HPFT’s Wellbeing Team was one of 22 IAPT services selected by NHS England (out of a total of 146 IAPT services) to pilot the provision of specialist psychological interventions for adults living with long term conditions (LTC). The initiative was driven by the evidence base around the benefits of psychological support for adults with LTCs who are three times more likely to develop mental health problems than those who do not present with physical health conditions. The pilot was for HPFT to deliver this new service via an integrated model of care, embedding and co-locating the service in physical healthcare settings at GP surgeries, community clinic settings and local hospitals. The project focus has been on developing this pathway for adults living in Hertfordshire with diabetes initially, with the aim of using this learning to develop and expand the service to other LTCs.
NCCMH - Improving Access to IAPT Pathway
From start: No
During process: Yes
In evaluation: No
PP Collaborative: Yes
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Dr Peggy Postma Clinical Lead, Hertfordshire Wellbeing (IAPT) Service
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
18 months ago HPFT’s Wellbeing Team was one of 22 IAPT services selected by NHS England (out of a total of 146 IAPT services) to pilot the provision of specialist psychological interventions for adults living with long term conditions (LTC). The initiative was driven by the evidence base around the benefits of psychological support for adults with LTCs who are three times more likely to develop mental health problems than those who do not present with physical health conditions. The impact of a comorbid mental health problem and LTC can be devastating, leading to poor adherence to self-management and medication regimes. Poor self-care inevitably causes a deterioration of the physical health condition, which in a condition like diabetes can lead to severe disability. Many psychological problems are treatable, resulting for the individual in improved wellbeing, empowerment and better management of their physical health condition. For the NHS this means reduced healthcare utilisation and substantial cost savings. The pilot was for HPFT to deliver this new service via an integrated model of care, embedding and co-locating the service in physical healthcare settings at GP surgeries, community clinic settings and local hospitals.
The project focus has been on developing this pathway for adults living in Hertfordshire with diabetes initially, with the aim of using this learning to develop and expand the service to other LTCs. The project has recently been chosen as regional champion in the NHS70 Parliamentary Awards for the Excellence in Mental Health Care category. The national winner of the award will be chosen at a ceremony on 4 July. The team is delighted to have been nominated by MP for Watford Richard Harrington for their outstanding work in improving services locally. They are delighted to be on the final shortlist of ten out of the 750 entries received. NHS England has included the Hertfordshire model as an exemplar of good practice in several of their publications and our Clinical Lead recently was invited to deliver a webinar to IAPT Teams nationally to share our experience of developing this pathway and learning from the process. Overall everyone has benefited from the scheme. Both the Diabetes and Mental Health Teams are incredibly proud of everything they’ve have achieved. Evidence-based clinical practice has led to high quality diabetes care and management, being delivered to all that need it. Patient feedback has been very positive, with improvement in practical aspects of diabetes management as well as their quality of life, all being noted as areas of benefit. Results of the scheme so far have seen a staggering 33% reduction in healthcare utilisation which not only benefits those living with the condition, but also provides significant cost-savings to the NHS.
What makes your service stand out from others? Please provide an example of this.
Right from the start the service recognised that for true integration to become a reality we would have to invest time into relationship building with our colleagues in physical health care settings. It was crucial to identify and work with key people within the diabetes network to champion the role of IAPT and persuade them not only of the benefits of our interventions for their patients but also of the potential impact on their own workload. To facilitate this we paired up IAPT therapists with physical healthcare colleagues (such as diabetes specialist nurses) where our therapists co-attended diabetes clinics. This “shoulder to shoulder” work, while initially resource intensive, has proved to be a highly effective way of developing mutual insight and co-education in a way that promotion alone has previously struggled to achieve. While arguably this initial investment of time may not have seemed “productive”, in the end it paid dividends, with physical healthcare colleagues really “getting” what IAPT could and could not offer. Through the development of this shared understanding and setting up of robust pathways, specialist colleagues are now making highly appropriate referrals and contacting staff regularly to discuss patients.
