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NHS reform and transition
A primary care approach
to mental health and wellbeing
Case study report on Sandwell
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Contents
Executive summary
2
Introduction
3
Background
4
The drivers for change
6
The commissioning response
7
A collaborative primary care model for mental health and wellbeing
9
A stepped approach to provision
10
Learning points for implementation
17
Conclusion
19
Acknowledgements
20
References
21
02
A primary care approach to mental health and wellbeing
Executive summary
The importance of mental health and
wellbeing cannot be understated. It affects
and influences the lives of individuals,
families, communities and societies. There
is growing evidence that positive mental
health and wellbeing at a population level
can reduce health inequalities and improve
wider outcomes in relation to physical health,
social cohesion and economic productivity.
This report presents a detailed case study of
the journey Sandwell’s health commissioners
(then Sandwell PCT, now Sandwell and West
Birmingham Clinical Commissioning Group)
went through to respond to a number of
important health inequalities within its local
population. It focuses on how its health service
commissioners responded to specific health
inequalities to develop a primary care-led
approach to improving mental health and
wellbeing. The specific health inequalities
they sought to address included:
•poor levels of mental and physical health
•social deprivation
•poor access to low-intensity community
mental health and wellbeing services
•heavy use of secondary care mental
health services.
Sandwell’s primary care approach to mental
health and wellbeing is a direct and practical
response to stark health inequalities within
its locality and challenges that many health
service commissioners across England face. The
approach, known as the collaborative primary
care model for mental health and wellbeing,
uses the principles of collaboration, co-location
and integration to support its population to
access low-intensity services and healthcare
professionals when making referrals. The
purpose of each low-intensity service is to
empower the population to make decisions
about their own care and improve emotional
resilience and wellbeing.
The approach also illustrates how early
intervention and prevention, through a stepped
approach to provision, can improve existing
service infrastructure.
The Sandwell primary care approach to
mental health and wellbeing has shown some
promising early outcomes, with over 4,000
people completing prevention, wellbeing
and health improvement programme, saving
around £800,000 in prevention costs. In
addition, over 3,000 people have accessed
talking therapies, saving around £600,000. It
provides some key learning points for wider
commissioners to consider, namely:
•the continued need to align primary
healthcare with key partners and
stakeholders, including probation services,
secondary care acute and mental health
providers, schools, libraries and colleges
•the importance of investing in education
and training for primary care and community
care staff
•the importance of clinical and service
user engagement.
Under new commissioning arrangements
ushered in by the Health and Social
Care Act (2012), the Sandwell example
highlights the need to respond to strong
evidence of local health inequalities. At a
local level, clinical commissioning groups
(CCGs) along with health and wellbeing
boards may wish to utilise the evidence
within joint strategic needs assessments
to drive a primary care-led approach to
mental health and wellbeing services. At
a national level, the NHS Commissioning
Board and Public Health England will need
to work together to enable this type of
local innovation and priority setting.
A primary care approach to mental health and wellbeing
Introduction
There is growing evidence that positive
mental health and wellbeing at a population
level can reduce health inequalities and
improve wider outcomes in relation to
physical health, social cohesion and economic
productivity. This case study report illustrates
the vital role that health commissioners
can play in ensuring mental health and
wellbeing services are accessible, meet local
needs and drive collaborative working.
It presents a detailed case study of the
journey that Sandwell’s health commissioners
(then Sandwell PCT, now Sandwell and West
Birmingham Clinical Commissioning Group)
went through to respond to a number of
important health inequalities within its local
population. These include poor levels of mental
and physical health, social deprivation, poor
access to low-intensity community mental
health and wellbeing services and heavy use
of secondary care mental health services.
The report focuses on four specific aspects of
Sandwell’s story:
1. The demographic context and drivers – the
specific health inequalities that prompted
the development of a primary care-led
approach to mental health and wellbeing
and its priorities.
2. The collaborative primary care model that
Sandwell’s health service commissioners
adopted to address the challenges.
3. The service infrastructure that has been
developed to make the model a reality
and work across a whole population while
meeting individual needs.
4. The learning points from the
implementation of the model for other
commissioners.
‘There is growing evidence
that positive mental health
and wellbeing at a population
level can reduce health
inequalities and improve
wider outcomes in relation to
physical health, social cohesion
and economic productivity.’
