Islington Practice Based Mental Health Care: Roll-out plans and progress

Report to: Board of Directors (Public) Paper number: 3.2 Report for: Information Date: 26 th October 2017 Report author/s: Emily van de Pol, Divisional Director, Community Mental Health and Primary Care Report of: Andy Rogers, Chief Operating Officer FoI status: Report can be made public Strategic Aims Supported: Early and effective Intervention Helping People to live well Research and innovation Cultural Pillar Supported: We keep things simple We are connected Title: Islington Practice Based Mental Health Care: Roll-out plans and progress Executive Summary Following the successful implementation of a PBMH team in 9 Islington GP practices, Islington CCG has now commissioned for the PBMH service to be rolled out across all 4 GP localities (33 GP practices in total) by the end of March 2018. The service aims to: Develop capacity within Primary Care to manage mental health need through up-skilling GP and other primary care colleagues Improve access to specialist mental health care for those who are most at risk and those with the greatest need Reduce rates of referrals to secondary care through early intervention Delivering efficiencies to the wider system through offering a timely and preventative service. This includes increasing capacity with community mental health teams to offer proactive care coordination The model involves placing a senior, specialist multi-disciplinary team in GP practices where they will work closely with GPs to offer: An accessible, responsive, local and non-stigmatising mental health service Consultation, training, information and advice including liaison with C&I s specialist care pathways Assessment of mental health need and short term interventions This way of working has had very positive feedback from service users, GPs and clinical staff alike. 1

Significant work has been done on further refining the service model, recruitment, GP engagement, EPR configuration and staff development. At present the service is available in 13 practices or 45% of the borough population and is on track to deliver a borough wide offer by end March 2018. Recommendation to the Board The Board of Directors is requested to: Note progress made towards the delivery of an Islington-wide Practice Based Mental Health (PBMH) service. Risk Implications The PBMH service is high profile within the Borough; GP and CCG expectations are high. Failure to deliver the service as contracted and with its related outcomes will lead to reputational damage. Risks identified therefore pertain to service mobilisation and include: GP estate: Co-location is core to building capacity within primary care. Some GP practices may not have adequate space to house practice based teams and may require additional space Recruitment: Delays in full mobilisation as a consequence of needing to advertise/ interview several times to secure high calibre candidates and process issues Configuration: PBMH teams have been developed around 4 GP localities. The CCG is now rolling out CHINS which will replace localities however it is not clear how these will be configured Absence of key management staff/ churn: The Senior Service Manager who has been leading the implementation will leave his post at the end of the calendar year. The Divisional Director will be away from work for 6-12 months from November 2017. These are logged at project level and where relevant on the division risk register. Finance Implications The delivery of a borough wide PBMH service should increase capacity to manage increased volume and complexity of mental health need within primary care. Increased mental health capacity within primary care has the potential to impact on Trust and wider system finances through: Efficiencies as a result of early interventions: Readily accessible and proportionate care at the earliest possible opportunity should prevent more costly interventions later Minimising duplication: Through providing an expert assessment complicated by a senior clinician to avoid repeated assessments between specialist services Moderating activity in the Trust s secondary care/ specialist services. Experience across all trust PBMH services to date is that the presence of an established service reduces referrals into secondary care. If inbound referrals decrease by 30% (the STP assumption) and the rate of discharge from secondary care services remains constant, the total number of service users cared for in C&I s specialist care pathways will fall over time or, where incoming referrals have been increasing over the years as is the case in some teams, caseload activity will stabilise. This creates capacity for specialist care pathway staff to work with smaller numbers of the most unwell service users using an assertive care coordination approach (e.g. 20 people 2

per care coordinator caseload rather than 35) which should in itself lead to fewer mental health crises. Figure 1: Impact of the reduction in incoming referrals as a consequence of PBMH If it is further assumed that people who have recovered from an episode of ill health can be effectively supported by primary care (e.g. those in clusters 0-3 and a proportion of cluster 11), the impact on specialist care pathways and teams is enhanced. The anticipated financial impact is that The increased staff resource required to manage increasing rates of activity is capped Staffing and skill mix in some community teams could be reviewed if there is a significant reduction in activity Reduced demand for acute and crisis services supports the Trust s ambitions to avoid using private/ out of area acute placements The expansion to a borough wide offer has been funded by 965k new investment from Islington CCG Equality and Diversity Impact / Single Equalities Impact Assessment In recognition of Islington s diverse population including BMER and LGBTQ groups and acknowledging the stigma and barriers to accessing care these groups face to care, the service has an explicit aim to offer an accessible service that reduces stigma and enhances equitable engagement. Performance against this ambition is being monitored. There is no indication that the service will affect one group less or more favourably although there is the option to work more assertively to engage hard to reach groups in the future. Other considerations: No legal or compliance issues have been identified This reports has not been produced to meet External Assessor/Regulatory requirements There is no requirement to publish this paper No consultation is required as an outcome of this report 3

