Developing a Primary Care
Mental Wellbeing Network
Rhiannon England/David Maher
April 2014
Whole System Review – A case for change
1)
System re-design is required with a shift towards primary care based provision
2)
A prevention strategy will reap short and long term benefits
Social resilience and primary prevention improve individual and population mental well being
Secondary prevention interventions, including employment, housing and social networking, improve the quality of life and recovery
prospects for people with mental health problems
3)
Pathways and access routes must be clear – a real single point of entry
With information about the range of services readily available to users, carers and professionals
4)
Quality improvement is vital
5)
Outcome measurements need development
Successful implementation will:
improve and simplify access to specialist services
increase access to universal services
Increase independence, choice and control
support individuals to live ordinary, independent lives in their local communities
focus on both the social, health and employment requirements of patients at all steps of their care experience
promote resilience and staying well
2
Effective & Innovative Commissioning
Least Intensive First Time
Mental health services to work with community services, local organisations and primary care to enable people to access the right
services as early as possible
Care Closer to Home
Continue the emphasis on preventing hospital admission & extending the options for out of hospital care through the use of Serious
Mental Illness Local Enhanced Services
Building resilience
Commitment to the recovery model, promote the ability to live ‘ordinary’ independent lives & support people to use Recovery Plans
to map their success and keep positive
Customer Service
Safe services of excellent and effective quality, choice and control and outcomes focused
GPs as patient advocates in commissioning planning
Building collaborative care networks
Working with Local Authorities and other partners in building truly integrated support pathways for people
Why Primary Care?

GPs are trusted

nine out of ten patients were satisfied with the care they received at their surgery and over half of
patients were ‘very satisfied’ (54 per cent). Only four per cent of patients were dissatisfied with the
care they received. This suggests that the current doctor-patient relationship is highly valued and that
the public place a significant degree of trust in doctors as professionals.

GPs know their communities, know their patients, and are best placed to apply a local
and patient centred evidence base to designing future MH services