03
04
A primary care approach to mental health and wellbeing
Background
The Government’s mental health strategy,
No health without mental health, describes
mental wellbeing as “[a] positive state of mind
and body, feeling safe and able to cope, with a
sense of connection with people, communities
and the wider environment.” It affects the
lives of individuals, families, communities and
societies, and influences individual behaviour,
wider social cohesion, social inclusion
and economic prosperity.1 Positive mental
wellbeing also improves overall physical health,
encourages recovery more rapidly and promotes
higher levels of employment and productivity.2
Psychological wellbeing
A growing amount of research has explored
the benefits of positive psychological states
such as contentment and fulfilment,3 often
collectively referred to as psychological
wellbeing. Far from being associated with
the absence of mental health difficulties,
psychological wellbeing has distinct causes
and significant implications across a range
of wider outcome areas. For example, people
who report higher levels of wellbeing tend
to be more involved in social and civic life,
are more likely to behave in environmentally
responsible ways, have better family and social
relationships at home and are more productive
at work. In addition, a recent review of
literature has found that wellbeing is positively
associated with positive health outcomes.
In response to the growing body of evidence in
the area, the Department of Health launched
the coalition Government’s mental health
outcomes strategy, No health without mental
health (2011). The strategy emphasised an
important shift in policy, giving considerable
attention to promoting positive and more
preventative approaches for mental health and
wellbeing across populations. The strategy also
made mental wellbeing a priority for public
mental health.4
Sandwell’s socio-economic landscape
A metropolitan borough located within the
West Midlands, Sandwell is comprised of six
towns; Oldbury, Rowley Regis, Smethwick,
Tipton, Wednesbury and West Bromwich. It is
also the 14th most deprived local authority in
England with 53 per cent of its wards described
as “very deprived” (as of 2011).
The borough has some important socioeconomic contexts in its population, such as:
•around 23 per cent of residents are from black
and minority ethnic (BME) groups, specifically
of South Asian origin (Indian, Pakistani
backgrounds)5
•the area has a high unemployment figure
at 4.5 per cent, compared to the England
average of 3 per cent (as of 2010) – this is due
to the decline in manufacturing in the past
decade, which saw the number of jobs in the
region fall by 13 per cent, compared with a 7
per cent fall nationally
•it has higher-than-average Job Seeker
Allowance (JSA) claimants rates in comparison
with regional and national levels – this
includes higher overall unemployment
(including those not claiming benefit) and
lower economic activity rates
•the borough has higher than average levels of
‘non-decent’ homes and 7.4 people per 1,000
households receive statutory homeless status
(as of 2010).
A primary care approach to mental health and wellbeing
Physical health
The physical health of people in Sandwell is
also generally worse than the England average.6
•Life expectancy for both men and women is
lower than the England average. In the most
deprived areas of Sandwell, life expectancy
for men is 10.1 years lower than in the
least deprived areas. For women, it is
5.9 years lower.
•Over the last ten years, all-cause mortality
rates have fallen. Early death rates from
cancer, heart disease and stroke have fallen,
but remain worse than the England average.
•23.5 per cent of year 6 children are classified
as obese.
•A lower percentage than average of pupils
in Sandwell spend at least three hours each
week on school sport.
•Levels of teenage pregnancy and
GCSE attainment are worse than the
England average.
•Estimated levels of adult ‘healthy eating’,
smoking and obesity are worse than the
England average.
•Rates of smoking-related deaths and
hospital stays for alcohol-related harm are
higher than average.
Gathering the evidence for change
In 2006, Sandwell Primary Care Trust, currently
in transition to Sandwell and West Birmingham
Clinical Commissioning Group, undertook a
mental health GP profiling assessment. This
identified that Sandwell had high levels of
mental ill health in wards that are socially
deprived and have high unemployment. A gap
analysis also showed that the diversity of needs
in the borough were not being met, leading to
higher-than-average representation of BME
groups within acute services and generally low
uptake of community lifestyle services.
Part of this was due to fragmentation, as
primary care services were not sufficiently
connected to secondary care mental health
services. Sasha Gelpi, mental health promotion
lead, said “at that time, the system was close
to collapse, GPs were not referring patients to
the right services due to a lack of awareness
and unresponsive services. Community services
were very disconnected or had 18-month
waiting lists – something had to change.”
The GP profiling assessment also highlighted
that there were correlations between people
diagnosed with depression and other long-term
conditions, particularly cardiovascular disease
and diabetes. Of people attending GP surgeries,
nearly one-third have mental health problems.
