CPFTs PWS (IAPT) service was selected as a first wave early implementer site by NHS England to integrate psychological therapies with services providing care for individuals with long term physical health conditions (LTCs) in October 2016. Initially focussing on 3 specific LTCs: respiratory disorders; cardiac disorders, and; Diabetes within PWS, the aim of this service development was to promote the integration of psychological therapies within care pathways for individuals with LTCs in order to normalise the experience of psychological distress in individuals with these conditions and provide treatment for co-morbid depression and anxiety disorders within the physical health care environment.
Highly Commended in Increasing Access to IAPT Category - #MHAwards18
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
CPFTs PWS (IAPT) service was selected as a first wave early implementer site by NHS England to integrate psychological therapies with services providing care for individuals with long term physical health conditions (LTCs) in October 2016. Initially focussing on 3 specific LTCs: respiratory disorders; cardiac disorders, and; Diabetes within PWS, the aim of this service development was to promote the integration of psychological therapies within care pathways for individuals with LTCs in order to normalise the experience of psychological distress in individuals with these conditions and provide treatment for co-morbid depression and anxiety disorders within the physical health care environment. Pilot studies conducted prior to these developments indicated that in addition to benefits for patients, this model of working can produce significant financial benefits for the local health care system as a result of reduced healthcare utilisation by individuals receiving treatment.
24 High Intensity and 4 PWP staff within PWS have now received specialist training within the service and are fully integrated within physical health community and hospital teams across the county that provide treatment for patients with these conditions. Staff members are linked to specific teams and clinics and are co-located, attend MDT meetings and utilise their IT system to promote a close collaborative and integrated way of working. This also enables the sharing of knowledge and development of staff within both PWS and physical health care teams.
What makes your service stand out from others? Please provide an example of this.
The first patients were seen in the pathway in April 2017. Throughout the FY 17/18, the first full year of operation 1847 referrals were received and 1825 patients entered treatment. The recovery rate for those completing treatment was 51.23% and reliable improvement was 66.61%. Patient self-report data gathered through use of the CSRI questionnaire demonstrated potential cost savings to the local health economy (except GP services) of £354,654 (to Feb 18). Additionally, GP appointments showed a 70.94% reduction, A&E admissions reduced by 66.46%, inpatient admissions by 75.45% and ambulance usage reduced by 60.55% following treatment. This represents significant success and has been reported nationally in the Health Service Journal, NHSE website (https://www.england.nhs.uk/2018/05/mental-health-game-changer-care-leads-to-75-reduction-in-hospital-admissions/) and national media (https://www.facebook.com/cpftpws/photos/a.833371223427209.1073741828.833025750128423/1547468875350770/?type=3&theater)
In addition to this, the service has taken an extremely collaborative and supportive approach to other services, offering meetings, guidance and learning for other CCG’s and Trust’s that have contacted PWS for support. Oftentimes this has been in conjunction with NHSE, and included presenting a webinar and delivering numerous presentations, in addition to providing 1:1 service visits for other providers.
How do you ensure an effective, safe, compassionate and sustainable workforce?
As a service, we are aware of and remain cognizant of the results of the British Psychological Society (BPS) and New Savoy staff wellbeing survey (2015) that showed 46% of psychological professionals surveyed reported depression. We therefore ensure that every staff member has regular operational (at least monthly) and professional supervision (1-2 weekly as desired/required) and is able to access psychological support for themselves if required. The service also encourages the use of peer supervision groups to foster a good team culture and support. In addition to this, all staff are encouraged to utilise the numerous CPD opportunities that are held across the service via a range of master-classes presented by experts in psychological therapies, in order that they maintain high skill levels to feel confident in their clinical practice.
With particular reference to the LTC team, each staff member has been offered the opportunity to attend 5(PWP) /10(Psychological Therapists) days specialist training in order to upskill their core modality training to work with individuals with LTCs, in addition to in-house training and additional clinical supervision with a specialist Senior Clinician. The service was also receptive to staff feedback in the early stages of the LTC project implementation. We were aware that many staff did not wish to work wholly within the LTC pathway; we therefore allowed all staff involved within this project to maintain at least 50% of their caseload within the core service. Although this meant additional staff training was required, this can be seen to have had an incredibly positive impact upon staff retention within this pathway, with only 2 Band 7’s involved leaving the pathway/Trust. The turnover rates of PWP’s has been slightly higher, largely due to the development and promotion opportunities that have been afforded to these staff as a result of the expansion of services.
