Wellbeing Service Hertfordshire – HPFT – NCCMH – Improving Access to IAPT

Working collaboratively with GPs, diabetes specialists, secondary mental health care and service users; Hertfordshire Wellbeing Service has focused on expanding Improving Access to Psychological Therapies (IAPT) services for people with diabetes.


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


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


Working collaboratively with GPs, diabetes specialists, secondary mental health care and service users; Hertfordshire Wellbeing Service has focused on expanding Improving Access to Psychological Therapies (IAPT) services for people with diabetes.


Access to IAPT

Referrals are accepted from GPs and GP practice nurses, Diabetes Specialist Nurses, dieticians and podiatrists and specialist nurses and consultants in the hospital setting. Self-referral is also available. Standard screening for mental health problems is part of the local routine care package for all people with diabetes. All healthcare professionals involved in the integrated diabetes pathway are familiar with the screening tools used by the service and can administer these. This helps to destigmatising mental health and reduces existing barriers to engagement.

In collaboration with colleagues in secondary mental health services Hertfordshire Wellbeing Service has developed a joint referral form for professionals. This is available in electronic form on the GP “DXS” system. Professional referrals as well as self-referrals are screened for risk by the single point of access (SPA) and then allocated to the appropriate service (IAPT or secondary care). Professional referrals may be handed directly to staff working in the integrated setting in which case the suitability of the referral is discussed in situ before being processed by the SPA (upload of referral on system).


IAPT (whole service) referrals 2500090% of patients began treatment within 6 weeks of referral and

100 % began treatment within 18 weeks of referral.

People using IAPT with a long-term condition (LTC)5890*92% of patients began treatment within 6 weeks of referral and

100 % began treatment within 18 weeks of referral.

Note – figures for referrals received in 2016/17 financial year

* referrals with a recorded LTC, not all will be presenting reason for referral


In contrast to the general IAPT pathway, where a high proportion of assessments are carried out by psychological wellbeing practitioners, most assessments for the integrated diabetes pathway are carried out by high-intensity therapists during a face-face appointment. All patients are contacted by a booking clerk to invite them for an assessment and agree a suitable time and date.

Outcome measures

In addition to measures for the IAPT Mental Health Services Data Set (MHSDS) and patient experience questionnaire the service uses the Diabetes Distress Scale and the Client Service Receipt Inventory. Typically outcome measures are sent to the person to complete prior to their first appointment, in some situations measures can also be completed with the therapist. Where possible the service collects data on HbA1c levels at intake and at follow up. All data is inputted on the patient electronic record system (PCMIS). The project’s assistant psychologist leads on the gathering post-discharge follow-up data including the CSRI and HbA1c levels.

For the last financial year, the completion of IAPT MHSDS outcome data for all appropriate service users was 96.7%. High levels of data completion are encouraged through weekly reports which highlight where measures have not yet been uploaded. Reports on non-recovered cases discharged from the service are made available on a weekly basis and are used during supervision sessions to identify potential areas for improvement. Such reports are invaluable for identifying factors such as unexpected high drop-out rates and driving service improvement, including the range of interventions offered. The service also routinely gathers service user feedback and uses this to improve the delivery of interventions.

NICE-recommended interventions

Following assessment, the patient and therapist make a collaborative decision about allocation to an appropriate intervention and intensity level according to need.  In addition to CBT, the service offers interpersonal therapy, Couples Therapy for depression, dynamic interpersonal therapy and eye movement desensitisation and reprocessing. Any modifications to interventions are in line with those recommended in the top up training delivered by the University of East Anglia and commissioned by NHS England.


All staff and supervisors delivering care on the integrated diabetes pathway have attended the top up training delivered by the University of East Anglia. Previously, all IAPT staff have also completed CPD training on working with LTC delivered by the Oxford Cognitive Therapy Centre. Trainee high-intensity therapists and psychological wellbeing practitioners (PWPs) were also employed to cover staff recruited to the LTC work stream. Staff receive weekly 1:1 supervision and monthly group supervision by a clinical psychologist with special interest in LTC. The service invites diabetes specialist nurses to attend these supervision sessions. This helps to encourage referrals into the service.