These relationships are maintained: physical healthcare staff now regularly attend IAPT LTC group supervision sessions which enables them to better understand how IAPT interventions are helping their patients and in turn allows them to advise IAPT staff on medical issues. From our previous work with people with LTC we had learnt that there are significant barriers to engagement for this patient cohort, with people sometimes struggling to see the merit of a psychological intervention for what they perceive to be a pure physical health problem. With this in mind we proposed a “high intensity” assessment model which deviates from the standard IAPT model where most people are offered an initial assessment via telephone. In the “new” model, anyone coming through the LTC pathway is offered a face to face assessment with a high intensity CBT therapist. During this session the patient is provided with a psychological formulation of their presenting problem which allows them to understand the interaction between their mental health difficulties and their physical health condition – making explicit how a psychological intervention can make a difference. Any ambivalence to engaging with psychology can be discussed and motivational issues addressed. Patients, Commissioners and referrers have welcomed this model. Of note is that we have significantly higher conversion rates (referral into treatment) for the LTC pathway than for our “CORE-IAPT” pathway, reflecting both the appropriateness of referrals being made (see point above) as well as the impact of our assessment model.
How do you ensure an effective, safe, compassionate and sustainable workforce?
A total of 34 IAPT staff underwent specialist training commissioned by NHS England and delivered by University of East Anglia to upskill them to work with people with LTC, five days for Psychological Wellbeing Practitioners (PWPs) and 10 days for High Intensity Therapists (HITS). The LTC training enabled staff to adapt standard CBT models and protocols to meet the complex and multi-faceted needs of people living with a long-term condition. This training has greatly increased confidence and competence in our workforce for working with this population. We worked with staff to manage any initial anxiety they may have had about committing to the LTC project. We took on board their concerns, responded to their feedback, and actively encouraged their input through monthly LTC team meetings. Staff started to enjoy the “pilot” challenge, understanding that along with the IAPT national team and our commissioners, we were all learning from this process and making positive changes. This stance helped to promote a sense of ownership and pride in our workforce. Staff are supported by a robust supervision structure where they benefit from weekly individual supervision delivered by a LTC trained supervisor as well as additional LTC group supervision which allows for case discussion, reflection and shared learning. As mentioned previously, physical health care colleagues regularly attend these group supervision sessions which offers further opportunity for staff to learn about medical management of their patients as well as a chance for physical healthcare staff to learn about how psychological interventions benefit their patients. A further opportunity for input and support is provided by the regular steering committee meetings. From start of the project this group has benefited from service user input and they have been highly influential in the development and promotion of the project.
Who is in your team?
Clinical Lead HPFT x 1 band 8C Deputy Clinical Lead x 1 band 8B Senior Clinicians x 3 band 8A High Intensity Therapists x 16 band 7 Senior Psychological Wellbeing Practitioners x 2 band 6 Psychological Wellbeing Practitioners x 12 band 5
How do you work with the wider system?
From previous initiatives within the service it’s clear that promotion itself is not enough. Key to the success of this project in terms of effectively building relationships and communicating the benefits of this initiative, has been the introduction of “shoulder to shoulder” work with mental and physical health care colleagues. Wellbeing therapists were “paired up” with diabetes specialists who then spent time sitting in on diabetes clinics, gaining an understanding of the problems presenting in these clinics and developing a mutual understanding with these specialists around where psychology could make a difference. Although time consuming, there were considerable potential long term benefits. While initially this did not generate an influx of referrals seen now, through the development of these relationships and shared understanding, developed robust pathways. Specialist colleagues are making highly appropriate referrals into the service and contacting mental health staff regularly to discuss patients. It has made the case for co-location and sharing of resources easier. Diabetes specialist nurses (DSNs) now regularly attend Wellbeing LTC group supervision sessions, enabling them to provide a medical perspective as well as gaining an understanding of psychological interventions for their patients. This is considered a small triumph in the provision of integrated care and the model will continue to be rolled out.
Do you use co-production approaches?
An expert by experience was recruited to find out the best ways to engage service users. Their ideas have been instrumental in the development of outreach activities and they have contributed all along the way, including to the design and wording of promotion materials. They are also on the steering group and regularly share information about the service on a social media group for local people with diabetes.
Do you share your work with others?