Background There is good evidence of the clinical and financial benefits of providing improved mental health support within the primary care setting. These benefits include easier access for people at increased who risk of mental illness who may otherwise not engage with support leading to later more costly interventions and poorer outcomes. However there are barriers to realising these benefits and support is required. GPs want closer links with mental health experts, who can provide quick and easy access to advice when needed. While mental health care comprises a significant proportion of GP activity, high quality mental health care is not consistently provided. Referrals between GPs and hospitals can be significantly delayed and after waiting, people often find that referral criteria for specialist secondary services are not met. This can leave people with mental health difficulties feeling rejected, unsupported, and confused. In December 2014 in response to these challenges, the trust commenced the Islington Primary Care pilot. The C&I Primary Care Mental Health model co-locates a senior, specialist multidisciplinary team in GP practices where they offer: An accessible, responsive, local and non-stigmatising mental health service Consultation, training, information and advice including liaison with C&I s specialist care pathways Assessment of mental health need and short term interventions The model of care has been co-produced with service users. In its first phase, a Primary Care Mental Health Team, since re-named Practice Based Mental Health (PBMH) was available in 9 practices in the North, Central and South West GP localities (33% of the borough s population). This pilot phase noted: Positive service user experience Those who have used the service commented the on the benefits of accessing their mental health care in a primary care context including that this was quicker, more comforting (than having to travel to attend a hospital clinic) and that communication between PBMH and their GP was excellent. Another commented Having this approach meant that during a recent crisis period I was able to see a psychiatrist, psychologist, and psychopharmacologist quickly and conveniently at my GP's surgery..the integration of the service into the practice setting allows for a quicker and more responsive approach, information can be directly shared with my GP who is better supported in the longer term job of managing my treatment and evaluating my progress Positive/Improved GP experience GPs who have access to the serve report positive relationships with the teams who visit the practice, improved communication, a more timely service and ready access to advice and support. One GP commented it s led to clearer communication channels, easier referral methods and easier access to advice in managing patients. A reduction in referrals to Trust secondary care services In December 2016 as part of the 17/19 contract round, the CCG agreed a further 965k investment in the service to deliver a borough wide offer. 4

Aims and Objectives The service aims to: 1. Develop capacity within Primary Care to manage mental health need through: Appreciating that many/most service users who access Secondly Care mental health services also utilise primary care. Up-skilling and supporting Primary Care colleagues so that a greater proportion of lower level need can be managed through routine contacts with GPs, practice nurses etc. Delivering an increasing proportion of mental health care in collaboration with GPs 2. Improve access to specialist mental health care for those who are most at risk and those with the greatest need through: Delivering a service that is accessible and non-stigmatising Supporting the identification and targeting of high risk groups in the local population Managing rates of referral to secondary care services through timely intervention in Primary Care leading to smaller caseload per Secondary Team worker and capacity for assertive care coordination Ensuring those service users who are well enough to be supported in Primary Care are transferred back to this setting 3. Delivering efficiencies through Offering a timely and preventative service Improving the assessment pathway and minimising duplication Facilitating recovery focused care coordination that better manages the risk of inpatient admission The Model and Configuration: Islington GPs have organised themselves into 4 localities with populations of 60-65 thousand resisted patients. The PBMH service therefore comprises 4 teams each working with the practices in that locality. Each consists of a range of disciplines including psychiatrists, psychologists, pharmacists, mental health nurses and social workers. They establish close working relationships with GPs, practice managers, nurses and other primary care partners to provide easy access to help, support and advice. The teams offer consultation and advice to primary care staff and direct assessments of service users in GP practices. For some service users, they offer a joint consultation with their GP, which helps to further integrate physical and mental health care for that individual. One recording system is used by all partners, facilitating timely and joined up communication PBMH is not a case holding service; instead they support case holding GPs. The configuration of the service is described in Figure 2 overleaf. The roles and staffing structure described are seen as a starting point. In the future the service would envisage employing peer coaches and/ or closer working with third sector organisations. Co-production and service user involvement have been at the heart of PBMH since its inception; involvement is sustained by the work of the Practice Based Advisory Committee (part of the sideby-side network) who consult and contribute in an on-going way to service design and evaluation 5

