Primary Care Wellbeing Service – Bradford – HC – #MHAwards18

The Primary Care Wellbeing service is provided by Bradford District Care Foundation Trust (BDCFT) and has been developed in collaboration with GPs, as a Cost Improvement Plan. The purpose of the team is to work collaboratively with practices to create a ‘shift’ in patients’ behaviour by taking a multi-disciplinary approach to working with people and their families. The approach is psychology led and is driven by the teams 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 aim of the team is to support GP practices with some of their most complex and vulnerable patients who have comorbid physical and mental health problems

Highly Commended in Innovation in Community MH Category and Highly Commended in Integration of Physical and MH Care Category - #MHAwards18


  • 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.

The Primary Care Wellbeing service is provided by Bradford District Care Foundation Trust (BDCFT) and has been developed in collaboration with GPs, as a Cost Improvement Plan. The purpose of the team is to work collaboratively with practices to create a ‘shift’ in patients’ behaviour by taking a multi-disciplinary approach to working with people and their families. The approach is psychology led and is driven by the teams 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 aim of the team is to support GP practices 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 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 model is threefold: integrating physical and mental health, improving quality of life and making savings. GPs identified primary issues around chronic / persistent pain, repeated unnecessary investigations, and requests for medication where symptoms could not be explained by medical pathology. GPs described found interactions with these patients challenging due to time constraints (in the 10 minute consultation); and lack of knowledge how to provide an alternative to a medical intervention and having no alternative to offer the patients. The team (together with a GP) discussed these issues with a patient focus and they worked collaboratively in developing a Pain training approach for patients. Patients too were dissatisfied with high doses of medication and decreasing quality of life and poorer mobility. These patients spoke about how very empowering and positive this was and not only did it help them to stop significant amounts of medication, but some also started employment again.

This inspired a GP training program to support GPs in other practices alongside our Expert Patients by Experience to help set up the psycho-educational pain groups. The GP training was also planned and executed with the following aims: – To support the practice in reducing opioid prescribing and educating patients about persistent pain and the effects of opioids in long-term use. – To train, guide and support practitioners in developing biopsychosocial targeted for different patient groups. – To introduce psycho- educational patient support group as an alternative to prescribing. – Create a library of accessible resources for clinicians and patients. – Developing an evidence based training package for Primary Care Providers. We work actively with patients at all levels of care and value the contribution that service users are making and proactively seek to make changes in the light of feedback. Patients have been key in role in the success of this training


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

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 1 0.6 Clinical Psychologist 8a 1 0.8 Clinical Psychologist 7 1 0.4 Specialist Dietitian 8c 1 0.2 Occupational Therapist 7 1 0.8 Physiotherapist 7 1 1 Assistant Psychologist 5 1 1 Personal Support Navigator 4 1 1 Team Manager 8a 1 0.6 Student Intern – 2 2 Volunteer Counsellor – 1 0.2



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 Primary Care Wellbeing Service is represented by its clinical lead on the Bradford Integrating Mental and Physical Health Strategy Group.

This group is multi-agency and is Bradford District-wide, covering all three Clinical Commissioning Groups. Its main aim is to bring together agencies to produce a commissioning strategy that sets out a work plan for integrated mental health and physical health provision. This includes developing: • Motivated and multi-professional teams focused on delivering person-centred care • Tools and techniques to change dynamics of patient care • Workforce competencies to reflect shift from bio medical model • New models of supervision and training • Increased focus on health behaviour change 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?

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 recently 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) 2) CORE – 10 Screening Measure (Clinical Outcomes in Routine Evaluation) 3) AAQ-11 (measure of psychological inflexibility or experiential avoidance) 4) The Distress Thermometer (describes experienced distress) 5) EQ-5D-5L (describes perceived overall health) 6) Client Goal review (measure of improvement at review) 7) 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) COSTS/ SAVINGS Evaluation This part of the evaluation was not built in to the initial proposal and has been problematic. The GPs identify patients who are high on the risk stratification tool as suitable patients. However, we have found this Is not a reliable methodology as these patients maybe high as they have expected health care costs, this only predicts risk of emergency admission in the next 12 months and costs provided ae bed days only. We are currently working closely with Dr Foster and S1 and Blackpool Extensivist Model of Care who had similar methodological challenges. The second problem which was not built into the evaluation is that although the team have lots of anecdotal data about preventing hospital admissions, unnecessary operations, appointments as well as taking patients to necessary appointment to prevent deterioration and ultimate increase in costs – we currently have no way of measuring this reliably. *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)?

