New primary care teams are helping to catch people early in the spectrum of mental illness. Stuart Shepherd explains
"Up to now," says Alison Munns, a GP in Stevenage, "family doctors have had little to offer patients with mild to moderate mental ill-health issues other than medication or self-help material."
Things are set to change across much of Hertfordshire, following the county's success with several pilot and pathfinder sites for the national programme for Improving Access to Psychological Therapies. Results from the larger original demonstration sites also persuaded the government to announce last October£173m of annual funding by 2010 for the programme across England, starting with£33m in 2008-09 to get the roll-out started.
The earliest of the county's pilot schemes (Watford, St Albans and Letchworth) brought in newly created primary care mental health teams to provide a range of advice, support and treatment programmes. Since their inception in 2006 these enhanced primary mental health services have used a "stepped care" approach adapted from National Institute for Health and Clinical Excellence guidelines. They also use a model based on the work of "happiness economist" Lord Layard and the improving access national demonstration sites in Doncaster and Newham.
"We had about 18 months of running these pilots in Hertfordshire. Mixed enhanced primary mental health teams of link workers and primary care workers took referrals from a small group of practices in different primary care trusts before they stretched their reach outwards," explains Wayland Lousley, Hertfordshire Partnership foundation trust planning and commissioning manager for mental health.
"This is about catching people early on in the spectrum of illness for anxiety and depression," he says. "Get the right information at the right time and from the right person and somebody with mild to moderate symptoms can help themselves to recover more quickly."
The strongest link
Link worker posts have been created as a role redesign from existing mental health teams. This is a senior post, with leadership, liaison, education and referral responsibilities as well as clinical duties (providing structured high-intensity psychological interventions such as cognitive behavioural therapy) and has been taken on by experienced community psychiatric nurses, social workers or occupational therapists.
Mr Lousley says: "As the name implies, link workers use their experience and familiarity with services to assist with the integration between primary and secondary care in those cases where patients need to move further along the pathway into specialist care or beyond."
The primary care mental health worker role is designed both to support the GP to observe patients during the step one period of "watchful waiting" and, where referral to the enhanced primary mental health team is indicated, to support delivery of some of the low-intensity step two care programmes such as computer-guided cognitive behavioural therapy. In some of the Hertfordshire venues, these posts are being filled by mental health graduates.
Hertfordshire moved to pathfinder status in September 2007. This attracted£170,000 of Department of Health funding.
Since then its enhanced primary mental health teams have taken 120-250 referrals a month. More than 66 per cent of these patients have been women aged 31-40. About 50 per cent of all referrals present with mild to moderate depression.
Of the wide range of treatment options available, 31 per cent have had computer-guided cognitive behavioural therapy, 20 per cent have had guidance for anxiety self-help, and 15 per cent have had support through depression self-help programmes.
"As the service has developed, GPs have become much more confident and skilled in referring people to us," says Wendy Curtin, link worker with the Letchworth enhanced primary mental health team.
"Patients tell us that the initial assessment we take them through, where they talk about their problems, the outcomes they seek and the treatment options, is one of the most important hours of their lives."
The vast majority are satisfied or very satisfied with the choice of treatment, the length of wait for treatment and overall experience. All patients discharged from the service in Hertfordshire show reduced monitoring scores, demonstrating an increase in well-being.
"This has been about examining how to move Improving Access to Psychological Therapies to a commissioning-led service embedded at a local level, to relate the success and impact of the demonstration sites in terms of health, well-being and access with pre-existing structures in other areas," says Mr Lousley.
"We have to make sure that we are redesigning current services and roles in line with the new money, changing practice and structure, with a clear focus on primary care as we build on what we have already done and extend across the whole county."