A leaflet explaining the service has been produced and distributed to healthcare professionals, GPs, practice nurses. • The Clinical Lead was invited to present this work at the East of England Clinical Network on 10 May 2018 • The Clinical lead and a senior clinician were invited to present a national webinar about the pilot for health professionals by NHS England on 30 May 2018, together with representatives from Diabetes UK. They stressed the importance of working together as diabetes and emotional health are inextricably linked • Information events to explain the integrated service – next one is in Watford on 19 June. GPs can book a place here: https://www.eventbrite.co.uk/e/herts-valley-integrated-diabetes-service-information-evening-tickets-46103418566 <ok • All 22 pilot sites are required to update the national team every month of progress. We are proud that in recognition of our progress the HPFT Wellbeing Team are one of four sites to feature in a forthcoming publication “Positive practice guide for Integrated care in IAPT”. We now have the go ahead from NHS England to roll out to other LTCs
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
Outcomes and achievements include: • Referrals are received from GPs and GP practice nurses, DSNs, dieticians and podiatrists and from specialist nurses and consultants in the hospital setting. All healthcare professionals involved in the integrated pathway are familiar with the screening tools used by the service to identify cases and can administer these. Providing standard screening for mental health problems for all people with diabetes is becoming a part of the local routine care package for diabetes. This helps to destigmatise mental health and reduce existing barriers to engagement • We are pleased that this pilot has helped facilitate the establishment of LTC pathways and commitment from other providers to provide seamless holistic care for service users, thus naturally supporting integrated working and the mutual benefits of co-location • In-patient mental health wards, as well as community settings, have access to the diabetes patient advice line Monday-Friday 8am-5pm to provide additional support and guidance for general situations or individual patients as required. This has been very well received by all the mental health team members and has seen significant improvement in communication • Monthly multi-disciplinary meetings are held with representatives from the mental health team, community diabetes service and the acute diabetes service. Specific patients are discussed, and an individualised plan of care is agreed for each patient.
Action points are agreed and these are reviewed at a later meeting; to ensure the plan is followed through and assess if further actions need investigating. By their attendance, the mental health team are seen as part of the diabetes team – rather than something separate. This in itself is vital to ensure patients view their mental health as being just as important as their diabetes care • One-to-one sessions are offered for individual patients to discuss all aspects of their diabetes and well-being. These can either take place with an IAPT therapist or as a joint appointment with the diabetes specialist nurse. These sessions usually take place in the diabetes centre, which again re-enforces joint working and the fact that the mental health staff are part of the multi-disciplinary diabetes team • Group sessions, including cognitive behavioural therapy, are offered for patients that are identified as needing that environment. Patients can move between group and one-to-one sessions as it is felt appropriate • Referral forms have been reviewed and re-designed, ensuring they are simpler and more informative. This enables timely and efficient triaging to ensure patients are offered the appropriate service. In addition to written referrals, because we now share work space, staff are also able to discuss patients face to face, which leads to a greater understanding of the complexities of individual cases. Data is being collected using the following methods: • disorder specific measures • the Client Service Receipt Inventory (CSRI) Diabetes Distress Scale (DDS) Results so far show significant improvements at discharge following the measurement taken at the start of their IAPT treatment. The average DDS score at the start of IAPT treatment was 42 and at discharge, this had reduced to 30 which represents a reduction of almost 29%. The DDS provides an indication of how well people are self-managing their diabetes with high scores representing poor management. The Client Service Receipt Inventory (CSRI) was taken at the start of treatment and 3 months post IAPT treatment.
This measure records the number of physical healthcare appointments over a given period (3 months). We showed a 33% drop in healthcare utilisation following IAPT. 53% of service users who finished their treatment had recovered from their symptoms of anxiety and depression. Please see below feedback from stakeholders on this initiative: Service User feedback: “This service provided me with the space to talk about worries about my diabetes no one else has asked me about before …. I really valued that.. as well as the subsequent support…” LS Service User Our Service user representative: “All newly designed healthcare interventions seem to claim that they are patient centric, but the HPFT Wellbeing Team Project really is an exemplar of putting the patient right at the centre of a multi-disciplined team” AB – chair – Maltings Surgery PPG We have developed a questionnaire for our diabetes specialist nurses colleagues to gather feedback about the experience of integrated working: “Running a clinic with a therapist was inspiring… they very skilfully engaged my patients in a conversation about their difficulties in a way that was reassuring and destigmatising. My patients have self-referred and are getting great support” KF Diabetes Specialist Nurse Therapist feedback: “The LTC training has enabled me and my colleagues to work in a more holistic way with this client group, and has given us the tools to address a number of inter-connected areas affecting clients’ wellbeing, including the physical side of their conditions. “This, in turn, has helped to alleviate some of the anxieties that therapists have in the past felt when working with long-term conditions, trying to adapt standard CBT models and protocols to the complex and multi-faceted needs of clients living with a long-term condition”.