In addition, 15 per cent of GP consultations,
and a staggering 50 per cent of hospital
outpatient consultations, arise from a high cost
group with medically unexplained symptoms.
The GP profiling assessment report suggested
that there was an immediate need to prioritise
and make adequate provision and prevention
for depression, which represented the highest
prevalent disorder, with high numbers of
people not receiving therapy but receiving
anti-depressants.
05
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A primary care approach to mental health and wellbeing
The drivers for change
The socio-economic, service provision and
access challenges in Sandwell translated into
three drivers for creating a radically different
approach to mental health and wellbeing
provision within Sandwell.
1. The need to tackle the low aspirations and
emotional distress associated with severe
deprivation at a population level.
This concerned establishing a preventative
and early detection integrated primary care
and mental health model that would pick up
individuals in the population that may fall
under the radar of acute services. Examples
include people who feel lonely, isolated or
have low self-esteem and have associated
physical health problems.
2. Improving access to and the infrastructure
for referrals to low-intensity mental health
and wellbeing services.
This was about developing a primary and
community care delivery model which
included signposting, and building within
that capacity to respond to individuals and
their families, including those who have
complex needs. This also incorporated
those who are socially excluded, including
the homeless, alcoholics, and also those
presenting with medically unexplained
symptoms, frequent and persistent
attendees.
3. Improving the engagement of primary care
and creating more integrated models for
provision.
This included challenging the more dominant
psychiatric disease model through the
development of a bio-psychosocial approach
that was more holistic and person-centred.
A primary care approach to mental health and wellbeing
The commissioning response
The PCT’s director of commissioning and chief
executive appointed a primary care mental
health and wellbeing lead at Sandwell PCT (Lisa
Hill) who, working in partnership with the PCT
Professional Executive Committee (PEC) chair
and mental health lead (Dr Ian Walton GP),
started to develop a more collaborative and
primary care-led approach to mental health
and wellbeing.
The PCT commissioners used the evidence of
poor service provision and access to work with
local stakeholders to develop a business case
for change. This work took into account the GP
profiling work and the outcomes from a series
of hearts and minds events in which local
service users expressed their dissatisfaction
with current services. They explained that “one
size does not fit all.”
In order to respond to the challenges, the
commissioners ensured that time and
resources were put into listening to the
needs of the local population, mapping best
practice evidence and scoping its options for
partnership working. As such, the PCT then did
the following:
Listened
They set up a number of further listening
exercises with the residents and GPs of
Sandwell to gather a frontline view of problems
and what needed to change. Key to this was
understanding how GPs navigated existing
services. Lisa Hill explained: “We started from
scratch, had little GP engagement and no
service user or public engagement, we set up
some hearts and minds events for them to
tell us their frustrations and stories. We took
a bottom-up approach, that was to ask how
the patient perspective could inform the care
pathway, and what would work for GPs.”
‘In order to respond to the
challenges, the commissioners
ensured that time and resources
were put into listening to the
needs of the local population,
mapping best practice evidence
and scoping its options for
partnership working.’
Analysed
They undertook a further local needs analysis,
where individual general practice profiles
were developed to establish the prevalence of
patients that were presenting mental health
issues and the implications for resource usage
and savings that could be met under the
Quality and Outcomes Framework (QOF). The
team also assessed a broad range of ‘human
needs’ and piloted the use of an emotional
needs audit form to assess requirements.
Dr Ian Walton explained: “The key themes
that came out from our emotional needs
audit were around security, safety, emotional
connectedness, self-esteem and compassion –
you have to look at emotional health before you
can tackle physical health.”
Mapped
They used asset mapping, identifying which
existing community services could be used
more effectively such as local libraries and
children and family centres. This was also about
the PCT garnering a better understanding of
which local services/approaches worked well
among the Sandwell population and its various
communities.
07
08
A primary care approach to mental health and wellbeing
Modelled
Both the demand and capacity of the workforce
were modelled building on earlier innovative
work profiling the local primary and secondary
care workforce, which resulted in a Health
Service Journal (HSJ) award.
Measured
They identified a system to collect pre and postoutcome measures. They knew that in order
to prove that a new primary care-led model
for mental health and wellbeing would work,
they would need to have a robust evidence
base. Sandwell PCT decided to purchase
the COREIMS system (Clinical Outcomes in
Routine Evaluation Information Management
System).7 They used CORE-10 from the system,
a ten-question clinical outcome measure
that monitors an individual’s level of mental
wellbeing and level of risk. The system also links
well to primary care indicators within the QOF.
