Primary Careand Mental Health

David Kingdon Professor of Mental Health Care DeliveryClinical Service Director - Adult Mental Health

5 YEAR FORWARD VIEW• ‘Primary care staff are not yet fully

equipped to provide high quality mental health care.

• More than four out of five practice nurses have responsibilities for which they have not been trained, with 42 per cent having no training at all in mental health, according to the Royal College of GPs.

• The training of GPs could also be improved to ensure they are fully supported to lead the delivery of multi- disciplinary mental health support in primary care.’

5YFV

• ‘This will involve developing, evaluating and implementing models of primary care whereby GPs and practice nurses take responsibility for delivering the full suite of physical care screenings, outreach, carer training and onward interventions or referrals, in line with NICE guidelines.

• This model should include outreach workers or carer training to support people to access primary care because many people with psychosis struggle to access services, and give GPs and practice nurses the training and time they need to deliver NICE-concordant screening and care.’

5YFV• The new models of care being piloted by the

vanguard sites offer opportunities to improve care for people with mental health problems by, for example: – working with Primary and Acute Care Systems

(PACS) to incorporate mental health screening and support within maternity pathways, and considering new payment models for integrating mental health care within tariff prices working with Multispeciality Community Providers (MCP) to provide integrated psychological support within wider primary care and community services provision, and supporting mental health inpatients more effectively to manage their physical health

5YFV• ‘People with mental health problems often also receive

poorer physical health care. Those with severe mental illness die on average 15-20 years earlier than the general population.

• They are three times more likely to attend A&E with an urgent physical health need and almost five times more likely to be admitted as an emergency, suggesting deficiencies in the primary care they are receiving.

• The reverse is also true – people with long term physical health conditions do not routinely have mental health support included in their care package.

• In future, new models of care will support people’s mental health alongside their other needs, including physical health, employment, housing and social care and will have a greater emphasis on prevention, self-management, choice, peer support, and partnership with other sectors’

Mental Health Task Force

• ‘Models of primary mental health care are also under-developed, and people with mental health problems are not always well supported in primary care with either their mental or physical health care needs.

• ..vanguards..’

General Practice Forward View

• ‘…. what we do, namely person-centred coordinated care of complex physical, mental and social issues…

• Investment in an extra 3,000 mental health therapists to work in primary care by 2020, which is an average of a full time therapist for every 2-3 typical sized GP practices.’

What are the issues?• Nine in ten people with mental health problems are

seen in primary care: – i.e. they have to get really ill before they meet

criteria for CMHTs– 30% of consultations involve mental health

issues• 63% of patients committing suicide saw their GP in

previous year– Only 8% who died had been referred to

specialist mental health services in previous year

• 26% were under mental health services• MHTF target to reduce suicide rate by 10% by

2020/1

Workforce• GPs are stretched and recruitment is a major

problem• Psychiatrists are stretched and recruitment is a

major problem• CPNs are stretched and recruitment is a major

problem• Psychology is a very popular degree• Recruitment to clinical psychology, psychology

assistant posts & mental health practitioner programmes is good

• Similarly for ‘case managers’

Rathod et al. (2015). Pathways to recovery: A case for adoption and implementation of systematic pathways in psychosis and Schizophrenia. Jointly produced by Imperial College Health care partners and Wessex Academic Health Sciences Network.

Rathod et al. (2015). Pathways to recovery: A case for adoption and implementation of systematic pathways in psychosis and Schizophrenia. Jointly produced by Imperial College Health care partners and Wessex Academic Health Sciences Network.

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Southampton

 Individual Family/home

basedCommunity - Structural

Systems

Early Years and Family Formation

Perinatal pathways of support for mothers PERINATAL TEAM (SHFT)

General wellbeing supportAssessment or risk and early interventionSpecialist SupportInpatient 

Support  for Attachment  Peer Support Groups for young mums (or young fathers)

Maternal health Health visitingPrimary Care

Children and Adolescents

Self Management Approaches (including digital)Psychological interventionsCAMHS (Solent)/BRS Service DSH rota/Psych Liaison/FDAC 1:1 therapy and pathways groupsNo Limits Safehouse 1:1 support Independent visitors Substance use (DASH) Housing/money advice MASH – safeguarding children