Has your service been evaluated (by peer or academic review)?
The Hertfordshire Wellbeing (IAPT) service was one of the first six IAPT services to have achieved accreditation by the Accreditation Programme for Psychological Therapies Services (APPTS) in 2016. APPTS is a partnership between the Royal College of Psychiatrists’ Centre for Quality Improvement, and the British Psychological Society. It takes psychological therapies services through a supportive and engaging process of self and peer review to assess how each service is performing against an agreed set of quality standards. Feedback is collected from frontline therapists and service users, as well service managers, and areas of achievement and areas for improvement are identified. As well as identifying and acknowledging services that have high standards APPTS provides a network through which best practice can be shared, to facilitate service improvement. The APPTS project team provides year-round support to help accreditation members maximise opportunities for learning and development. Earlier this year the Hertfordshire Wellbeing Team were approved Interim (re)Accreditation.
How will you ensure that your service continues to deliver good mental health care?
The plan is to consolidate everything that has been established over the past few months. In addition, monthly reflective sessions are taking place. This allows team members to reflect on certain situations with patients, to see what went well and how we to alter future approach. This will enable the service to continue to deliver the very best care for every patient, every day. Both teams are delighted with the close collaboration that has developed and all believe that this service will continue to go from strength to strength. Ongoing funding has been agreed.
What aspects of your service would you share with people who want to learn from you?
Challenges encountered and solutions Despite the evidence it is not always easy to persuade healthcare colleagues of the benefits of psychological interventions for people with LTC. Physical healthcare staff often have insufficient time to explore mental health issues, and prioritise the identification and treatment of physical problems. Conversely when mental health problems are identified some still attribute these problems to an inevitable reaction to the LTC which therefore is `untreatable.’ There are also barriers to engagement with our potential service users. Some people with LTCs find it hard to see the merit of psychological therapies in the context of their physical health problem or find the stigma associated with mental health issues prohibitive. It became evident that in order to succeed, a great deal of time needed to be invested in order to foster relationships with colleagues in physical healthcare settings, as well as reaching out to people who would benefit from mental health care interventions. The chance to become a pilot site provided an ideal opportunity for an adequately resourced team. Some health care colleagues didn’t feel they had the time to take on another project, so a lot of work went into explaining how it would benefit their patients and in turn reduce their workload by pairing up therapists with healthcare staff. This “shoulder to shoulder” work was probably the best investment our service made. Co-education also led to highly appropriate referrals resulting in high conversion rates. Despite our staff being used to data collection at every session, it was a challenge to embed new practice and ensure that staff collected the additional data specific to this project. Staff were supported by our data quality lead as well as team of assistant psychologists who sent out weekly reminders. In addition we motivated staff by presenting outcomes/ data at the monthly team workshops.
How many people do you see?
For West Hertfordshire we took 10,092 people into treatment in the last financial year. 1,044 of these people were on the LTC pathway constituting 10% of all people entering treatment. Please note that during that financial year we had approval from NHS-E and our commissioners to expand to other LTCs so these figures do not just represent people with diabetes.
How do people access the service?
We accept professional referrals as well as self-referrals. We work hard to make the service accessible for everyone. This includes seeing people at home if they struggle with mobility issues and providing the interventions we deliver via a range of options including face to face, telephone support, computerised CBT and group interventions.
How long do people wait to start receiving care?
91.4% of all people coming through this pathway were seen within six weeks of referral. Please note that the IAPT national target is for 75% of people to be seen within six weeks.
Hours the service operates *
Normal office hours are 9-5 however service users can access treatment between 8am-8pm
Brief description of population (e.g. urban, age, socioeconomic status):
The service provides psychological interventions for people aged 16+ (no upper age limit)
Size of population and localities covered:
The service is for residents living with diabetes in West Hertfordshire
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): *
Herts Valleys Clinical Commissioning Group and NHS England
Provided by (e.g. name of NHS trust) or your organisation: *
Hertfordshire Partnership University NHS Foundation Trust (HPFT)
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