Dr Julian Stern and colleagues explain how they brought about a new mental health service that delivers integrated care to complex patients who have not historically been well served
Team Around the Practice or TAP is a new primary care mental health service launched less than a year ago in Camden. It is an innovative partnership between the Tavistock & Portman Foundation trust, Camden CCG and MIND in Camden.
The ambition of this service, based exclusively in primary care throughout the borough, is to deliver integrated and collaborative care for a large number of complex patients who traditionally fall “between the gaps” of services. Receiving referrals from almost all GP surgeries (32 of 35) throughout this very diverse borough in North London, TAP offers a variety of interventions.
Firstly, it provides direct clinical intervention to patients experiencing medically unexplained symptoms (MUS), personality disorder and other long term mental and physical health conditions.
Skilled psychological therapists work with patients in their own GP practices, delivering evidence-based therapies including short-term psychodynamic therapies, family and couple interventions, dialectical behaviour therapy (DBT) and cognitive analytical therapy (CAT).
Many of the patients referred to the service are frequent attenders in primary & secondary care or A&E, and if not managed appropriately are at risk of iatrogenic investigations and high health care costs.
Secondly, the team offers consultation, support and training to GPs and other primary care staff by helping staff members think through the complexities of setting limits, establishing and understanding boundaries and managing the frustration and uncertainty that working with highly complex patient groups often brings.
This kind of innovation should be the hallmark of a 21st century NHS
Thirdly, in partnership with the voluntary sector organisation MIND in Camden, the service has developed a strong social prescribing arm, supporting patients in practical ways such as by enhancing their return to employment, education and improving overall functioning .
The majority of these service users lead an isolated life, separated from work, peers and the community at large, and many find undergoing social prescribing alongside a therapeutic intervention useful in order to address multiple aspects of their difficulties.
GPs know that a large percentage of patients coming into the consulting room cannot be cured and sometimes are very hard to know how to help. GPs and NHS staff often see the need to recognise and articulate the links between social and psychological experience and its impact on emotions and health utilisation.
The combined offering of the three arms of TAP described above, help some patients recover, and help others accept their limitations, and help GPs and primary care staff manage these patients and their sometimes intractable difficulties .
Research and development
The TAP approach is based on the award winning City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS) provided by the Tavistock and Portman NHS Foundation Trust. PCPCS has been running for over 6 years and has won numerous national awards, including the 2013 Royal College of Psychiatrists Team of the Year award and the 2015 BMJ Mental Health Team of the Year award.
PCPCS has been subjected to an independent health economics study by the Centre for Mental Health, and the findings were striking, with 75 per cent of treated patients showing improvements in their mental health, and 55 per cent shown as having “recovered”.
Furthermore, PCPCS intervention reduced the costs of NHS service use by £463 per patients in the 22 months following the start of treatment, emphasising the economic value of the approach.
Many of the patients referred to the service are frequent attenders in primary & secondary care or A&E, and if not managed appropriately are at risk of iatrogenic investigations and high health care costs
This study helps PCPCS, (representing the Tavistock Primary Care Model) in its aim to evidence the value of pioneering a design for integrated and collaborative care, particularly at a time of great financial pressure and the growing recognition of the need to reduce fragmentation across the health and social care economy.
On the basis of such acclaim and evidence, the Tavistock and Portman NHS FT was successful in its bid to win the tender for the TAP service. In addition to the therapeutic and consultative interventions offered by PCPCS, TAP’s offer of social prescribing brings a unique angle to the service, triangulating the mental, physical and social aspects of health care provision.
Waiting times are kept as low as possible to ensure a responsive and user friendly service for patients and GPs alike.
Back in Camden, GPs and patients alike are for the most part delighted with the TAP service. GP feedback has been very positive, with one GP stating “the access and shape of the service – and the people involved – are marvellous”, and another “I found it very valuable and enjoyable to have the space to talk on this level.”; the team is only too aware of the constant threats, challenges and pressures that GP’s and providers alike are confronted with, on an almost daily basis, and of the need to continually strive to improve the model, and sustain this level of positive feedback .
Over 96 per cent of discharged patients, many of whom have previously not engaged with other psychological services, expressed the highest level of satisfaction with the service, with one patient reporting that “the sessions have been invaluable to me, and have helped guide me through a particularly negative time in my life.”
PCPCS intervention reduced the costs of NHS service use by £463 per patients in the 22 months following the start of treatment, emphasising the economic value of the approach
Outcome monitoring and research have been embedded in the service from day one, with research group OPM (Office for Public Management) conducting an external evaluation of TAP. Already the results are looking positive, as data collected from a small sample of discharged patients shows statistically significant improvement on measures of anxiety, depression and social functioning.
We conclude with a final quote from Geraldine Strathdee, National Clinical Director for Mental Health at NHS England. Writing about the PCPCS model, in the Centre for Mental Health publication described above, she wrote: “This kind of innovation should be the hallmark of a twenty-first century NHS.
”By combining local innovation with learning from the experiences of others, the NHS can offer better care despite the tough financial climate. This is a challenge we cannot, and must not, ignore.”
Dr Julian Stern is a consultant psychiatrist in psychotherapy, and the director of adult and forensic services at the Tavistock and Portman Foundation Trust, Katherine Yon is an assistant psychologist, and Tim Kent is the service lead and consultant psychotherapist at Team Around the Practice