Primary care mental health models in Scotland

Primary Care Mental Health Models in Scotland

Introduction

The purpose of this paper is to outline some of the Mental Health models that are in place across various board areas in Scotland, which demonstrate good practice, and seeks to draw out some of the commonalties and success factors from them. This is not an exhaustive list and the intention is for this to be a live document which can grow to include other examples that Members would like to add. This will give us an understanding of current mental health service provision in primary care settings, where there are potential gaps and help inform recommendations on how services can be improved.

From the models of good practice sourced so far we have gleaned a number of success factors and potential impacts that are common across all models cited.

These are:

• Regular reflective practice (or other wellbeing support) is an essential part of being able to deliver a sustainable, compassionate mental health service;
• integration needed with digital/remote primary care mental health and wellbeing resources, such as the health, wellbeing, and mental illness content on NHS inform, interactive self-care guides, NHS 24's 24/7 mental health hub, the Breathing Space crisis line, computerised CBT, telephone CBT, telephone interpersonal counselling, and the various specific digital therapies available through SIlvercloud, Sleepio. These can improve access and reduce clinician time;
• many models are GP Practice based and all use the wider multidisciplinary teams (MDTs);
• some of the models have identified the need to raise GP Awareness about the role and availability of the wider MDTs;
• a skilled assessment at the point of presentation is crucial to the quality of the overall patient experience;
• continuity and a joined up service needed;
• reduction in GP and GP Practice attendance rates;
• some highlight the benefits of no referral system or discharge. MDTs are able to directly access advise and support;
• request for assistance model used in Allied Health Professionals (AHP) Children and Young People services and has shown to promote shared responsibility and decision making;
• all of the models highlight the importance of providing GP teams and wider primary care multidisciplinary teams with training, standardised operational procedures and opportunities for feedback;
• the models highlight the benefits of cluster working; and
• the models bring training opportunities for practice based staff.

As part of the next iteration of this report these factors will be further expanded to provide more detail.

The following sets out a brief summary of the models so far sourced in primary care:

Patient Assessment & Liaison Mental Health Service (PALMS) – Tayside

PALMS was launched in February 2019 in Dundee. The purpose of the project was to enable access to a within-GP practice Mental Health Specialist (MHS) with the outcome being that assessments carried out by MHSs should allow patients access to the most appropriate mental health support through referral/more tailored signposting, whilst also helping to reduce GP workload.

Funding of the project allowed embedding of two Band 8a 0.5 WTE clinical/counselling psychologists into two Dundee-based GP practices. Each of the clinicians held regular 5 sessions a week within the respective practices.

The inclusion criteria was patients 16-64 years old and the pilot was designed to encourage self-referral. As part of this posters and leaflets were added to waiting rooms and adverts added to the practice website. Reception staff, GPs and other clinical staff were provided with flowcharts to guide them on identifying suitable patients for the PALMS service.

Each appointment lasted 30-60 minutes, depending on severity of presentation, and took place in one of the medical centre consultation rooms. Through assessment the MHS considered whether accessing MH/support services would be appropriate and by what method this would be best achieved. Direction of referral/signposting was based on factors such as nature of difficulties, severity, and level of impairment. The MHS role also extends to providing information on mental health coping strategies and self-help material, signposting to local community support services and, if appropriate, making referrals to specialist NHS services for further treatment.

Evaluation:

• GP feedback was highly positive and indicated that consultancy with MHS was valued;
• for reception staff involved in triaging telephone calls and making PALMS assessment appointments, the perception was that this did not cause their roles to become more challenging;
• the PALMS pilot appeared to provide support towards increased MDT;
• significant reduction in re-presentations for mental health consultations four months after PALMS assessment indicating workload for GPs may have decreased in this regard;
• non-referral routes were the most common post-assessment outcomes for patients, followed by referrals to other NHS/non-NHS services; and
• Primary care psychology (NHS) was the largest recipient of referrals that were made. This would fit with severity of presentation, the majority of which were within mild-moderate category.

Data indicated the requirement for 1 session per 2,000 patient population. It also highlighted the need to move towards cluster based working with the view of each practice not having physical space to accommodate the PALMS service. The pilot indicated the best way of moving forward is having a Band 8A responsible for each of the clusters with a number of Band 7 Clinical Associates in Applied Psychology/ Psychotherapists and Band 6 Mental Health Nurses in post.