‘They identified a system to
collect pre and post-outcome
measures. They knew that
in order to prove that a new
primary care-led model for
mental health and wellbeing
would work, they would need to
have a robust evidence base.’
Sourced funding and partnerships
They sourced funding and partnerships
opportunities, by adopting a starfish (i.e.
networking with all potential partners – like a
starfish ‘fusing’ and keeping the connection
by ‘growing another limb’) methodology
to partnership working. The PCT looked for
opportunities where its organisational policy
objectives and strategic visions aligned to
national policy in order to access internal and
external funding.
A primary care approach to mental health and wellbeing
A collaborative primary care model
for mental health and wellbeing
Following a number of local pilot initiatives
to test delivery approaches, a commissioning
approach was developed by Sandwell to
align mental and physical wellbeing, called a
collaborative primary care model for wellbeing.
The approach works on the principles of colocation, integration and collaboration.
recurrent mild to moderate problems, including
stable severe psychiatric disorders. The key
areas for collaboration for more complex cases
with multi-agency working are:
•mental health, alcohol, dementia and
wellbeing assessment tools
•gateway workers
Co-location
The approach uses co-located services, as
these are proven to improve access to care and
offer a more effective service for people with
mild depression. Those with mild to moderate
mental health needs, commonly seen in
primary care, can be treated alongside those
with psychiatric conditions. Managing patients
in a primary care setting also reduces stigma
and improves adherence to treatment.
Integration
The approach ensures the integration of
services at a local level, especially the link
between acute, primary and secondary
healthcare, wellbeing and social care services.
The PCT streamlined its primary care mental
health budgets and planning cycles under
one role – the primary care mental health and
wellbeing lead. This lead has oversight and
responsibility for commissioning all the services
that come under the population and primary
care level (i.e. all low-intensity mental health
and wellbeing services).
Collaboration
A collaborative care model incorporating case
management shows benefits, particularly with
older adults and people with persistent or
•maternal mental health
•involvement of carers
•patient registry
•psychiatric consultation
•shared care protocols and integrated care
pathways with agencies such as maternal
mental health, probation and maternity
services.
Flexibility
The approach also emphasises flexibility. The
PCT’s local needs analysis identified that there
were some specific populations who were
not having their mental health needs met at
a low-intensity level. These were identified
as the lesbian, gay, bisexual and transsexual
population, those with hearing disability, young
people (under 16s), carers and South Asian
populations (i.e. men of Pakistani origin).
Lisa Hill said that “this is where co-location
is important. We do not want to create new
services for diverse populations, it is more
about those populations having access to
existing resources. So for those people with
hearing disabilities, we hire/train staff in sign
language. To reach Pakistani men, we would
hire community development workers, or to
locate services in the local faith community.”
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A primary care approach to mental health and wellbeing
A stepped approach to provision
The Sandwell approach combines positive
self-help, psycho-education, condition
management, talking therapies and access
to specialist support, all of which have been
developed with service users who are ‘expert
by experience’, to ensure that the primary care
mental health needs of the patient are reflected
throughout the model.
Sandwell adopted a stepped approach to
primary care mental health, which uses
different levels of care to ensure the consistent
flow of service users between the steps,
resulting in no waiting lists. The steps are
graduated from low to high intensity and are
non-exclusive. The care pathway is integrated
to reflect that recovery is built into each step, so
that people can be referred back to primary care
at any point. The approach assesses patients
using COREIMS and allocates them to stepped
levels of service. Service users are offered a
range of evidence-based approved interventions
available, to give people a choice of services,
with different interventions offered within each
step (see Figures 1 and 2).
Lisa Hill explained that “the smooth
transition between steps ensures that the
patient experience is not disjointed and the
population’s range of needs is met. We want to
ensure that a person is referred appropriately so
we unclog the secondary care system.”
The population is offered the most
straightforward treatment that is likely to
benefit them. As progress will be closely
monitored through COREIMS, those not
improving in low-intensity services will be
quickly picked up and offered alternative care.
