Psychological Wellbeing Service – Cambridgeshire & Peterborough NHS Foundation Trust – Winners #MHAwards19

The Psychological Wellbeing Service (PWS) based in Cambridgeshire is an IAPT service which was set up in 2009 to offer short term psychological therapies (predominantly CBT) to patients presenting with mild to moderate anxiety and depression. In October 2016 PWS received money from NHS England to introduce an integrated model of working for patients with physical health problems. This model advocated patients being able to access psychological care alongside their physical health care in a holistic approach. We became one of the original pilot sites and the second largest nationwide to set up this model of working and focused on Diabetes, COPD and Coronary Heart Disease. The aim of the project is to increase access to psychological support for this group of patients with the belief that reducing underlying anxiety and depression empowers patients to self manage and reduce health utilisation.

https://www.cpft.nhs.uk/services/pws/managing-your-long-term-condition.htm

Winners #MHAwards19

Co-Production

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

Evaluation

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

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

The Psychological Wellbeing Service (PWS) based in Cambridgeshire is an IAPT service which was set up in 2009 to offer short term psychological therapies (predominantly CBT) to patients presenting with mild to moderate anxiety and depression. In October 2016 PWS received money from NHS England to introduce an integrated model of working for patients with physical health problems. This model advocated patients being able to access psychological care alongside their physical health care in a holistic approach. We became one of the original pilot sites and the second largest nationwide to set up this model of working and focused on Diabetes, COPD and Coronary Heart Disease. The aim of the project is to increase access to psychological support for this group of patients with the belief that reducing underlying anxiety and depression empowers patients to self manage and reduce health utilisation. Our model is to have identified psychological therapists trained in working with physical health problems and be embedded in the community and hospital teams.

 

They are co-located and meet with the teams regularly to discuss the patients. This model normalises psychological difficulties as part of what any patient may need to deal with, ensures ongoing professional multidisciplinary conversations and facilitates direct referrals to the therapist /service. We now have forty four psychological therapists located across the county within the teams in the hospital and community settings. We offer a range of treatment options including face to face, over the phone, online and in groups. We also provide the psychological input into the group programmes run in the cardiac rehabilitation service, pulmonary rehabilitation and in Peterborough we do input for the Peterborough Dose Adjustment Course (PDAC) which is the local equivalent of DAFNE. The teams have all welcomed the integration and have found the mutual learning from each other has greatly enhanced their practice. This has been topped up by ongoing training that we offer the teams to increase their understanding of psychological care. We obtain ongoing patient feedback which also remains positive. “After 20 years of having diabetes I feel like I can now manage it and I don’t have a go at myself all the time like I used to (Outcome: GAD 7 reduced from 21 to 5 and PHQ 9 reduced from 18 to 2).” “From the initial interview onwards I felt that every effort was made to understand my problems in spite of my frequent inability to articulate them clearly. This patient and careful approach was very much appreciated and helped me eventually discover an effective strategy for coping. An example of the NHS at its best!” We are on the point of a further expansion which will increase our integration to other physical health conditions including chronic pain.

 

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

Our service is well integrated across the county with increased patient access and satisfaction. In June 2018 the Peterborough CHD team won the Integrated Care prize at the BHF Awards which took place at the British Cardiovascular Society Annual Conference. https://www.bhf.org.uk/for-professionals/healthcare-professionals/articles/profile/heart-patients-need-better-access-to-psychological-support-says-award-winning-team

 

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

Our local provider for the initial training for the staff was the University of East Anglia. We have worked closely with them to ensure the content of the training meets out service need and the therapists feel prepared to embark on working within the physical health teams. We are currently training our 4th cohort of therapists. The therapists divide their work 50/50 between their LTC commitments and ongoing core IAPT work. We find this model works well for therapists who want to develop new expertise but for it to not necessarily become the sole focus of their practice. Following the initial training we set up shadowing days with the physical health teams so the therapists can meet the staff, understand how the teams work and meet patients at different stages of their disease trajectory. We put great value on protected clinical supervision which ensures the staff are supported and continue to develop their clinical expertise. They receive individual fortnightly LTC supervision which they alternate with the supervision of their core IAPT work. This is provided by the LTC senior clinicians who have experience in working in this area. The senior clinicans are supervised by the Liaison Psychiatry Service based at Addenbrookes hospital. As an overall service we provide ongoing training for our staff. Over the coming year we have two training days on ACT and two on trauma. We also provide specific training for our LTC therapists – the recent day we did was on “A Transdiagnostic CBT Approach to Overcoming Adversity” provided by the Oxford Cognitive Therapy Centre. We have staff on the pathways who have physical health issues and we use their experience and knowledge to inform the work we do. We offer a weekly Mindfulness group run at lunchtime in Cambridge for staff to attend. A recent peer review of the overall service confirmed our good staff retention rate (95%) and our staff morale and satisfaction as high.