Occupational Therapy (OT) in Primary Care - Lanarkshire

OT clinicians are skilled in assessing the components of everyday occupations and roles that matter to people, identifying the impact of developmental, physical and mental health conditions on these occupations and devising intervention plans to enable people to overcome areas of dysfunction and engage fully in their day-to-day lives. Funding from the Scottish Government supported the recruitment of two 0.6 whole time equivalent (WTE) Band 7 OT Advanced Practitioner posts to an 18 month secondment opportunity which commenced in October 2017.

The OT service accepted referrals from all of the GP practice team for registered patients aged 16 and over who identified issues arising from mental or physical ill health which related to their occupational performance and/or environment. All those referred were contacted by telephone within two working days and triaged in order to establish patient need, confirm appropriateness of referral to OT or need for alternative intervention/service, and offered an initial assessment appointment.

Depending on need, patients engaged in a brief intervention (1-3 contacts) or an episode of care (4+ contacts). All contacts were recorded in GP Vision. Written and verbal feedback was also provided to GP teams and health and social care providers. The OT service was located within the GP practice. Telephone triage within two working days and initial assessment within two weeks enabled patient need to be met 'at the right time' and 'in the right place'.

Educating GP clinical teams at the start of the test combined with a consistent OT presence, feedback from patients and OT use of Vision electronic records increased GP team knowledge about what OT is able to offer. As a result GPs made fewer inappropriate referrals. This highlights the importance of providing GP teams and wider primary care multidisciplinary teams with training, standardised operational procedures and opportunities for feedback.

Educating reception staff is key to enable them to confidently triage patients to OT as a first point of contact. To date limited protected learning time to train reception staff and the challenge of developing a simple algorithm for reception staff to follow in order to triage relevant patients to OT has prevented this.

Evaluation:

• The test concluded that OT service provision in primary care requires a range of qualified and support staff to meet patient need including Band 7 Advanced Practitioners, band 5 and 6 clinicians, band 4 support staff and administrative support;
• the OT service has increased primary care capacity to manage patients, reduce onward referrals to secondary care services and reduce uptake of social care and sickness benefits, whilst improving health outcomes;
• measurable benefits were recorded for patients in terms of improvement in their occupational performance and quality of life;
• GPs reported a notable reduction in attendance rate;
• GPs valued having direct access to OT through co-location in the GP practice;
• inclusive criteria enabled patients with multiple co-morbidities, whose mental or physical health resulted in reduced occupational performance, to have access to a streamlined service; and
• the test highlighted that GPs lack of awareness about the role and availability of OT services and this had a negative impact on patients' access to OT.

Craigmillar Medical Group – Mental Health Model - Lothian

As GPs working in an area of high deprivation, the prevalence of mental health issues is very high, across all ages. The practice estimates that mental health issues were discussed in around one third to one half of all our GP consultations. Previously all mental health workload was managed by the GPs – or referred on to local voluntary/third sector organisations or specialist services, with varying levels of engagement.

Craigmillar Medical Group have recruited a team of three primary care mental health nurses, (one lead nurse – band 7; two nurses in training and development posts – band 5). The team see a large number of young people, from the age of 12, referred internally from the GPs. They are contacted quickly by telephone and offered an appointment after school. Common issues discussed are social anxiety, gender identity, self-harm and peer pressure issues (drugs, alcohol etc.).

Their interventions consist largely of crisis management, general psychological support and signposting to local services. A very small percentage of patients are referred on to Child and Adolescent Mental Health Services (CAMHS).

Evaluation:

• Around 400 referrals in 6 months. High DNA rate for appointments – team responded by initiating phone triage / consultation both as initial assessment then follow up. About to have a drop-in session by invite – where all of the team will see patients who attend;
• they are based within the GP practice so access is less intimidating;
• 30 minute appointments;
• the practice uses a triage system to meet needs, including having a care plan with a named clinician (GP, PN or MHN) for those in the top tier of need. Trauma informed discussions take place to discuss care needs with patients in a proactive way and there are 4-weekly meetings to discuss cases;
• reception staff are now called Care Co-ordinators and they all look after a cohort of patients so they develop relationships and know them well;
• the whole team has undergone team building and profiling so they know and respect each other's 'type', particularly helpful when having difficult conversations as it makes it less personal;
• they offer a primary care model of mental health provision; no formal internal referral system, rapid access to appointments, shorter and more frequent appointments, no "discharge" from the service;
• they are often already known as healthcare professionals to patients' families (often parents) therefore less stigma, more trust;
• they focus on de-medicalising social issues (estimated 99% of referrals are for mental distress and not mental illness); and
• quality assurance is maintained through regular case discussion, joint consulting and good access to specialist decision support.