Figure 1. Stepped approach to mental healthcare in Sandwell
Wellbeing
Emotional
resilience
Prevention
Step
0
Wellbeing
Self-help
Promoting
wellbeing
Self-care,
conditions
management
Step
1
Guided self-help
Emotional
Information
resilience
Education
Education
Prevention
Community
settings
Triage available
in community
and health
settings
Advice
Low-intensity
service
Step
2
Range of 1:1
low-intensity
supported
interventions
Pathways to work
Improving access
to psychological
therapies (IAPT)
High-intensity
service
Step
3
Primary care
resource
High-intensity
psychological
interventions
Psychological
interventions for
people with longterm conditions
Step
4
Access to
psychotherapeutic
interventions
from integrated
child and adult
mental health
teams
Early
intervention,
psychiatric liaison
service within
primary care
Step
5
Centralised
resources to
provide specialist
care and support
– secondary care
services
A primary care approach to mental health and wellbeing
Figure 2. Integrated primary care and wellbeing model
This diagram depicts the Sandwell primary care mental health and wellbeing model. Within the model, people
can step up or step down according to need.
Wellbeing is a theme at all levels through the model and access to programmes incorporating wellbeing and
positive psychology is offered in a range of settings including faith, schools, children and family centres, health
and community venues.
High volume
Minor, self-limiting and
longer-term conditions
Graduate workers
Community
development workers
MIND community
wellbeing service
Confidence and
wellbeing team
Faith networks
Schools
Community
Low intensity
Mainly minor/mild
(anxiety and depression)
Improving access to psychological
therapies (IAPT)
Counselling services
GP leads
Psychology
Outreach, self-help and guided self-help
Mental wellbeing promotion
Targeted and universal lifestyle services
Employment, accommodation
Education
Self-care
Health improvement programmes
Personalisation
Pt education – co-produced programmes
Step 0
Local community
prevention, advice,
prevention
Whole population
Step
1
Access to talking therapies and consultation
NHS independent/voluntary sector/chaplains
for wellbeing
Low-intensity service integrated counselling and
therapy service
Access to talking
therapies
Population:
230 per 1000
Step
2
Practice-based
primary care
Population:
101–105 per 1000
Medium/high-intensity therapies
Mixed presentations
(moderate/complex)
Esteem team, probation, youth
offending team
Gateway workers
Community matrons
Health trainers and health visitors,
maternity services
Link workers
Severe illness
(Urgent/Crisis)
Single point access for crisis all ages
Rapid, Assessment, Interface
and Discharge (RAID)
Step
3
Collaborative/
shared care
Population:
20.8 per 1000
Step
4
Hospital and
community
beds
Population:
3.3 per
1000
Primary care workforce
Community primary care services
Early detection/intervention
Access to crisis prevention services
Ongoing management of long-term conditions
including physical and psychological needs
Service users and carers
High-intensity service
Psychiatric liaison
Shared protocols and assessment
Integrated/shared care
Mental health, alcohol, dementia and
wellbeing screening
Gateway workers
Patient register audit and management across
long-term conditions
Home treatment
Effective medicines management more considered
Ambulatory pathway from A&E
Co-morbidities
Assessment beds, respite beds, crisis beds
Hospital liaison
Consultation
Booked day case inpatient
Booked discharge
Specialised inpatient services
11
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A primary care approach to mental health and wellbeing
The service infrastructure
The broad range of wellbeing services put in
place reflects a stepped approach to care.
The purpose of each low-intensity service
is to empower the population to make
decisions about their own care and improve
emotional resilience and wellbeing. The
collaborative care model has a number of key
service features to enable this to happen.
Confidence and wellbeing service –
prevention and self-help (Step 0–1)
The confidence and wellbeing service is open
to all but is targeted for those identified by
the needs analysis, and provides low-level
interventions in the form of programmes/
courses that aim to help people at Step 0-1
cope with conditions including mild depression,
obesity, medically unexplained symptoms
and anxiety. In January 2012, Sandwell PCT
tendered this service to the Health for Living
consortium (Sandwell Mind, the Accord
Housing Group, Murray Hall Community Trust
and Black Country Housing Group), which was
awarded a £1.2 million three-year deal. This
move was a further example of the desire to
integrate and work on an inter-agency basis.
The service has core staffing, which includes
five self-help coaches, two community
development workers and a management lead.
Service users and carers have access and
signposting to a variety of group activities,
courses and programmes that support positive
mental health and wellbeing and provide the
resources of self-help coaches. Terry Rutter,
a self-help coach, explained: “We know that
group work supports people to become less
reliant on NHS services. We are here to lift the
mood of the population, empower Sandwell
residents to seek support, have choice and
help themselves to feel positive. Our aim is to
respond to low-level issues before they go to
primary care.”