 

 

As mentioned earlier we currently have 44 staff working on the integrated pathways which covers 4 offices. They are supervised by two senior clinicians who cover two offices each. They are distributed as follows: 19 therapists in Diabetic Pathway – 15 at band 7 and 4 at band 5 11 in the COPD pathway – 7 at band 7 and 4 at band 5 14 in the CHD pathway – 10 at band 7 and 2 at band 5 They have a caseload which is 50% LTC and work one day a week in the “service area” with the team and assess / treat the patients on the remaining days

 

 

How do you work with the wider system?

The structure of our model of care means we are in its nature working with other teams. We are embedded with the community and hospital teams across the county and continue to use a stepped care model of working. In our hospitals (The Royal Papworth, Addenbrookes, Hinchingbrooke and Peterborough City Hospital) we step up patients to the Liaison Psychiatry if a step 4 intervention is required. These services provide psychiatric opinions as well as some psychology input. In the community teams we will step up to our secondary care colleagues who we meet with regularly to discuss the referral between teams. We work on a referral basis to the local authority services and our therapists have a good working knowledge of the local services. The LTC team regularly take part in information evenings / days run by BHF, Diabetes UK and BLF. We are currently booked to do 4 information evenings across the county with the Diabetes Service and Diabetes UK. We also attend the support groups to meet the patients, discuss how psychological therapies can help them and facilitate referral into our service.

 

Do you use co-production approaches?

We are a heavily monitored service and include patient feedback during and on completion of treatment. This delivers a cycle of feedback which is used to inform changes in practice and service considerations. This provides us with the patient perspective which we can use to discuss potential changes and affirm things which are working well.

 

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

We have presented our work in many forums to share what we do and engage with other services in discussion regarding good practice. Last year we presented to the Norfolk and Suffolk commissioners to outline our model of care and in Birmingham alongside NHS England as an example of integrated care pathways. We also presented the LTC project to Simon Stevens (CEO NHS England) when he visited CPFT last year. We have attended World Mental Health Day events where we have talked with patients about the service and how we can benefit people with long term health conditions. One of our PWP’s is currently writing an article for the CPFT magazine called “speak your mind”. It looks at the merge of physical and mental health in the NHS “Psychological Wellbeing Service (IAPT) discusses the implications of treating both mental and physical health holistically and the ever-expanding treatment options available in your area”. A clinical psychologist trainee also did a review of our COPD group as part of her doctoral studies in September 2018 “Evaluation of a new integrated wellbeing group for those with COPD and related respiratory conditions”.

 

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

PWS collect the nationally mandated IAPT outcome measures including recovery and waiting times. We use these outcome measures to monitor our performance using the NHS Digital reports. Where improvement can be made, we deep dive into our data and liaise with colleagues in other IAPT services to understand best practice. Data is collected on a sessional basis providing recovery rates from start to completion of treatment. The annual recovery rate for the LTC pathway for 18/19 was 52.24% and reliable improvement 68.17%

 

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

In October 2018 we had a Peer Review of the overall PWS co-ordinated by NHS East of England Clinical Network. This looked at the LTC pathways as part of the overall picture. In conclusion the Review panel were positive and generally impressed with the service and the reaction of staff. In particular the panel commended the service for their emphasis on staff wellbeing as the way to provide excellent care to patients. A recommendation highlighted for the LTC team was to consider how digital platforms could be used within the IAPT LTC pathways. We work closely with IESO who are currently developing a platform focused specifically on type 2 Diabetes.

 

 

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

The LTC team has been built in a way that allows a steady flow of staff to come and go and for the structure to remain in place. This is overseen by two senior clinicians who work closely together and cover for each other in any times of absence. The commissioners are aware of the ongoing plans to increase access rates to PWS as outlined by NHS England – 2/3 of this expansion will be to within the LTC population. The commissioners have just agreed the expansion for this year and we are in process of setting up new pathways to increase our access rates in line with national targets.