Who is in your team?
1 x 8c Service Lead 1 x 8a Service Manager 2 x Band 8a Senior LTC Clinicians 1 x Band 7 Data Analyst 24-36 x Band 7 Psychological Therapists 8-12 x Band 5 Psychological Wellbeing Practitioners In addition, support is received from the rest of the service including: Team Leaders/Senior Clinicians: 8.4 x 8a Clinicians: approximately 100 other Band 4 to Band 7 (trainee and qualified workforce) Admin: 1x Band 5; 1x Band 4; 5 x Band 3; 3x Band 2 PWS SPA (Single Point of Access): 1 x Band 7 Team Manager; 3 x Band 6 Senior Clinicians; 5 x Band 4 Referral Advisors; 1 x Band 3 Administrator
How do you work with the wider system?
An essential component of the LTC pathway for the service was to integrate within the wider health and social care system to provide integrated care and support for individuals requiring support within the service. The service provides integrated and seamless care for patients with LTCs to access Psychological Therapies tailored to suit individual needs. One-to-one CBT (or other modality) assessments and interventions are delivered by a dedicated psychological therapist working within each identified LTC team. Closer working between the teams has ensured prompt uptake of treatment and helped to remove barriers associated with attending a specialist mental health service, thereby decreasing stigma, reducing cancellations and DNAs. PWS have also integrated into the educational component of rehabilitation and treatment groups.
They now deliver a group intervention on emotional and psychological wellbeing and provide details on how to access individual psychological treatment if further treatment is required. This has led to a more positive patient experience, a more proactive approach and faster, more effective treatment. Joint working and training has also resulted in the LTC teams having better recognition and understanding of co-morbid mental health problems. Whilst simultaneously, the psychological therapists are better informed about the nature of coexisting physical health problems. We have staff linked to a number of GP practices where this is practicable, and also have close links with local voluntary organisations. The service also works closely with other primary care and secondary care services provided by CPFT to reduce multiple assessments and deliver joint care between primary and secondary care when required.
Do you use co-production approaches?
In developing a psychoeducational component to local physical health rehabilitation and treatment groups (including cardiac rehab and PDAC) close liaison with physcial health services and individuals with LTCs was an integral step in this process. The result has been incredibly well received and successful groups, improved relationships and closer integration with the physical health care teams, and a (now shortlisted) nomination by the cardiac team in Peterborough for the development of this group, and other elements of integrated working for the national British Heart Foundation awards.
Do you share your work with others?
We use the IAPT minimum data set as standard to show improvement and recovery data for individuals accessing the service, alongside disorder specific measures of improvement. For LTC patients we have also utilised the CSRI, a self report healthcare utilisation tool. As noted above, these have shown the following outcomes: Throughout the FY 17/18, the first full year of operation 1847 referrals were received and 1825 patients entered treatment. The recovery rate for those completing treatment was 51.23% and reliable improvement was 66.61%. Patient self report data gathered through use of the CSRI questionnaire demonstrated potential cost savings to the local health economy (except GP services) of £354,654 (to Feb 18). Additionally, GP appointments showed a 70.94% reduction, A&E admissions reduced by 66.46%, inpatient admissions by 75.45% and ambulance usage reduced by 60.55% following treatment.
Has your service been evaluated (by peer or academic review)?
NHSE monitoring as first wave site. Outcomes published nationally.
How will you ensure that your service continues to deliver good mental health care?
We are currently continuing to collaborate closely with commissioners in order to ensure the service can continue to deliver to the high standard that has been achieved over the initial 15 months of this Project. The Service Manager has also been developing a number of senior staff (encouraging shadowing and learning) to enable them to understand numerous elements of the managerial role and LTC project, for them to be able to step-in, if and when this may be required.
What aspects of your service would you share with people who want to learn from you?
We have shared, and will continue to share a number of successes and challenges, including: Successes: • Pre-existing LTC service • Good links with the hospital & community teams • Motivation by the teams to make it work • Good communication • Managing expectations • Good understanding of local geographical areas and differing needs • Positive feedback from patients and physical health teams • Evidence of cost savings resulting from reduced healthcare utilisation. Challenges: • Logistical difficulties e.g. agile working vs. MDT working • Integration difficulties e.g. COPD and differing service providers • Working within teams vs. meeting IAPT targets • Different systems e.g. IT – pcmis/EPIC/ System one /lorenzo / Rio • Data collection to evidence health utilisation costs • Referrals e.g. too low/inappropriate • Training for PWS staff – takes time / not everyone wants to do it • National shortage of IAPT staff – need staff to deliver this
How many people do you see?