To support integration and co-location, the
confidence and wellbeing team are encouraged
to work with existing service providers, such
as local authorities, social care and voluntary
sector partners, to build capacity through
training and development. The team also
works with GPs and social workers on a regular
basis to highlight their ‘offer’ in relation to
emotional support and the process for referring
to them. The team provide a mix of conditions
management and wellbeing programmes,
detailed in Figure 3.
The Hub – a single referral point
Since February 2011, Sandwell residents and
health and social care professionals have had
the same access routes to confidence and
wellbeing services via the Hub, either online or
via a single phone number. They all speak to a
wellbeing coordinator who acts as a gateway
between services, but more than that, the
Hub takes on responsibility for low-intensity
referrals, ensuring there is follow up and noone is left waiting.
When a referral is made to the team, they
aim to respond within three days (with
Step 2 referrals they respond as soon as
possible). Following a phone assessment,
the outcome is always to refer them into
a service on the same or following day.
Louise Perkins, wellbeing coordinator, said:
“I came to the Hub from a customer service
background. To me the Hub is no different, we
have a commitment to respond to referrals
and provide the best service we can.”
The service model has a dedicated website
and directory (www.confidenceandwellbeing.
co.uk), which holds current information
of local services and events and links to
community activities and is kept updated
by the local service user group.
A primary care approach to mental health and wellbeing
Figure 3. Conditions management and wellbeing programmes
One-off
workshop
Stress and relaxation workshop (group/approximately 1.5 hours)
A course to learn some simple techniques to help manage stress and relax including a simple
relaxation exercise.
Health improvement programme (group/eight weeks/1.5 hour sessions)
A six to eight-week programme designed to help manage stress and anxiety, build confidence
and develop communication skills. As well as including tips to help boost your mood and
improve sleep, this programme includes a variety of relaxation techniques.
Food and mood programme (group/three weeks/two-hour sessions)
A three-week programme designed to help build positive relationships with your food,
including food savouring exercises, learning about how foods can help improve your
wellbeing, and access to a selection of healthy recipes.
Long-term conditions programme (group/six weeks/1.5 hour sessions)
A six-week programme which teaches ways to cope with condition management, including
learning ways to manage stress, increase self-confidence, independence and become aware of
your emotions.
Group
programmes
Chin up (group/eight weeks/two-hour sessions)
A fun interactive wellbeing programme for young people (11–18) looking at the core
emotions. Targeted at those most likely to offend, seeks to prevent teenage pregnancy.
Internet-based self-help (one to one/requires internet access)
An initial face-to-face appointment with a self-help coach to discuss the programme followed
by regular telephone support throughout. Suitable if you have mild anxiety or depression.
Positive mental health training (one to one)
This programme encourages self-development via the acquisition of life skills through
relaxation and visualisation techniques. The programme involves working through a series
of CDs.
Breathing space (one to one/six weeks/one-hour sessions)
When stressed we tend to overbreathe which can impact us emotionally and physiologically.
This is a breathing awareness programme that helps you reduce feelings of stress and anxiety
through regulating and harnessing mindful breathing techniques.
Emotional freedom technique (EFT)
Known as the tapping technique, EFT is useful for a variety of conditions including emotional
stress, trauma, insomnia. Sessions are one to one.
Other group
support
Flourish: a self-care programme
Delivered by service users with first-hand experience of the mental health system in Sandwell.
A group programme over a few weeks or bite-size chunks, delivered from doctors’ surgeries.
It is a self-help support group designed to help people cope with their mental health
and recover.
Welfare rights support – benefits advice
Includes home visits, offering proactive assistance in accessing benefits, assisting with debt
issues and financial advice.
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A primary care approach to mental health and wellbeing
For referrals with more complex needs, there
are two clinical supervisors on hand to support
the wellbeing coordinators to refer clients to
the right services. This is important as Sandwell
Psychiatric Liaison services (Step 3–4) also refer
clients to the confidence and wellbeing services
for recovery/additional emotional support (the
Flourish programme).
The key to the Hub is the use of a single primary
care mental health and wellbeing referral form,
developed by Sandwell PCT in partnership with
the Hub and GPs. It is designed to support
GPs and primary care health professionals
to know which services are available and
identify any risks with their patient. A similar
form has also been developed for referral
to the secondary care psychiatric liaison
service, which has a single point of access.