 

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

The project required clear mapping out initially as the services vary hugely across the county with some services being provided by out of area organisations. (eg pulmonary rehabilitation in the north of the county is provided by mid-Essex). This needed to be clear from the outset so we knew where to place to staff and how to design the multi-disciplinary working. The biggest challenge was regarding information flow. The services we are involved with run on 5 separate computer systems so the information doesn’t easily follow the patient. We set up a process using letters which can be uploaded onto to different computer systems so clinicians can check where a patient may be sitting at any one time (eg waiting for assessment/ treatment or currently being seen). We also had to train a number of staff on different IT systems so referral information could be transferred securely from one system to the next in accordance with clinical governance protocols.

 

How many people do you see?

We had 13,525 patients entered treatment in 18/19 against the contractual annual target of 13,440 which meant a surplus of 85 patients. There is good use of social media presence/awareness and also use of local media – radio/newspapers. Approximately 1120 patients per month provide feedback that they contacted the service following exposure to a local media advert. We have a continual program of groups that run – we offer “Managing your Wellbeing with COPD” three times a year in Huntingdon and Cambridge which usually has around 7 members per group. We are about to run “Managing your Wellbeing with Diabetes” – this is currently recruiting.

 

How do people access the service?

As an overall service we work on a self-referral system via the web-site and telephone contact. These are then triaged by our SPA (single point of access) who process and refer onto the local offices. Referrals that look like they would not be appropriate for a short term therapy are signposted to other services. The PWS patient information leaflet is available on the service website in the 20 most popular languages used in Britain. We have around 20 bilingual therapists working across the county and we have easy access to translators as and when they are required.

 

How long do people wait to start receiving care?

The waiting times from referral to treatment in 18/19: mean is 21 days, maximum wait 145 days. This will be due to specific reasons e.g. restricted patient availability and waiting for a translator. 99.2% of patients who completed treatment in 18/19 received their treatment within 18 weeks. We had 13,525 patients entered treatment in 18/19 against the contractual annual target of 13,440 which meant a surplus of 85 patients. Waiting times in PWS are positively comparable with the national average

 

How do you ensure you provide timely access?

The LTC referrals are referred straight into the local offices so they can be processed in a timely fashion. This ensures patients can be seen and discussed with the referring teams and the structure of multi-disciplinary working is maintained. This process is done within the week where upon the clinician working with the referring team will pick them up for assessment.

 

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

The IAPT dataset includes demographic information including ethnicity and date of birth. This means we identify patient groups who are not accessing our service for example older adults and those from BAME groups

 

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

The IAPT dataset includes demographic information including ethnicity and date of birth. This means we identify patient groups who are not accessing our service for example older adults and those from BAME groups

 

What is your service doing to address and advance equality?

Like many IAPT services, PWS service users are predominantly White British and between the ages of 18 and 64 therefore we have tried and continued to establish links with BAME communities and reaching out to older adults organisations including Age UK and residential homes. Despite some resistance, we continue our efforts to engage these difficult to reach groups.

 

 

How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?

PWS and CPFT as an organisation ensure that patients are provided with a comprehensive assessment at a time and place convenient to them using a range of assessment tools provided within the IAPT guidance for example GAD and PHQ. Additionally, we ensure we adhere to NICE guidance and the IAPT NHSE guidance whilst recognising that there should be flexibility on session numbers where clinically appropriate. PWS have robust processes for patients transitioning from CAMHS to primary care or from community mental health teams by discussing patients on a 1:1 basis to ensure the service users are suitable to be stepped up or down. PWS attend meetings with secondary care colleagues to inform and engage the teams with the criteria and interventions that PWS can provide.

 

How do you meet the needs of people using the service and how could you improve on this?

Our service offers NICE recommended treatment for anxiety and depression and we closely adhere to the appropriate protocols. We offer step 2 and 3 support and have identified mechanisms for stepping up to step 4 as outlined earlier in this document.

 

 

Have you implemented any of the mental health care pathways developed by the NCCMH (on behalf of NHS England)?

IAPT Long Term Conditions Pathway

 

 

Is there anything else you want to share about what makes you an example of positive practice?

We have dedicated and motivated team of therapists who are passionate about what they do and the care they deliver – they are a great example of professional care!

 

 

Commissioner and providers

Commissioned by: Cambridgeshire and Peterborough Clinical Commissioning Group

 

Provided by:  CPFT

 

 

Population details

Brief description of population (e.g. urban, age, socioeconomic status): The PWS will see adults across the age range from 17 upwards – there is no upper age limit. The service covers built up cities with an educated population (Cambridge and Peterborough) to rural Fenland villages with high levels of socio-economic deprivation.

 

Size of population and localities covered:  900,000+ across Cambridgeshire and Peterborough

 

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