Clinical leads and managers 1 consultant clinical psychologist (8c)*

1 operational lead (8c)*

0.6 deputy clinical lead with specialist interest in LTC (8b)*

0.5 team manager (8a)

Therapy staff 3 senior clinicians (8a)*

1 senior psychological wellbeing practitioner (band 6)*

7 high intensity therapist (band 7)

4 psychological wellbeing practitioners (band 5)

1 assistant psychologist (band 5)

Note – the workforce numbers above are whole-time equivalents (WTE)

* are not exclusive to the expansion project but also provide input to the core IAPT programme

Working with the wider system

Hertfordshire Wellbeing service has developed an integrated diabetes pathway in collaboration with colleagues in secondary mental health care and physical health care – spanning across primary care, specialist care and the West Hertfordshire Hospital Trust. The pathway includes routine screening for mental health, joint referral processes and regular steering committee meetings with partners, commissioners and service users to assess progress. The service is also currently developing a joint training package to be delivered in the acute hospital and community setting, informing on interventions and pathway.

As part of their initial work, staff sat in on specialist clinics with diabetes specialist nurses. This provided an opportunity for co-education and raised awareness about the remit of the service. In the past, staff also attended the patient diabetes education courses where they raised awareness of the service and invite people to self-refer to IAPT services. Senior staff regularly attend GP practices meetings, hospital MDT meetings and diabetes nurse forums to inform on the remit of the IAPT initiative. Prior to the project going live a pre-pilot initiative to test different ways of engaging people with diabetes was carried out in a local GP surgery. This provided service user feedback and was important in developing promotion material. The service is currently in the process of setting up a dedicated service user group with people who have used the pathway with a view to using their expertise to further improve the service.

Quote from the service on their key learning and achievements 

Challenges have arisen at many different levels. Identifying and working with key people within the diabetes network to champion the role of IAPT has proved important in influencing others where busy schedules and caseloads and, at times a lack of understanding of the benefits, can make engaging with physical health colleagues difficult. “Shoulder to shoulder” working such as sitting in on clinics alongside physical health colleagues, while initially resource intensive has also proved an effective way of developing mutual insight in a way that promotion alone has previously failed. While initially this did not generate an influx of referrals, through the development of these, shared understanding and robust pathways, specialist colleagues are now making highly appropriate referrals and contacting staff regularly to discuss patients.

Running a “pre-pilot –pilot” late 2016 to explore challenges around engagement was very useful. Local GP surgeries allowed a trial of different ways to identify and engage service users. With the help of a service user representative an outreach method was trialled where anyone on the register with diabetes was texted by the GP surgery, inviting them to complete a brief survey. This helped identify those with potential need for input and these people were invited to self-refer. Evaluation showed that this method did not achieve the objective of engaging people who perhaps needed the service most and resulted in the more intensive process described above.

It has been helpful to “start small”, learn from these experiences and make improvements prior to rolling out elsewhere. Having service user input was invaluable. Equally by initially focussing on just one LTC (diabetes) has allowed an in depth understanding of the physical care pathway and ensured integration at all levels. Indeed, there are still some areas including podiatry and dietetics where they are due to roll out work to. From the staff’s point of view there has been an appreciation of the value of immersing themselves in one area, consolidating knowledge and building robust relationships with health care colleagues. As a service – while focusing on just one LTC may not have initially achieved the numbers of a broader approach may have, they are hopeful the quality of work around engagement will ultimately pay dividends.

A further strength of the initiative has been the work done with colleagues in secondary mental health to develop a comprehensive integrated pathway. This will deliver a seamless pathway for service users presenting with the whole spectrum of mental health difficulties as well as level of physical health problem.

Further details

Commissioning Herts Valley CCG and East and North Hertfordshire CCG
ProvidersHertfordshire Partnership University NHS Foundation Trust
Operating hours8am to 8pm Monday to Friday
Population size1.15 million



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