We work in partnership with the local acute trust under a service level agreement. Our service offers psychological assessment and interventions for those experiencing psychological distress as a result of or in relation to their physical health.
What We Did
We work in partnership with the local acute trust under a service level agreement. Our service offers psychological assessment and interventions for those experiencing psychological distress as a result of or in relation to their physical health. For example, we work with those experiencing adjustment issues, difficulties engaging with medically recommended treatment, anxiety and depression relating to losses associated with their physical health condition, trauma symptoms following a procedure and so on. In addition, we provide teaching and training, supervision and consultation to staff groups to promote psychological awareness. The service has had over 850 referrals since its (re)launch in September 2012 with a staff of 1.8 WTE, which has grown from the initial 1 WTE. The service sees those aged 16 and over who are under the care of an acute trust Consultant in relation to a physical health illness or injury which may be acute or long term.
Mental health difficulties which occur as a cause or consequence of physical illness can exacerbate perceived symptom severity, increase distress, reduce treatment adherence and increase healthcare costs. Around 1/4 of patients with a chronic medical problem experience clinically significant psychological symptoms (White, 2001). Psychological factors (cognitions, beliefs, attitudes) can mediate coping with physical health problems and may be more significant than the severity of the disease in this respect (Sensky, 1990). We know that anxiety and depression are at least ‘twice as likely’ in those with a long term condition (LTC) and that concurrent mental health problems have a significant impact on the costs related to the management of LTCs, indeed, concurrent mental health problems also contribute to poorer clinical outcomes for the patient and a lower quality of life (‘Transforming our healthcare system’, The Kings Fund, 2011).
Our service offers a range of evidence-based therapies including CBT, Mindfulness and CAT-informed therapy. We are a developing service working in our current guise since September 2012, during which time we have focused on service development and enhancing the patient experience. Our work is underpinned by the central tenet of ‘piecing together a fuller picture of the patient’ we believe that the service a person receives should be ‘about you, with you, and for you’. We receive referrals with predominantly medical information and we believe in our assessments it is essential to piece the whole picture of a person together to fully understand that individual’s presentation and the impact upon all areas of their life.
Examples of recent initiatives include: We write a summary letter following screening to the patient and copy this to professionals, followed by a mid-point and ending update letter. Other letters would be written if prompted by a change or significant information to share. By routinely writing the letter to the patient the summary information has acted as a further vehicle to convey ‘being heard’ and allows the inclusion of motivational reflections (e.g. praise for their open-ness, acknowledging that it can be difficult to talk with a another new person, and so on). Patients have commented that this letter has been useful for them to share with others and the copies to other professionals have added to their understanding of the patient’s presentation. As a team we find it enjoyable and engaging to see these letters as an important part of the therapeutic process. Recently a patient took a copy of their summary letter which reflected that her ‘mask’ of smiling and laughing ‘hid’ the sadness and pain she was experiencing, leading to others negating her needs at times. The patient noted that they took a copy of this letter to their PIP interview and it helped to inform the process, where they otherwise may not have been able to express this.
Changes to the referral pathway to increase the equity of referral to the service through promotion of its existence and purpose. We are increasing understanding of the role of Psychological Therapies in Physical Health through meetings / presentations with teams and clinical leaders. In turn this increases the quality of the referrals made to us.
We have introduced a stepped care model and increased the choice of Psychological Therapies available (Integrated psychological therapies, Cognitive Behavioural Therapy, CAT informed, Mindfulness). We promote other ways in which Psychological Therapies can contribute to patient care via indirect working e.g. staff training, group work, consultation.
We have further developed the Screening Clinic we introduced so that patients telephone in to choose from the available assessment slots (or indeed to request a specific requirement) to increase choice and suitability (e.g. to fit around their medications, other health appointments, when others can accompany them). This new process has seen a reduction in the DNA rate for first assessment appointments and also empowers the patient to ‘opt in’ to attend the service. This process also means that cancelled slots have the chance to be rebooked. We have maintained the reduced wait time for treatment, which has been reduced significantly from the service (re)launch which took on a legacy waiting list. Patients are continuing to commence treatment within 12 weeks of screening. This is an area we are constantly striving to improve, as we appreciate that any ‘wait’ when we are a patient feels too long.