ADAPT – Accessible Depressions & Anxiety Psychological Therapies (Grampian & Lanarkshire)

ADAPT was developed by NHS Education for Scotland (NES) and aims to double access to psychological therapies and interventions in primary care adult mental health and to develop the specialist mental health workforce in secondary care. This is achieved through:

• Expanding the competencies of the existing workforce to deliver the most effective treatments;
• increasing the workforce in primary care and providing training, supervision and consultation for the new primary care mental wellbeing workforce associated with Action 15 and the developing Primary Care Multidisciplinary Teams;- and
• providing guidance and support on the model of service delivery that enables cost-effective stepped care, patient choice, quality assurance and increases capacity.

The model draws upon the Increasing Access to Psychological Therapy (IAPT) services in England which demonstrate clinical recovery from anxiety and depression in 50% of people treated and see over 1 million people per year. Adjusting this model for the Scottish context to take into account the workforce commitments in the Primary Care Services Policy and the Mental Health Strategy a 'scalable' ADAPT team would comprise of; Clinical Lead 5%, Psychological Therapists 55%, Psychological Practitioners 25%, Link Workers 10%, and admin support 5%. It is suggested that the minimum ADAPT team size is 10 WTE.

• Clinical Lead provides leadership, governance of service, clinical supervision and psychological therapy.
• Psychological Therapists (e.g. specialist nurses, clinical psychologists, clinical associates and AHPs) provide assessment and therapies such as Cognitive Behavioural Therapy (CBT), Interpersonal Therapy (IPT), Mindfulness-based Cognitive Therapy (MBCT).
• Enhanced Psychological Practitioners (e.g. AHPs, nurses, psychology graduates, other caring professionals) conduct structured assessments and provide brief psychological interventions; such as Guided CBT, Behavioural Activation (BA), Motivational Interviewing (MI) and groups interventions.
• Link Workers & Welfare Advisors provide signposting to community services, psychological informed care and support groups.
• Admin staff provide a first-line contact and ensure the efficient administration of the team's caseload, support the patient pathway, and facilitate data recording and reporting.

Staff are trained in the competencies to deliver evidence based psychological therapies and interventions. Staff in the multidisciplinary primary care team whose role is not primarily to provide psychological treatment, can be upskilled in the competencies required to provide interdisciplinary care.

Staff could have access to NES training programmes including; psychological therapies, specific enhanced psychological interventions and the Enhanced Practitioner Programme.

NES has considerable experience in providing comprehensive education and training programmes in evidence based psychological therapies and interventions to support the provision of match stepped care in mental health services. These link with the NES training programmes for other practitioners working in Primary Care. The NES work-based national training programmes aims to build multidisciplinary capacity within all the NHS boards and partnership organisations across NHS Scotland, to provide psychological therapies and interventions within adult mental health services. This means implementation of expansion in services will involve close working with key national networks e.g. Heads of Psychology Services Scotland (HOPS). NES can provide education and training to support the ADAPT service model including the Clinical Doctorate, MSc in Primary Care, Diploma in CBT, and short training programmes. The Enhanced Practitioner Programme is a new training programme and would represent significant expansion at this level.

Evaluation:

• The pilot provided accessible, effective, person centred, integrated care in primary care settings in Lanarkshire and Grampian;
• training in adapting Cognitive Behavioural Therapy for common LTCs resulted in significantly higher knowledge, confidence and evaluated positively by staff, patients and service managers; and
• clinical outcomes included highly statistically significant improvements in depression, anxiety, quality of life and progress towards healthy lifestyle goals.

Primary Care Mental Health (PCMH) Service - NHS Dumfries & Galloway

The PCMH Service was initially piloted in 4 GP practices in Dumfries and Galloway for 12 months from mid 2017. Following a successful evaluation of the pilot collaborative work began with the GP cluster leads to develop and begin rollout of the service in early 2019.

The model now see's 13 experienced Mental Health Nurses based in general practice across the region. Sessions have been allocated at GP practice level based on GP population size. People can access the service via the individual triage system within each practice and appointments are booked via the electronic GP system. There is no requirement for people to see the GP or Advanced Practitioner (AP) prior to seeing the Primary Care Mental Health Nurse (PCMHN), thus assisting in reducing GP workload and streamlining pathways.

