Dr Liz Howells explains how an innovative scheme to ensure early intervention is benefiting patients with common mental health problems in the Swindon area

When the National Service Framework for Mental Health was published in September 19991 the mental health services in Swindon were struggling. Waiting lists for non-emergency therapy exceeded 18 months.

A primary care based service for patients with common mental health problems, which had no waiting lists and good outcomes, had been running in Swindon since 1994, but was confined to only five GP practices. In the financial year 1999-2000 Swindon PCT decided to roll out this service across the area to meet standards two and three of the NSF (Box 1, below).

Box 1: The seven standards of the National Service Framework for Mental Health
Standard one

Health and social services should:

  • Promote mental health for all, working with individuals and communities
  • Combat discrimination against individuals and groups with mental health problems, and promote their social inclusion
Standard two

Any service user who contacts their primary health care team with a common mental health problem should:

  • Have their mental health needs identified and assessed
  • Be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it
Standard three

Any individual with a common mental health problem should:

  • Be able to make contact round the clock with the local services necessary to meet their needs and receive adequate care
  • Be able to use NHS Direct, as it develops, for first-level advice and referral on to specialist helplines or to local services
Standard four

All mental health service users on CPA should:

  • Receive care which optimises engagement, anticipates or prevents a crisis, and reduces risk
  • Have a copy of a written care plan which:
    • includes the action to be taken in a crisis by the service user, their carer and their care coordinator
    • advises their GP how they should respond if the service user needs additional help
    • is regularly reviewed by their care coordinator
  • Be able to access services 24 hours a day, 365 days a year
Standard five

Each service user who is assessed as requiring a period of care away from their home should have:

  • Timely access to an appropriate hospital bed or alternative bed or place, which is:
    • in the least restrictive environment consistent with the need to protect them and the public
    • as close to home as possible
  • A copy of a written after care plan agreed on discharge which sets out the care and rehabilitation to be provided, identifies the care coordinator, and specifies the action to be taken in a crisis
Standard six

All individuals who provide regular and substantial care for a person on CPA should:

  • Have an assessment of their caring, physical and mental health needs, repeated on at least an annual basis
  • Have their own written care plan which is given to them and implemented in discussion with them
Standard seven

Local health and social care communities should prevent suicides by:

  • Promoting mental health for all, working with individuals and communities (Standard one)
  • Delivering high quality primary mental health care (Standard two)
  • Ensuring that anyone with a mental health problem can contact local services via the primary care team, a helpline or an A&E department (Standard three)
  • Ensuring that individuals with severe and enduring mental illness have a care plan which meets their specific needs, including access to services round the clock (Standard four)
  • Providing safe hospital accommodation for individuals who need it (Standard five)
  • Enabling individuals caring for someone with severe mental illness to receive the support which they need to continue to care (Standard six)

and in addition:

  • Support local prison staff in preventing suicides among prisoners
  • Ensure that staff are competent to assess the risk of suicide among individuals at greatest risk
  • Develop local systems for suicide audit to learn lessons and take any necessary action

A steering committee consisting of the PCT’s GP mental health lead, two local independent counsellors, two members of the Swindon psychology department and a PCT manager, was set up. GP practices and their counsellors were invited to join the service and contribute an agreed amount per patient of their practice-based service funds to pay counsellors’ salaries.The PCT would fund the core service.

The aims of the service

Swindon Fast Access Primary Care Mental Health Service’s key aims were to offer an immediate response to individuals in need of therapy and to use the available resources equitably, offering a little to many people rather than a lot to a few.

A three-tiered approach to management was developed (Figure 1, below), the main features of which are:

  • ease of access;
  • a no waiting policy;
  • patients book their own appointments.

The service would make maximum use of the following resources:

  • self-help literature;
  • brief intervention work;
  • group therapy.
Figure 1: The Swindon Fast Access Primary Care Mental Health Service's three-tiered approach to mental health services

How the service works

Interventions are based on the principles of brief therapy, with the emphasis on coping and on the individual’s personal and social resources.

At the first appointment most patients are offered minimal intervention consisting of advice, self-help material including website access, computer-based cognitive behavioural therapy (CBT) and access to courses teaching a range of coping skills.