We have developed patient information leaflets to help referrers to introduce the idea of referral to psychological services, normalising some of the experiences that someone with a physical health condition (recent or long term) may experience. We believe this and reduced wait time has contributed to our low DNA (did not attend) rate of around 5% (including screening and therapy appointments). We now hold clinics at three different sites to improve accessibility and patient choice.
As a team we work closely together, supporting and constructively challenging each other to continue to improve and progress the service we deliver. We complete regular outcome measures with clients and provide opportunity for verbal and written feedback from both service users and referrers. Reflection and idea generation is built in to the day-to-day conduct of the team and supervision sessions.
Below are a small number of quotes from patients who have completed assessment and treatment within our service- ‘Strategies helped me to deal with everyday events, allowing me to move forward- being able to not feel fine and not feel guilty about it. More people need access to this service’ ‘It was helpful to discuss the problems I face with my disability’ developing ways to cope’ ‘I felt very supported…I recognised bottling up my fears and feelings was not helping me’ ‘After my illness and diagnosis, I didn’t feel like me anymore but slowly now I am getting my confidence back and regaining my life’. ‘Getting things out in the open, off my chest, to someone who listens…’ ‘My therapist was very understanding, I felt relaxed at all times with my therapist like I could talk about any problems without being judged.’ ‘Exploring how my past behaviours impacted on how I interacted with others and ultimately how this affected my health.’ ‘I now understand my role in my health & my life’.
Below are a small number of quotes from Consultants in the Acute Trust who refer to our service- ‘This is a timely service which my patients have fed back positively about’ ‘As a physician dealing with patients with chronic conditions I have found this service very useful to refer to help patients develop coping strategies, adjustment problems with the illness & exploring motivation issues’; ‘We are learning as a team from the way this team work with patients and the reports we get back’.
Wider Active Support
Our direct partner organisation is the local Acute Trust. The referral pathway to our service is via Acute Trust Consultant only, although the referral itself may be initiated by a nurse, physio or other healthcare professional. It is essential that we maintain good communications and promote psychological awareness amongst the Acute Trust staff groups, therefore the team reach-out to staff groups and Consultants via regular email communications and offering to attend/present at their development/ study sessions, taking up invites to present to junior and trainee staff groups (encouraging a psychological awareness in those at the beginning of their careers). As a team we ensure that we keep accurate and timely data sets to submit to the Acute Trust as required and to build a case for growth as appropriate. We have found that staff groups also find the stats interesting, e.g. where we can show the average number of sessions to discharge and changes in patients’ subjective and objective rating of distress.
As a relatively small service (compared to the footprint of the Acute Trust we provide to), we have looked to maximise our limited resource by linking with other services. We have developed training packages for other healthcare professionals which promote psychological awareness, our hope in skilling other professionals to consider the ‘whole’ person and to work more confidently with both physical health and mental health is to allow earlier intervention and signposting. We are building pathways with local IAPT services as well as community provisions. The service has a good working relationship with the local Expert Patient Programmes and Health Improvements Service, liaising to provide mutual feedback and updates on service developments. We regularly promote and signpost our patients to these services. We work alongside the Acute Trust’s physio-led groups and community exercise referral schemes. We have good working relationships with the interpreting services and endeavour to have consistency in the use of the same interpreter throughout a patient’s assessment and intervention sessions.