Primary Care have developed skills in managing Long Term Conditions

GPs understand the bio-psycho-social aspects of mental illhealth and are able to take a
more holistic view of ‘what works’
Local Context – A Primary Care model of Mental Health
5
A primary care model of mental health requires building (The City and Hackney 3 Cs):
-Capacity within primary care to care for repatriated CMHT patients as part of commissioning intentions to deliver increased
care closer to home
-Confidence within primary care by increasing liaison and shared care management of patient groups
-Competence within primary care to develop the skills and motivations to effectively and safely treat more patients with
mental health conditions as part of core primary care
An effective model will ensure:
-Working partnerships with community mental health services, third sector organisations, and service users
-Co-production of pathways to a range of evidence-based & risk-assured, well-being and preventative interventions
-Promotion of the principles of recovery and social inclusion
-Raised awareness of the mental health needs within GP practice registered populations
-Raised level of skill and knowledge available within primary care in the recognition, assessment and treatment of mental illness
-Increased capacity within primary care to manage the needs and treatment of people with serious mental illness
-Evidence based Primary Care mental health interventions integrated across clinical networks
-Improved communication between mental health services and Primary Care
City and Hackney MH Enhanced Primary Care Model
Primary Care (44 Practices working in 6 Consortia)
Funding required
(from shifted FOA
and dementia
cluster 18)
Funded through
dementia bed
centralisation
Funded nonrecurrently
6
Primary Care
Liaison
(Clusters 3,11)
1 x WTE
Primary Care
Liaison
(Clusters 3,11)
1 x WTE
Primary Care
Liaison
(Clusters 3,11)
1 x WTE
Primary Care
Liaison
(Clusters 3,11)
1 x WTE
Primary Care
Liaison
(Clusters 3,11)
1 x WTE
Primary Care
Liaison
(Functional
Older Adults,
Cluster 18)
1XWTE
Primary Care
Liaison
(Functional
Older Adults,
Cluster 18)
1XWTE
Primary Care
Liaison
(Functional
Older Adults,
Cluster 18)
1XWTE
Primary Care
Liaison
(Functional
Older Adults,
Cluster 18)
1XWTE
Primary Care
Liaison
(Functional
Older Adults,
Cluster 18)
1XWTE
Primary Care
Liaison
(Functional
Older Adults,
Cluster 18)
1XWTE
Primary Care
Dementia
Advisors
1x WTE
Primary Care
Dementia
Advisors
1x WTE
Primary Care
Dementia
Advisors
1x WTE
Primary Care
Mental Health
Guides
Primary Care
Mental Health
Guides
Primary Care
Mental Health
Guides
Primary Care
Dementia
Advisors
1x WTE
Primary Care
Dementia
Advisors
1x WTE
Primary Care
Dementia
Advisors
1x WTE
Primary Care
Mental Health
Guides
Primary Care
Mental Health
Guides
Primary Care
Mental Health
Guides
Primary
Care
Clinical
Support
Secondary Care
Funded through
SMI shifted activity
Primary Care
Liaison
(Clusters 3,11)
1x WTE
Primary
Care
Ancillary
Support/
Guides
Acceptance Criteria
Secondary Care to Local Enhanced Service
Local Enhanced Service into Primary Care GMS
Currently under the care of secondary care and a:
Non-CPA Patient in Cluster 3
Non-CPA Patient in Cluster 11
Non-CPA Patient in Cluster 1,2,18 who meet criteria for Local Enhanced
Service (ie Depot provision)
Non-CPA Patient on SMI Register who meet criteria for Local Enhanced
Service
GP as RMO coordinates decision following a formal multi-disciplinary review
with the prescribing GP, practice staff and the Mental Health Liaison Function
Managing well in settled accommodation and able to meet basic living needs
Patient is stable and has no significant clinical, social or risk management
issues
Requires minimal assistance with medication concordance and is stable on
medication, but will require review and monitoring
No outstanding care-plan actions
Patient is able to exercise choice
No additional needs above those provided under QOF
Identified relapse Management Plan
Agreement of patient and MDT LES Team
Less than 3 contacts in preceding 12 months
Not requiring depot medication
7
Key Roles
SMI Local
Enhanced Service
SMI QOF
Primary Care
• Co-ordinates transfer of patient to GP care including Information
Governance authorisation from patient.
• Enables development of rapport between the patient, any carer,
secondary care and the GP.
• The transfer process offers the opportunity to clarify and model the
monitoring process with the GP.
• Monitoring includes ensuring case notes are updated across
management systems
• Transferred patients are reviewed clinically initially six monthly to
ensure appropriate care and appropriate stepping up or down.
• Intervene to provide interventions for brief periods to re-establish
clinical relationships that show signs of breaking down.
• Supports the clinical assurance process for moving SMI patients
onto a Local Enhanced Service provision.
• Provide pre-assessment support for those patients who may need
stepping up into secondary care.
• A patient registration and tracking system maintained by liaison
function supports the GP in maintaining continuity of care and
provides information about satisfaction and other quality
assurance metrics.
• Coordinates quarterly Consultant-Led clinics for case discussion
and professional development.
• Supports the delivery of a Development Curriculum to upskill
primary care in managing mental health conditions.
Enhanced Primary Care Liaison Function
Secondary Care
• Determine the appropriateness of referrals according to selection
criteria guidelines.
• Prepare and write the transfer summary, then co-ordinate the
transfer process.
• Collate risk assessments and medication management plan.
Stepped Care Cost & Monitoring Framework
LOCAL ENHANCED SERVICE
PAYMENT
MONITORING
Patients on depot medication.
£80LES
percosts
quarter
due to the shift of
Lithium – 3 monthly blood monitoring.
patients
(i.e. £320 per year)
NHS ELC Wide
£137,600
Depot or other antipsychotic medication – 6
monthly GASS.
Comprehensive care plan review including holistic
health review – 2 per annum by Liaison Nurse, PN
and GP. 2
SMI patients discharged into primary care not on
depot. This pays for the second of the bi-annual
clinical reviews conducted by the practice for SMI
patients (the first review is covered under QOF
payments). 1
£100 per year
Initial year 1 payment for SMI register data
matching with ELFT.
£250.00
LIAISON FUNCTION
COST
MONITORING
Quarterly consultant-led clinics & development
sessions operating at practice, cluster and/or
network level.
Liaison Nurse
12 x Band 6
12 x Band 5
£100,000
Cluster and network level engagement with
Effective Shared Care Arrangements agreed and
implemented.
Responsible to secondary care clinical governance
but with accountability to primary care. Shared
care agreements at practice level4
9
*£100 per patient discharged into primary care
£700,000
Transforming health services – Case Examples

Primary Care based mental health provision through Serious Mental Illness Local
Enhanced Service- (EPC- Enhanced Primary Care)

Primary care based psychological therapies support for:

medically unexplained symptoms where significant psychological features are present

Personality disorders, experiencing crisis or difficulty engaging in services and where
secondary or tertiary care is not appropriate

People with mental health problems who have been discharged from services and do
not meet referral thresholds for current primary or secondary services

“Frequent attenders” for GP consultations in primary care

Difficult or poor engagement in services

A&E based psychotherapy support for frequent attendees, MUS and difficult to
manage patients

Rapid Assessment Interface & Discharge service:

Psychiatric liaison service reducing admissions, reducing length of stay and
rapidly coordinating care

Providing holistic support for acute in and outpatients

Streamlining care pathways for those with co-morbidities