Total referrals in FY 17/18 >13330 Total accepted referrals in FY 17/18 = 13330 (approx) Facebook Page and Website active, but unable to give visit/reach figures at present, but could provide this if required at a later date.
How do people access the service?
Self-referral (c.80% of all referrals); GP; any other physical or mental health, or social care staff member can also refer. The service actively promotes access through local media, social media and maintaining close links and integration with a range of other services. All referrals are processed by the PWS SPA, the Service’s specialist referral management team.
How long do people wait to start receiving care?
Our most recent data indicates that 91% of all referrals enter treatment within 6 weeks and 98% of all referrals enter treatment within 18 weeks. This compares favourably with the national targets of >75% entering treatment within 6 weeks and >95% entering treatment within 18 weeks. There are occasionally outliers (less than 2% of all referrals) who may wait slightly longer than this due to the service working hard to accommodate patient choice regarding type, time and location of treatment.
How do you ensure you provide timely access?
As stated in your example list, we operate a streamlined referral management process via PWS SPA to ensure patient referrals are not unnecessarily delayed. SPA staff are then able to direct book patients into an assessment slot within the appropriate clinical team. We also ensure that where prioritisation is key for wellbeing, or nationally recommended (e.g. postnatal) this occurs, however as a service we do try to minimise prioritisation as this can negatively impact upon the wait time of all other individuals on our waiting list. Staffing levels are always maintained above our minimum service specification to ensure referrals are not delayed. Overtime and bank staff are utilised where necessary in the SPA.
What is your service doing to identify mental health inequalities that exist in your local area?
We aim to collate “inappropriate” referrals and note where individuals have unmet needs to inform the local understanding of this.
What inequalities have you identified regarding access to, and receipt and experience of, mental health care?
BAME recovery rates and access are lower than that for the WB population, both nationally and locally. We have conducted an investigative report into this and shared with the wider Trust and CCG.
What is your service doing to address and advance equality?
Working with local minority social groups in order to promote equality of access. Translating materials to ensure all individuals can be aware of and access treatment. Also using translators. Adapting materials suitable for use with individuals with mild learning disabilities. Ensuring staff are aware of the ability for those on certain benefits to reclaim the cost of their travel expenses so finances are not a prohibitive barrier to accessing treatment.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
PHQ-9, GAD-7, IAPT Phobia measure; IAPT employment measure; W&SAS; CSRI, in addition to other disorder specific measures and a full bio-psychosocial assessment.
Please find below an email sent by the CPFT Chief Executive to the LTC Team: Dear [LTC Team] Thank you so much for these slide decks – they are excellent. I am so proud of the leading edge work you are doing – it really is excellent and so great to see it recognised nationally. I get loads of material through my inbox and can sometimes not manage to fully read all the backing documents and this is such a clear way of getting across what you do and why. I look forward to seeing this develop further over future years. Can I also say how obvious it is that having a number of you who have worked together for many years – really shines out as making such a difference for excellence in service delivery and development. There is a confidence about you as a team that really is outstanding Well done – great work Tracy
Core hours are Monday – Friday 9-5, although clinical appointments are available between 08:00 and 20:00
Brief description of population (e.g. urban, age, socioeconomic status):
There is a mix of urban and rural areas and the population of the County is spread across a large geographical areas. The County has an Index of Multiple Deprivation (2015) score of 133.
Size of population and localities covered:
In the 2011 Census the population of Cambridgeshire was noted to be 806,700. The population affected by common mental health disorders within the County is noted to be 93,940 according to Cambridgeshire and Peterborough CCG (CPCCG). The Service largely aligns with the Cambridgeshire & Peterborough County borders, although does provide some services slightly across the borders into Northamptonshire and Hertfordshire.
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): *
Cambridgeshire and Peterborough CCG (CPCCG)
Provided by (e.g. name of NHS trust) or your organisation: *
Cambridgeshire and Peterborough NHS Foundation Trust (CPFT)