In conjunction with The University of Leeds, an evaluation that was undertaken in 2016 which was commissioned and delivered by Clinical Support Unit in Bradford. The evaluation reported measurable costs changes. It predicted longer term savings around patient care and demonstrated specific examples. The service is currently undertaking a service evaluation which involves in-depth discussions with patients to obtain qualitative data on patient experience.


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

Trust Managers and representatives of the service meet on a monthly basis with GP Commissioning leads to oversee the work of the team, discuss new developments, assess numbers in service and trouble shoot issues, eg reed coding etc. There are a number of initiatives mentioned earlier as regards sustainability opportunities: – Development of pain training / groups in general practice – Development of Chronic fatigue care pathway stages 3-5 (to prevent out of area referrals). Commissioner lead – Extending the model to other GP practices (Primary Care Home) – Providing consultations on complex cases for other services Funding for the service will be reviewed in 2019 and discussions are ongoing with commissioners.


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

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. Aspects of the service that we would be particularly keen to share would be: • 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 is currently commissioned for 200 patients. Numbers of referrals have increased by 50% over the last 12 months. The commissioned target is to reach 200 patients by September 2018 and we are on track for this.


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 should be no more than 2 weeks. This sometimes takes longer if there are other professionals involved in their care eg MHS


How do you ensure you provide timely access?

We recognise how important engagement is and also many of the patients have often felt let down by other providers Telephone support or the GPs or surgery staff continuing to provide contact is also key if there are delays in appointments (eg if someone’s on holiday etc)


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. There exists a significant need for addressing the socio-economic needs of this 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



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

Screening tools are used routinely by the different disciplines in the team depending on the presentation. Examples Assessment tools are also frequently used screening around executive functioning problems (DKEFS, BADS); The DISCO (along with screening tools -AQ and EQ) for diagnosis of Autism Spectrum Conditions IQ (WAIS IV) FOR IQ


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

The care is holistic, longer term and joined up with other professionals in the patients care. This will improved over time with the local work that is ongoing in Bradford, eg the Integrating Mental and Physical Health Strategy group work, mentioned earlier.


What support do you offer families and carers? (where family/carers are not the service users)

We work very closely with families and carers and this significantly supports the work we do. Carers/ families can be referred into the team for help eg counselling, physio, etc.


Further information

We have been able to be reflective, adaptive and creative in our work and respond directly to patient need. Eg We employed a dietitian who specialised in gastro but also in eating disorders due the significant number of people in the service that had eating disorders or disordered eating. We are able to be more flexible in how we work – ensuing that patients get the care they need when the need it and where they need it.


Hours the service operates *

The service operates on a 9am to 5pm basis, Monday to Friday


Population details

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

Bradford District is the fifth largest metropolitan district (in terms of population) in England, after Birmingham, Leeds, Sheffield and Manchester. 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 Bradford is substantially an urban area with inner city deprivation. It also has significant rural communities which are often isolated and have difficulty accessing services. A large proportion of Bradford’s population is dominated by the younger age groups. More than one-quarter (30.2%) of the District’s population is aged less than 20 and nearly seven in ten people are aged less than 50.

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 The service is currently exploring expansion via: • GP home • Providing complex biopsychosocial assessments / interventions for chronic fatigue patients (steps 3-5) who had previously been sent out of area for treatment

Commissioner and providers

Commissioned by (e.g. name of local authority, CCG, NHS England): *

Airedale, Wharfedale and Craven Clinical Commissioning Group

Provided by (e.g. name of NHS trust) or your organisation: *

Bradford District Care Foundation Trust



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