The service offers mental health triage, assessment, brief interventions, assisted self-management and appropriate signposting for those with mild to moderate mental health issues. The approach aligns itself to the Scottish Governments 2017- 2027 Mental Health Strategy as the focus is on ease of access, early intervention and self management, as well as early identification of more serious mental health issues.

The service uses a multi-disciplinary/multi-agency approach facilitating timely onward referral to other agencies and the wider mental health services where appropriate, ensuring people are seen by the right person at the right time. Active participation with family and Carers is encouraged, recognising the contribution Carers make to an individuals' recovery.

Each PCMHN is aligned to the locality CMHT, operational responsibilities; clinical supervision and training are jointly supported by GPs and CMHTs. This arrangement ensures the PCMHNs receive adequate support, are skilled and confident to carry out their work and quality is developed which supports performance. It maintains the connection with secondary mental health and has improved links and consistency between Primary Care and secondary Mental Health Services.

Covid-19 has moved work towards reduced face to face contacts with more consultations taking place via telephone or NHS Near Me. Remote working has afforded the ability to provide cover across practices and localities to respond to staff absence. So far, feedback from people offered telephone or NHS Near Me appointments has been that this provides the support required and they feel comfortable with this.

Evaluation:

Local research study carried out with the GPs identified the PCMH service reduced GP workload and provided capacity for them to focus on the more complex patients, leading to a reduction in GP stress levels. The study highlighted that early assessment and intervention by a skilled specialist provided more effective non-pharmacological management of people with mental health difficulties, thereby reducing prescribing.

PCMHNs were viewed as a resource to educate, support and advise the primary care team, co-location was felt to support delivery of a collaborative approach to person centred care; enabling sharing of knowledge/understanding and building relationships. Joint working between PCMHNs and pharmacists on antidepressant reviews has been welcomed.

Patient/carer feedback (qualitative surveys) has been extremely positive across the region. Core 10 and GIS were used to score patient outcomes on perceptions of their mental health, connections to family, community and social groups. 50% of patients achieved their personal outcomes, 22% were signposted to other appropriate services/agencies, 10% disengaged (18% had an unidentified outcome).

Referrals to secondary services, e.g. CMHT, Psychology, have been dealt with effectively and efficiently, ensuring people see the right person at the right time.

Compassionate Distress Response Service – NHS Greater Glasgow & Clyde

The Compassionate Distress Response Service was commissioned late 2019/early 2020 from Glasgow Association for Mental Health (GAMH) which started providing an out-of-hours (5pm – 2am, 7 days) service by telephone during Covid-19 lockdown from late May 2020. The service is for people aged 18+ resident in Glasgow City who are emotionally distressed and require support but do not require medical or specialist psychiatric assessment.

Distressed people are referred to the service from statutory services, including first responders, GP Out of Hours, Out of Hours CPNs, NHS24, A&E and Mental Health Assessment Units, Urgent Care Resource Hub, etc., provided they have capacity to engage and consent to do so. The service gives 'listening' support to each individual via telephone (this will also be face to face and outreach when appropriate post-Covid), provides support to develop a plan of action to alleviate their distress and onward referral to appropriate support services for each person accessing the service. People who are referred to the service should receive a call within an hour of referral for immediate support and receive a follow up phone call the following day. The case is kept open for a month, or more in some circumstances.

Initial feedback from this research supported the need for in-hours provision for general practice referrals and this service commenced in September 2020.

The Jigsaw Project - NHS Greater Glasgow & Clyde

The Jigsaw Project was established in the Drumchapel GP Cluster, funded as part of the NHS GG&C Primary Care Mental Health Transformation Fund bid to the Scottish Government.

The project aimed to consider, better understand and help find solutions for people who experience longer term mental health difficulties who were not well-served by existing arrangements. The project also helped to raise awareness of other community supports which help improve mental health and a directory of these was produced for each locality to assist GPs to direct patients to these.

The voice of people with lived experience ran throughout the project, alongside those of GPs and their teams (regarding managing their own mental wellbeing as well as that of their patients). A Jigsaw tool kit was developed to engage with the community to identify problems and solutions, and these 'jigsaw lids' helped illuminate wider perspectives on the issues. The project also provided seed funding to local groups to develop solutions to poor mental health.

Mental health services were seen to rely too heavily on GP practices to support those whose needs were not being met, which impacted on their stress levels and mental wellbeing. The study found some evidence of GPs negatively affected by their workload around mental health and the challenges of negotiating the system and, although preserving non-clinical space within the diary was one of the successful approaches to avoiding burn out, most felt they were operating at the full extent of their resilience. Mutual support has improved across the cluster and active support such as Mindfulness Based Stress Reduction training and yoga practice have supported this within primary care.