Figure 2: Service and Team configuration Performance and Evaluation The service has agreed a comprehensive set of outcomes and ambitions which inform data collection for later service evaluation in addition to quarterly review. These are set out in the table below. The intention is to capture and quantify the improvements in service user and referrer experience noted in the pilot (see background ) as well as the impacts on activity described under Finance Implications Outcome/ Ambition Demonstrable recovery on clinical outcome measures Patient reported positive experience of care Patients report feeling in control of their care Patients reported recovery outcomes An accessible service that reduces stigma for many patients who prefer to receive care from their GP Data Description Where a patent has extended contact with the service, recovery will be measured based on the Core 10 measurement tool. Client Satisfaction Questionnaire Client Satisfaction Questionnaire % patients who have a personalised crisis/ care plan TBC patient representatives from the Side by Side network to develop a way of measuring this. Activity and demographic data including waiting times, DNA rate, location of appointment etc. No. joint consultations with primary care Service evaluation/ case study on experience of stigma Increased primary care capacity Borough coverage, PBMH practice attendance and training offered Increased primary care confidence GP self-reported Increased primary care satisfaction GP self-reported Reduction in referrals to secondary care Stabilise/ reduce acute activity: (Admissions, LOS, crisis Team referrals) Reduced caseload size (from baseline) Reduced acute division activity Table 1: Service Outcomes 6

Data will be collected from EMIS Community, the new primary care based Electronic Patient Record system which is accessible to GPs that has been configured for PBMH as part of the mobilisation. The new record system will go live in October 2017. For this reason data on many of the outcomes above is not yet available. It is however possible to see the impact of PBMH on activity into Islington s secondary care services when comparing trends in referrals to specialist care pathways including Rehabilitation and Recovery Teams; the Personality Disorder Service; the Complex Depression, Anxiety and Trauma Service and Crisis Teams. The linear data/trend line for practices that do not have PBMH in place shows an increase in referrals into secondary care services over the past 9 quarters. The opposite is true of practices where PBMH is in place; secondary care teams are receiving fewer referrals from patients who have a GP supported by a practice based team. Figure 3 Impact of PBMH on referrals into Islington s secondary care services Strategic Alignment and relationship to other work streams Enhancing primary care mental health services is a key work stream in the North Central London mental health Sustainability and Transformation Plan. Locally the delivery of PBMH is at the heart of the Trusts clinical strategy. Specifically the service: will work in partnership with the Integrated Practice Unit supporting GP s to manage people living with SMI not under the care of secondary services support the C&I Clinical Strategy to provide early, community based psychological treatment and interventions to the local population close to home work very closely with Islington icope services, recruiting to posts that span the services and using psychiatry resource to enhance the IAPT offer 7

will shortly host staff from the Individual Placement Support Trial to increase referrals to that service The service also coordinates the Trust support into Islington s Integrated Health Networks enhancing integrated, coordinated management of people with complex, high care needs in the community As Islington develops its Care Close to Home Networks (CHINS), a construct of the STP, the service will most likely reconfigure to map onto these new structures to further enhance local relationships and integration of care. Mobilisation and realising the benefits As noted above the expectation is for 100% borough wide PBMH coverage by end March 2018. Initial contact and go live dates have been scheduled for all practices within this timescale. Mobilisation planning has taken into consideration learning from the pilot and other PBMH services the Trust has delivered specifically The importance of robust, trusting relationships between GPs and the MDT. These take time to embed and establish. Patters of referral practice when PBMH starts in a new practice described below and demonstrated graphically though a comparison of referrals to PBMH year on year overleaf. Phase Time Scale Referral Type Phase one: 0-3 mouths from go-live in a new practice Loudest High number of referrals; typically the patients who cause GPs the greatest concern. Phase two: 4-6 from go-live in a new practice Quiet Concern Moderate number of referrals; the cohort of patients GPs are concerned about but who do not necessarily access care). Phase three: 6 months + from go-live Plateau Referrals stabilise; New need Table 2: The typical pattern of referrals when commencing PBMH in a new practice Mobilisation to date has been contingent upon staff recruitment. Where necessary temporary staff have been recruited to keep plans on track When the service is fully established and embedded, work to transfer stable cluster 11 and other patients back to their GPs with PBMH support. This is likely to commence in 2018/2019 Communication and Publicity The service has not had a public launch opting instead for one to one contact with GPs as part of a carefully managed process to mitigate the risk of teams being overwhelmed. At present the service does not take self-referrals but has developed information for service users. The service is developing an internet page to ensure Trust staff is up to date with the roll out and now provide 6 weekly updates to Islington GPs via their bulletin. The service may choose to publish an evaluation at a later date. In the meantime the team is considering opportunities to highlight and share the work and model, for example the lead consultant is submitting a blog to NHS E which 8