From initial contact with the patient we aim to communicate in a way that demonstrates that they are our focus, we address all correspondence to the patient and copy to their GP and referrer (rather than copying to the patient). In line with The Kings Fund 2012 document on ‘preference misdiagnosis’, establishing the patient’s priorities and short/long term goals is a key foundation for the work we go on to do in collaboration. We offer a choice of day/time and locations for appointments as far as is possible, and have increased staffing by 0.8 WTE to allow for two additional clinic sites. We invite all patients to complete a feedback questionnaire and complete regular reviews mid-therapy to reflect upon how things are going from each perspective. While we do not work directly with carers, patients are welcome to bring someone with them to their first appointment and where appropriate and agreed, we may continue to have a carer or relative present for short summaries at the end of sessions or for ‘check ins’.
We are working with people who have physical health issues and at times may be too unwell to attend, struggle with mobility and access, be awaiting test results/surgery dates, have other competing appointments with numerous professionals, struggle to sit, find the ‘conventional’ 1 hour session too long therefore, we have embedded elements of flexibility into our approach. We conduct some sessions standing or while moving around the room, we write brief summaries of session contents to aid memory and recall. We make clinical judgements about placing our input ‘on-hold’ if a patient is awaiting results or surgery and feel unable to commit to therapy at the time. We may offer a period of telephone consultations if a patient is unable to attend while recovering from a procedure or surgery.
We ensure that we keep the ‘full picture’ in mind and at times may need to problem- solve issues that seem outside of the ‘norm’ as a therapist, but nevertheless can be just as therapeutic. For example, if a patient is really struggling to get a GP appointment we may there and then ring the surgery to try to facilitate this, or signpost them to sources of support to address financial worries. In these times, some people are struggling to eat and pay rent – we appreciate that without our basic needs being met the foundations of psychological wellbeing are not present and attempts at therapy could be futile.
As a team we have a monthly journal review/team meeting which allows us to reflect upon service issues and share ideas for improvements or innovations. In addition, the team lead has an ‘open door’ approach between formal supervision sessions and encourages open communication. The team are very supportive of each other, we have a shared responsibility for the quality of our service delivery, and so everyone’s input and feedback is valued. Our administrative support staff are invaluable and provide constructive feedback on things we implement, leading to improvements. There is an enthusiasm within the team which is maintained through a shared desire to do a ‘good job’ and to facilitate others to help themselves.
Looking Back/Challenges Faced
We have learnt an important lesson from absorbing ‘extra’ as we have very enthusiastic staff who are motivated to be good clinicians, they go the extra mile however, we have learnt that we need to be careful not to raise unrealistic expectations by absorbing ‘extra’ in the short term without planning for additional resources needed to sustain this in the long term. It is challenging to acquire additional resources in the current climate of the NHS and the drive to help, which brought most people to this career, can be costly to staff members if not managed appropriately- we have to remember to apply human kindness to ourselves as well as others.
We have learnt that having the right resources, in the right place (including environments which facilitate) is an important way of valuing our staff group and ensuring that they have the most energy to work with their patients. For example, we added an additional clinic in a venue not owned by our trust which brought challenges including the safe storage and transportation of notes, access to PCs (no emails, no secure drive where documents can be filed), and difficulties in getting messages to the therapist. The intention was to increase patient access and choice but in seeking to offer this promptly we missed the opportunity to consider the resources which would have improved this for the staff and patients (e.g. smart phone or tablet, a case for transporting notes). It is thanks to our team members’ innovation and enthusiasm that potential obstacles such as this continue to be overcome.
In some senses though, we wouldn’t have experimented as much or learnt as much if we had ‘known then what we know now’. It has only been by ‘doing’ and testing out what is best for the patient that we have learnt about best principles for service delivery.
The service has recently faced a very challenging period while the team lead was on maternity leave. Being a small service this had the potential to cause instability and impact upon both the patients and staff members. During this period the focus was upon provision of core business – clinical assessment and therapy sessions to ensure service delivery could be maintained given the cost per case nature of the service. We were able to secure an increase in hours for one of our staff members so that the service had 1.6 WTE for this period. The period leading up to the staffing changes focused upon arranging interim supervision and management arrangements, ensuring the team had a clear understanding and documentation of its procedures and pathways. Time was afforded in supervision to allow staff members to reflect upon the impact of the changes and to consider additional resources they may need. In short, this challenging time was navigated due to the resourcefulness, dedication and passion of the team members.
