A New Model for Primary Care Psychotherapy: PCPCS in Hackney & TAP in Camden Dr Julian Stern

Transcription

1 A New Model for Primary Care Psychotherapy: PCPCS in Hackney & TAP in Camden Dr Julian Stern Mental Health, Ill Health and Personality Disorder Conference, June 2016, London

2 Structure of talk 1. A Model of Primary Care Psychotherapy and Consultation service the Tavistock model 2. Modifications as it has evolved 3. Case material-mr A, Ms B 4. Psychological Defences and Psychotherapeutic interventions 5. Links with the work of George E Vaillant 6. Research and Health Economics

3 Dr Rhiannon England, City & Hackney GP-in 2009 What we wanted was a service which had very flexible referral criteria - based in surgeries, for GP referral only - and who could both see patients and consult to GPs about patient management. (2009) We knew the service would have to be comprised of very experienced clinicians - as we also knew that the patients we were holding were often highly complex patients.

4 City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS) An innovative outreach service provided by the Tavistock and Portman NHS Foundation Trust-started in Supports GPs to manage patients with complex mental health and other needs that result in frequent health service use. Supports people with medically unexplained symptoms, personality disorders and chronic mental health problems. Many have psychiatric co-morbidity and many also have poor physical health/ltc s.

5 What we offer to patients-always seen in GP surgeries Assessment (1 or more sessions) identifying on-going care plan. Extended consultation (typically offered over 4-6 sessions working on a specific issue identified in assessment). Brief psychological treatment, one-to-one (6-16 week evidence-based psychological therapies, including cognitive behavioural, dynamic interpersonal, and mentalisationbased therapies. Group psychological treatment (brief structured psychoeducational therapeutic groups; physical symptom groups; and mentalisation-based therapy groups). Case management (face-to-face/telephone/service liaison). Family therapy and couple therapy.

6 Varied Approach to Interventions Brief Dynamic therapy Dynamic Interpersonal Therapy Mentalisation-based Therapy Cognitive Behavioural Therapy Couple & Family Therapy Mindfulness approaches Groups

7 What we offer to GPs Joint consultations with GPs and patients : 3 way consultation Professional consultation to GP and other primary care staff : 2 way consultation Case based discussion with GPs and other practice staff. Tailored trainings to GPs and other practice staff. Liaison with other services and agencies. Signposting to other appropriate services.

8 We haven t stood still Model & approach been built on flexibility, adaptability in the face of changing needs and context- Work in A and E, horticultural groups, care planning etc 2015: Won the bid - in partnership with MIND in Camden - to run the Camden TAP service (Team around the Practice).

9 An example of our Staffing Structure: Camden TAP

10 Maximising Positive Health & Social Care Outcomes for PCPCS & TAP Service Users Outcome monitoring Service user involvement Strong link with Mind in Camden and voluntary sector groups

11 Our patients

12 Propagating the model RCPsych Team of the Year award 2013 BMJ Mental Health Team of the year award 2015 HSJ (Health Services Journal) paper June 2016 E-learning modules Publications Presentations

13 Propagating the model-hsj June 2016 Taking mental health a step beyond primary care 10 June, 2016 By Dr Julian Stern, Katherine Yon, Tim Kent A new mental health service delivers integrated care to complex patients who have not historically been well served

14 An Award-Winning Service Winner of Royal College of Psychiatrists Psychiatric Team of the Year Award, Winner BMJ Mental Health Team of the Year Award, Showcased in many publications including King s Fund Document 2013 Delivering Better Services for People with LTCs. Centre for Mental Health Report 2014, demonstrating gold standard evidence of cost effectiveness.

15 External evaluations Capita (2011) & CMH (2014) (to be discussed later in presentation)

16 2 Recent Cases: Mr A and Ms B Mr A-seen twice for assessment by JS Then for brief dynamic therapy in our service Question of letters to GPs and liaison with GPs What is possible in Primary Care?

17 Links with the work of George Vaillant 3 Broad principles in enabling patients replace immature defences with more mature ones: 1. Stabilizing the external environment 2. Altering the internal environment 3. Controlling countertransference

18 External evaluations

19 Outcomes 3 PROMs GAD7, PHQ9, Work & social adjustment scale. 75% of all patients show improvements in their mental health, wellbeing and functioning as a result of treatment. 55% are shown as having recovered, meaning an improvement in mental health which moves a patient to below the threshold after treatment. These improvements compare favourably with those achieved by IAPT services, even though the latter typically treat less severe and complex cases.

20 Savings The treatment by the PCPCS reduced the costs of NHS service use by 463 per patient in the 22 months following the start of treatment. Savings in primary care accounted for 34% of this total (mainly fewer GP consultations) and savings in secondary care for 66% (fewer A&E and outpatient attendances and inpatient stays).

21 Good value for money A typical course of treatment by the PCPCS lasts for 12 or 13 sessions, at an estimated average cost of 1,348 per patient. The subsequent savings from reduced health service use are equivalent to about a third of this cost: a significant offset. Cost effectiveness Based on the cost-effectiveness framework used by NICE, it is estimated that treatment by the PCPCS has a cost per QALY (quality-adjusted life-year) of around 10,900. This is well below the NICE threshold range of 20,000-30,000, indicating that the service is good value for money.

22 GP Satisfaction - Very high levels of satisfaction It feels genuinely collaborative, the most rewarding relationship in 25yrs of practice. I really got a lot of benefit from the joint consultation. Excellent clinicians and very straight forward; I wish the waiting list could always be shorter. I think this is because there are problems with the quality of the alternate service - primary care psychology IAPT. It is very helpful to speak to therapist personally to see whether a referral is appropriate. It is usually easy to get hold of the therapist.

23 Thank you plex-needs-report