Early intervention helps to prevent chronic illness, and for many patients the resources offered at the first level are enough. This means that more time is available to be spent on patients with more resistant problems.

Those who require greater input are offered group sessions, behavioural programmes and occasional appointments with a psychologist or counsellor.

Others require more intensive therapy consisting of regular group support, more longer term intensive individual work and, for some, referral to secondary care services.

In effect, the service acts as a gateway to secondary services for all patients with common mental health problems. Patients with acute active psychosis are referred direct to secondary care.

Educational and therapeutic courses

Educational and therapeutic courses are run by graduate mental health workers, volunteers or ex-service users and are held during the day, in the evenings and at weekends at various locations throughout Swindon.

Topics are varied and include stress management, anger management, overcoming fears and phobias, relationship skills, bereavement, weight management, pain, and diabetes.

Many involve other healthcare professionals, for example counsellors, dieticians, physiotherapists, GPs and other members of the primary care team.

Some courses are run in collaboration with other community groups, for example Disabled Living Centre, Sure Start and Family Centres.

The psycho-educational courses focus on teaching cognitive and behavioural techniques. All the counsellors are trained in CBT, solution-focused therapy and brief interactions.

GPs are kept informed about their patients’ progress by means of brief notes on the computer as well as personal discussion.

How successful is the service?

Some 4049 individuals attended for initial, individual or group appointments during the period 1 April 2003 to 31 March 2004. The service is practice based and is therefore less stigmatising. The psycho-educational courses have a social and normalising effect.2 Instead of fostering dependency, the service is empowering patients through teaching them coping skills.

Patients like the fast access and the variety of times and locations available to them. Many prefer the solution-focused and coping strategies approach to standard therapy. It is also thought to be more normalising and less stigmatising.3

Evaluating the service

Users play an important role in all aspects of service planning, evaluation and delivery; there is a user committee and many users and ex-users work as volunteers. In addition to their therapeutic value, the focus groups provide useful feedback for developing the service.

Psychological morbidity is assessed by standard questionnaires (General Health Questionnaire, Beck Anxiety Inventory and Beck Depression Inventory), and statistically significant positive change has been found (Box 2, below).

Box 2: Impact of the service on GP consultations referrals to secondary care and outcomes
Change* in GP consultations for mental health problems in one 12 000-patient medical centre, April 2000 to March 2001
Fewer consultations 53%
More consultations 6%
No change (difference of <3) 41%
 
Decrease in referrals to secondary care, April 2001 to March 2002 (all GPs taking part) 56.9%
 
Outcomes At referral Post treatment
General Health Questionnaire mean score 15.05 4.2
Beck Anxiety Inventory mean score 25.9 13.47
Beck Depression Inventory mean score 23.58 12.25
* Criterion: increase or decrease of >=3

Patients consult their GPs less frequently after intervention, and the secondary care services receive fewer referrals.

Patient satisfaction is high, with 65% of patients reporting that their experience of using the service is positive. GPs report that the service has brought considerable benefit to their practices.

Rolling out the service

Eighteen practices joined the service initially and more have joined with each succeeding year. The service has now been rolled out throughout Swindon PCT and also covers more than a third of practices in the neighbouring Kennet and North Wiltshire PCT.

Our computer-based CBT programme is currently a pilot scheme and we hope to be able to roll it out throughout the whole PCT in September this year.

Conclusion

Our service has succeeded in meeting standards two and three of the NSF for Mental Health. As it is a proactive, early intervention service it also meets standard one; its links with carer support agencies help support standard six, and easy access ensures that it helps to meet standard seven. It has relieved pressure on the secondary care services and so indirectly contributes to meeting standards four and five.

References

  1. Department of Health. National Service Framework for Mental Health. London: DoH, 1999.
  2. Howells E, Law A. The Swindon Primary Mental Health Care Service. J Primary Care Mental Health 2001; 5(2): 33-5.
  3. White J. Treating anxiety and stress: a group psychoeducational approach using brief CBT. Chichester: John Wiley & Sons, 2000.

Guidelines in Practice, June 2004, Volume 7(6)
© 2004 MGP Ltd
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