Parenting ProgrammesCAMHS (Solent) Incredible years programme Foster parenting Adoption NVRSouthampton community family trust

Family TherapyCAMHS (Solent)

Whole School approachesHEADSTART (LA)CAMHS/BRS Schools worker teacher training virtual schooling Emotional welfare officers Bullying programmesBehaviour InterventionsBarnadosBUZZ (No Limits)

EducationFurther EducationUoS SSUPrimary CareSTAR (SHFT)

Adults Workplace support – line management interventionsPsychological Interventions – CBT, Solution focusedAMHT(SHFT)STEPS TO WELLBEING (DHFT)

EARLY INTERVENTION FOR PSYCHOSIS

Parenting supportParent support workers (CAMHS)

Carers supportCarers in southamptonRelateAMHT(SHFT)

Stigma & discrimination programmesLAMentally Healthy Workplace approachesMETrauma informed services  PIPPASubstance misuse servicesHomeless healthcare team

WorkPlaceHousing LANHS – GeneralPrimary CareSTAR (SHFT)

Later Life Self management for long term conditions

Pre-retirement prep

OPMH (SHFT)

Family based Dementia supportOPMH (SHFT)Socially connected care homes

Admiral nurses

Volunteering oppsSVS MINDPeer Mentoring/BefriendingPsychologically informed physical health settingsCommunity groups:    City Farm    Age UK    Church groupsTinder Foundation

Primary CareSTAR (SHFT)Home HelpNHS – GeneralCare Home Sector

Dementia Friendly communities

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PSYCHOSIS

SEVERE ANXIETY/DEPRESSION

‘BORDER-LINE’

INTERVENTION

EVIDENCE-BASE FOR PRIMARY MENTAL HEALTH CARE (Dowrick, 2016)Non-medical interventions for depression and related disorders: Psychosocial therapies

– Cognitive–behavioural therapy – Interpersonal therapy – Problem-solving treatment – Behavioural activation

Mindfulness Exercise Personal resilience Smoking cessationCollaborative Care

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Collaborative care for depression and anxiety

Cochrane Review (Archer et al, 2012), collaborative care was found to be associated with significant improvements in outcomes compared with usual care in the USA:

Care management, encompassing 6-12 contacts between care managers and patients over a period of no more than 14 weeks. The norm for all but the first contact was via telephone. Contacts were designed to be structured, including:

– Formal assessments of mood using the Hospital Anxiety and Depression Scale (HADS);

– Help for patients to manage any prescribed antidepressant medication;– Direct support for patients with behavioural activation, a brief

psychosocial intervention (Ekers et al, 2008) which aims to engage people in activities bringing improvements in mood.

Care managers keeping in close contact with GPs, using a structured protocol, receiving structured supervision from mental health specialists representing a number of different professional groups.

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UK Results:

At 4 (but not 12) months, quality of mental health significantly better for those in the collaborative care group, with no differences being found between groups for anxiety

Outcomes predicted by how much behavioural activation they undertook

Cost £272.50 per person receiving it, more satisfied with the care they had received than those receiving usual care

Collaborative care offered gains in quality-adjusted life years, and in the health economics analysis was judged as affordable.

Richards DA, Bower P, Chew-Graham C, Gask L, Lovell K, Cape J, et al. (2016) Clinical effectiveness and cost-effectiveness of collaborative care for depression in UK primary care (CADET): a cluster randomised controlled trial. Health Technol Assess 2016;20:14

Southampton Primary Care Mental Health ‘STAR’ Project

Initiative funded for one year as part of ‘Hubs’ project – ‘Prime Ministers Challenge Fund’

Objective: – provide structured needs (DIALOG) & symptom assessment (PHQ9 &

GAD7), problem-solving & connecting people to community resources Referral criteria: emotional needs Exclusion:

– currently receiving care from Substance misuse team, IAPT or MHT Staff:

– three Band 4 STAR (support, treatment & recovery) workers supervised by Band 6 CPN (back-up of CMHT/Clinical Services Director)

Working hours: – day time (+ evening/weekend sessions)