Evaluation:

The project highlighted the different ways of working amongst the public and Third Sectors but also the importance of continuing the dialogue and looking at solutions to improve communications, understanding and service delivery to better meet the needs of local people.

Initial data suggests that a significant proportion of those referred to mental health services are not accepted for treatment by the CMHT, but are directed to the PCMHT, Third Sector providers or back to the GP. This may be due to inappropriate referrals, lack of capacity or other issues but this perhaps suggests that better communications between GPs and mental health services (around what is and is not an appropriate referral) and a single point of entry to mental health support – of all kinds – would assist in ensuring patients receive the support they need.

The Govan SHIP Project - NHS Greater Glasgow & Clyde

The Govan SHIP Project was established in 2015 to provide additional resources within primary care to enable a more effective response to the challenges faced by health and social care professionals in deprived areas. The project was prompted by work of the Deep End Group and funded by the Scottish Government Primary Care Transformation Fund.

The project focussed on person-centred care delivered by MDTs, creating capacity for GPs to support more complex patients and understanding demand for health and care services at GP practice level. One part of the project focussed on mental health as more deprived areas have a higher incidence of mental health issues and there was a professional perception that mental health support services were not being accessed by those most affected and in need of support. The work involved consultation with a variety of key players: GPs, CLPs, wider primary care team, social work, PCMHTs, CMHTs, Lifelink, SAMH, GAMH, the Health and Social Care Alliance amongst others. Work was done to develop a better understanding of the type of mental health concerns presenting to primary care. Fresh data was gathered by reviewing GP consultations which had substantive mental health components and an audit of outcomes of referrals to mental health support services.

It was found that 20% of patients attended with a mental health issue, primarily (74%) with depression, anxiety, low mood or stress - a significant proportion (72%) were on medication (mainly antidepressants) to assist with this but were not linked into additional support services, although most had been referred/engaged previously. Overall, less than 20% of patients referred to PCMHTs and CMHTs received treatment, raising questions around processes. The study found that the way in which mental health concerns were responded to by different practitioners was inconsistent, there was not a shared understanding around the definition of mental health needs, and current support services were challenging for both referrers and patients. This suggested a need for clearer pathways, guidance and consistent practice.

Evaluation:

• Further analysis of referral outcomes to mental health teams needed;
• consultation with patients about their experiences of help for mental health issues needed;
• the need to develop a protocol for the routine mental health screening of all primary care patients with long term conditions (who often develop mental health issues);
• continued mental health input to the development of the CLP role;
• GP input to mental health service planning;
• better links needed with NHS 24, Scottish Ambulance Service and Police Scotland to coordinate local and national efforts;
• online referral guidance needed for GPs; and
• create a visible leadership team to be accountable at a strategic level for mental health, to support joined up, collaborative partnership working.

The National Digital Wellbeing Hub – NHS Tayside

• Enables staff, carers, volunteers and their families to access relevant support when they need it.
• Provides a range of self-care and wellbeing resources designed to aid resilience as the whole workforce responds to the impact of coronavirus (COVID-19).

The National Wellbeing Hub offers a range of resources and self-help materials to help individuals at work and at home. The National Wellbeing Hub also provides direct links that will enable individuals to access e-health programmes. There are computerised programmes and all NHS staff have free access. They provide a structured online programme based on Cognitive Behavioural Therapy, that focuses on supporting wellbeing, including managing mental health, building and maintaining resilience, managing stress and sleep.

The Scottish Government has also launched a new mental health helpline for health and social care workers. This helpline will offer support 24 hours a day, seven days a week.

Trained practitioners at NHS 24 will offer callers a compassionate and empathic listening service based on the principles of psychological first aid, as well as advice, signposting and onward referral to local services if required.

NHS Tayside Psychological Therapies Service are offering NHS Tayside staff the opportunity for brief 1-1 interventions (up to 4 sessions)with a psychologist. These are low intensity, informal but structured support sessions helping staff to:

• understand what they are experiencing, thinking or feeling;
• work out what can help, including practical exercises;
• get the best out of self-help materials; and
• identify other options for support.

These sessions are available to anyone who may be experiencing common psychological or emotional reactions to difficulties at work or home (including stress, anxiety, worry, low mood and sleep difficulties).