This is a challenging area for us as the service is a provider to provider service level agreement, so the continuation of the service is reliant upon the Acute Trust continuing to value the provision. As the service is based on a cost per case basis, should those leading the team move on or be vacant from post for a notable period, it would be in the best financial interests of our trust to ensure continuity and maintain the flow of income.
Any service changes and developments are clearly documented and all team members are aware of and included in their conception and implementation to ensure a form of ‘team memory’. We utilise a shared drive on the computer system to ensure resources are available and accessible to all team members (e.g. referral flow diagrams, assessment and report templates). We have an ethos of clear and open communication between team members to foster a transparent and shared vision of the service. The aim is for a sustainable service of high quality, with all team members having some ownership of this. In addition, there is a ‘corporate memory’ through a well-informed management structure and training offered to other staff groups offers an enduring professional understanding of patient’s psychological needs. Work with our medical colleagues also allows opportunity to disseminate awareness and understanding of psychological distress, allowing demonstration of the benefits of and need to sustain our service.
Our service has a role in skilling up other professionals within our own trust (e.g. our colleagues in IAPT) via supervision, training and consultation building capacity in mainstream mental health provision to work confidently and competently with concurrent physical health and mental health presentations is seen by us as one mode of ensuring this way of working is sustainable. In addition, we are dedicated to offering regular placements for psychologists in Doctorate training (from the Universities of Manchester, Liverpool and Lancaster) as an opportunity to further promote psychological approaches to physical health.
Our service provides regular training placements for those completing their Doctorate in Clinical Psychology which affords us the opportunity to complete audits and small scale research/evaluation. Examples of completed projects include a service evaluation of referrer’s experience of accessing our service (example responses are included in section 1 above) and a review of the returned service-user feedback questionnaires (quantitative and qualitative data). Training placements were on-hold during recent changes to the service staffing but we are due to have a trainee with us for the next 6 months were we hope to evaluate patient change through evaluation of outcome measures and subjective reports.
We are passionate about sharing our experiences in working in this area and the lessons we have and continue to learn. We enjoy enabling others to work confidently with those with concurrent physical health and mental health issues. At the heart of the Francis report is a central message of compassionate care and we see the key to this is ensuring staff see the person rather than the label/diagnosis.
We share with colleagues within our own trust via teaching and training sessions (e.g. ‘piecing together a fuller picture of the patient’, ‘working with the can of worms’, ‘our recipe’) and supervise several colleagues who have a specialist caseload within the mental health services of those with concurrent long term conditions. We have also initiated an annual physical health and mental health CPD day for the staff within our trust. We have also submitted examples of our service into the internal trust process for acknowledging and sharing practice which demonstrates the trust’s ‘Principles of Care’.
We share with health professionals in the Acute Trust through teaching and training events, team days and feedback from evaluations and data collection. For example, we completed a service evaluation of referrer’s experience of accessing our service and have fed back the results of that and our plan for implementation of further developments.
We look to share experience and our ethos with those who are coming in to the profession and contribute to the local Doctorate Clinical Psychology training programmes at Manchester, Liverpool and Lancaster (teaching, offering clinical placements, mentor role).
We are looking to share with our patients through a trust-wide service user engagement project which our team lead is involved in developing with colleagues and service users.
Is there any other information you would like to add?
Our service sits within and is provided by a Mental Health trust, with referrers ad patients being from the Acute Trust – this affords an opportunity to increase a shared understanding of the complex relationship between our mind and body and to contribute to de-stigmatising mental health. Through joint working, shared communications (particularly written summary letters and formulations where appropriate) we look to foster increased understanding and reduce the barriers that can prevent people from accessing support.