mental and Physical Health Steering Group around our approach and collaborating on a new evidence based pain pathway. We are also working closely with IAPT for MUS/ CF in providing the next level of assessment / treatment for patients who previously would have been sent out of area. DCP Annual Conference 17-18th January 2018: New models of care: Service development and Clinical Psychology leadership in integrated care Dr Suzanne Heywood-Everett, Dr Sari Harenwall NHS BDCT FT New models of care: a liaison psychiatry service for medically unexplained symptoms and frequent attenders in primary care Janine Bestall,1 Najma Siddiqi,2,3 Suzanne Heywood-Everett,1,3 Charlotte Freeman,4 Paul Carder,5,6 Mick James,5,6Brendan Kennedy,5,6 Angela Moulson,5,6 and Allan House1 BJPsch Bull Dec 2017


What outcome measures are collected, how do you use them and how do they demonstrate improvement?

The team uses both CROMS, PROMS and PREMs PROMS USED: Pre assessment and at discharge and repeated at 3 monthly time interviews (this was extended form 2 months) • CORE – 10 Screening Measure (Clinical Outcomes in Routine Evaluation) • AAQ-11 (measure of psychological inflexibility or experiential avoidance) • The Distress Thermometer (describes experienced distress) • EQ-5D-5L (describes perceived overall health) • Client Goal review (measure of improvement at review) • Individual patient goals PREMS USED: Use at 3 monthly intervals with PROMS and service evaluation • Patient satisfaction measure • Regular service evaluations – using semi-structured interviews (external if possible) CROMS USED: • GP goals • GP measure The service is also routinely involved in R&D eg portfolio studies eg ReQol The goals and PROMS are used in routine clinical practice for assessment, engagement and recovery. They are also used for service evaluation and development. The service was initially evaluated by SSU and a paper was provided including cost evaluation (2016) We are currently reviewing and updating our outcome measures to introduce more effective measures, for example, use of TOMs. The revised measures will be implemented by the end of June. *PROMS = patient-reported outcome measures; CROMS = clinician-reported outcome measures; PREMS = patient-reported experience measures


Has your service been evaluated (by peer or academic review)?

The service has made a significant difference both to the patient and to the practices concerned. The practices have identified a reduction in GP appointments and hospitalisation from the identified client group. In September, Dr Foster produced a report after an evaluation of the service. The aim of the evaluation was to assess the effectiveness of the Primary Care Wellbeing Service (PCWBS) Pilot. The PCWBS pilot, commissioned by the Bradford and Airedale, Wharfedale and Craven CCGs, aims to fill the gap around the mental health needs of people with physical health problems. Please see Dr Foster evaluation as attachment. file:///Users/gabby/Documents/DR%20FOSTER%20EVALUATION.pdf



How will you ensure that your service continues to deliver good mental health care?

Funding for the service is now recurring and is part of Bradford District Care Foundation Trust’s Block contract. The number of practices the service works with has increased and there is considerable interest from others. We are able to replicate the service in different practices by adapting our approach to facilitate practice differences. The service has been extended to take out of district Chronic Fatigue Service and works with those more complex patients. Costly out-of-district referrals are no longer required. We also take out of area psychiatric liaison referrals and complex case for assessment and consultation.


What aspects of your service would you share with people who want to learn from you?

We have been able to share our experiences of how the team was set up originally, how we have learned from these experiences and how overtime this has impacted on the changing service. We are continually looking for opportunities to attend events and share our experience, for example BPS conferences (2018/2019) Aspects of the service that we continue to share are: • Clarity and shared understanding of the model • Importance of jointly agreed data collection processes • Recruitment challenges and how we have addressed them • Impact of short term funding • Importance of collaborative working • Challenges in evaluation around cost savings • Commitment to this way of working


How many people do you see?

The service was originally commissioned to support 200 people. We are now taking referrals through the Chronic Fatigue Pathway and Psychiatric Liaison referrals.


How do people access the service?

GPs refer patients into the service. We offer appointments at home, surgery or preferred place wherever is best for the patient. For patients who have difficulties around access, we will meet them with a professional they already know or family member. If patients have difficulty during appointments eg unwell, under influence of alcohol etc, the team member will discuss with them what support they need and facilitate another meeting if necessary. All new referrals are discussed by the team at the weekly meeting and triaged with the most appropriate professionals. Primary issues will influence who is the lead clinician eg if it is mental health issues- it is more likely to be a psychologist that the physio. Assessment is often multi-disciplinary and can last over a few appointments and may involve liaison with other professionals, family members etc


How long do people wait to start receiving care?

The maximum time waiting for a first assessment appointment is 2/3 weeks.



What is your service doing to identify mental health inequalities that exist in your local area?

The service work in inner-city Bradford and Clarendon Practice has a 97% ethnic population.


What inequalities have you identified regarding access to, and receipt and experience of, mental health care?

The service is ageless and works with people across the full spectrum. The service has identified a number of people with learning disability and also neurodevelopmental disorders such as autism. This has meant for the first time people are accessing assessments and interventions appropriate for the needs and understanding. People with complex mental health problems access clinical psychology at the source. The team work collaboratively with a psychological formulation understanding symptoms in relation to childhood trauma etc whilst the patient can engage in the psychological work rather than waiting years on a waiting list and working with a psychologist in isolation


Commissioner and providers

Commissioned by:  Airedale, Wharfedale and Craven Clinical Commissioning Group Bradford City Clinical Commissioning Group Districts Clinical Commissioning Group

Provided by: Bradford District Care Foundation Trust


Population details

Brief description of population (e.g. urban, age, socioeconomic status):

The population of Bradford is ethnically diverse. The largest proportion of the district’s population (63.9%) identifies themselves as White British. The district has the largest proportion of people of Pakistani ethnic origin (20.3%) in England. The largest religious group in Bradford is Christian (45.9% of the population). Nearly one quarter of the population (24.7%) are Muslim. Just over one fifth of the district’s population (20.7%) stated that they had no religion. There are 199,296 households in the Bradford district. Most households own their own home (29.3% outright and 35.7% with a mortgage). The percentage of privately rented households is 18.1%. 29.6% of households were single person households. Information from the Annual Population Survey for January to December 2016 found that Bradford has 219,400 people aged 16 to 64 in employment. At 67.3% this is significantly lower than the national rate (74.3%). 90,800 (around 1 in 3 people) aged 16-64, are not in work. The claimant count rate is 2.8% which is higher than the regional and national averages.

Size of population and localities covered:  The Bradford District population is 532,500. The localities covered by this service are: Kilmeny Surgery, Keighley, 13,412 practice population Tong Surgery, Bradford, 8,682 practice population Moorside Surgery, Bradford , 7589, practice population Clarendon Surgery, Bradford, 8,400 practice population Holycroft Surgery, Bradford, 9,947 practice population The service is currently expanding to include • Providing complex biopsychosocial assessments / interventions for chronic fatigue patients (steps 3-5) who had previously been sent out of area for treatment – District wide • Psychiatric Liaison referrals – District Wide




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