Process of referral: – by GPs through ‘hubs’ from mid-November 2015

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Progress

Recruitment has been slow to take off… Publicity, visiting, networking, list searching (>10

visits/year) Referrals to CMHT who don’t meet criteria Discharges from CMHT & AMHT Reducing cost effectiveness, affecting staff morale &

jeopardising project Skill mix

Band 4: effective with majority Band 6: for support and more complex cases

Outcomes: Patient experience (qualitative study) & clinical outcome GP attendance rates

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Participants

PHQ9 mean 18.7 (3/55 <10) GAD7 mean 15.7 (6/53 <9) DIALOG items

Frequency (1) Percent Frequency (2)

Mental Health 29 44.6 3Consultations 1 1.5 0Physical Health 2 3.1 5Job situation 5 7.7 3Accommodation 7 10.8 3Leisure activities 1 1.5 1Friendships 4 6.2 2Partner/family 8 12.3 5Personal safety 0 0 3

Total 65 25

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Problems presenting:

– Termination - linked to Firgrove centre– Loneliness – renegotiated with family– Bullying by son – involved police– Intimidated by father – assisted to move out (confidence & location) &

deal with weekend drinking (substance misuse services)– Son with autism – safeguarding support– Abuse – linked to rape crisis (safeguarding)– Work pressures – left work– Suicidality – process in place for review; Acute MHT, CMHT, manage in

primary care– Depression – supported to IAPT/counselling– Autism spectrum – linked to RELATE email counselling– Daughter/sister – parents & brother with MI; linked to carers support– Male – suicidal feelings, sleep hygiene & linked to CALM– Son with ADHD - go back to ADHD support group & contact school re

attendence problems - son restarted school; reviewing meds with GP– Worried about FH of cancer - McMillan counselling set up. Linked with

IAPT & SARC: info on sleep hygiene and self-help for suicidal thoughts

Resources

(websites & leaflets)

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People want to access more healthcare online providing quality is not sacrificed

70%

75% of people would like to access their healthcare online providing quality is not sacrificed 

75%

More than 70 percent of all older patients in the UK want to use digital healthcare services

Families are demanding more convenient care that is easy to access

Sources: Capture the growth report, PwC, February 2016; Healthcare’s digital future, McKinsey, July 2014

Older demographicOnline healthcare Accessibility to services

Many

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STAR project: Digital dimension through a ’virtual nurse’ interface

Client&

family • Automated referral to services

• Automated apt. booking systems

Automated step-up

Automated step-down

Low Intensity High Intensity Low Intensity

‘Virtual nurse’ experience to provide: • Low level psycho-education

• Passive tracking (e.g. activity levels, sleeping)

• Active tracking (scales & questionnaires, facial emotions)

• Reminders 

Human connection to provide: • Remote psychological interventions

• Remote NHS Psychiatric/GP intervention

• In-person visit by healthcare professional

‘Virtual nurse’ experience to provide: • Continued skill embedding

• Passive tracking (e.g. activity levels, sleeping)

• Active tracking (scales & questionnaires, facial emotions)

• Reminders 

Interconnected tools along the journey to provide a seamless experience from the home

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• Delivers improved outcomes• Built on best evidence within each therapy area

• Multimedia to enhance learning experience and engagement

• Breaks down geographical barriers in bringing the family together

• Integrated into existing clinical pathway and practice

• Enhances compliance and improves engagement with patient and family

• Ability for pre-programing based on local protocol 

• Supports patient intake process and on-going self-care

• Acts as triage to refer to appropriate “step up” care 

• Integrated with NHS systems

• Ability to get important information back to treatment teams

• Supports treatment teams to prioritise resource

• Supports clinical decision making• Dashboard has potential to mitigate relapse

Online clinician-led intervention Virtual nurse avatarDecision support tools

Integrated digital solutions designed to improve outcomes, provide greater access, choice and convenience in a cost effective & scalable way

FOUR YEAR FORWARD VIEW Continue and develop primary care teams linked to IAPT &

CMHTs:– Psychiatrist & psychologist (sessional)– CPNs– STAR workers

Offering– Problem-solving & linkage– Brief interventions (individual & group):

worry & coping skills work for somatisation (‘MUS’) and emotionality (distress & anger)

– Work with SMI supported in primary care Reassess treatment packages (e.g. family work, CBT &

employment) Physical health care monitoring & interventions

– Consultation & support– Collaborative care planning with GPs/ED

Repeat attenders

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