Therapy services (Step 2–3)
To support slightly more intense needs around
emotional wellbeing, Sandwell has a range of
low-intensity therapy services, which are also
referred to via the Hub. These range from:
•Counselling services – for residents suffering
from bereavement, confidence issues, and
relationship difficulties (these are also tailored
to the needs of BME communities).
•Fit for work – a service to support employed
people who are finding it difficult to manage
their health condition at work or have long
periods of absence. This service provides
support to return to work.
•Listening and guidance – chaplains for
wellbeing offer a one-to-one listening service
for stress and bereavement.
•Trauma/post-traumatic stress disorder – a
service that can work with post-traumatic
stress disorder, trauma, emotional distress
and depression.
•Cognitive behavioural therapy (CBT) or talking
therapies (improving access to psychological
therapies) – providing psychological wellbeing
practitioners (PWP) and high-intensity
therapists, offering CBT for mild to moderate
anxiety and depression, in online and face-toface format.
•An esteem team for complex needs and
maternal mental health (MMH) – these are
gateway and link workers who can undertake
home visits, assess clients in primary care and
pre/post-natal women with complex needs,
ensuring clients look after their mental and
physical health.
Access to talking therapies is co-located and
integrated in Sandwell, with the flexibility to
respond to individual needs. For example, the
PCT commissioned the improving access to
psychological therapies (IAPT) service from
Sandwell Mind, a well-connected voluntary and
community sector provider and Black Country
Partnership Foundation Trust. This was to reach
whole populations that were not presenting
themselves at GP surgeries.
The service has recruited a team of full-time
low-intensity and high-intensity psychological
wellbeing practitioners (PWP) who cover the six
towns in the borough. Sue Vincent, IAPT manager
at Sandwell Mind, said: “As a non-NHS provider,
we have much broader reach and can see clients
in different venues in the community. We are
also trusted. This means our PWPs are more
person-centred, we have face-to-face listening
sessions and can make links to wellbeing services
more generally through our networks.”
Sandwell Mind is also well connected to the
Hub and has been receiving referrals since
February 2012. Sue Vincent said: “Referrals are
increasing slowly. What is reassuring is that
they come to us from GPs and Step 3 services
such as the psychiatric liaison services. What is
important is that we can refer too; the voluntary
sector referring to the statutory sector, it feels
positive and joined up.”
A primary care approach to mental health and wellbeing
The esteem team
The esteem team is another distinctive service
that targets more complex needs, such as
those residents in Sandwell with medically
unexplained symptoms, have diagnosed mental
illness but do not attend GP practices for their
physical health/medication, and those with
maternal mental health problems. As such,
the team has been recruited to be able to
undertake home visits, accompany clients to
medical appointments and have the ability to
bypass GP receptions if needed. They are also
culturally diverse to reflect Sandwell’s diverse
population. Dr Pauline Naughton, GP and clinical
lead, explained that: “The esteem team fulfil a
vital role, they fill the gaps in primary care, they
befriend and build trust with their clients, they
also have a duty to ensure physical health is
addressed alongside mental health.”
Psychotherapy and chaplains for
wellbeing services
In a similar way, the Sandwell model for
mental health and wellbeing includes therapies
that can be delivered at primary care venues
such as walk-in centres and GP practices. A
good example is the psychotherapy service,
developed to respond to residents with cases of
post-traumatic stress or psychological trauma,
which can receive direct referrals or those via
the Hub. The psychotherapists are supported
by GPs and are capable of delivering therapies
from Step 2 to 3 through a primary care setting.
Another example is the chaplains for wellbeing
service, which is available at selected GP
practices/drop-in centres in Sandwell. It serves
patients, carers and health service staff who
present emotional issues and who would
benefit from simply talking to an understanding
person. Chaplains for wellbeing address the
spiritual and/or religious needs which influence
health, in order to:
How does it feel to work in an
integrated way?
Sandwell’s approach to collaborative care is not
only beneficial to patients, it also empowers
and develops staff in their roles. Key to this is
working in a joined-up and integrated way.
“It feels liberating to work this way, to feel part
of something that is so good, compared to the
old system. We feel like there is more choice
for patients and carers, and referrals are so
much smoother. It feels so much quicker and
more helpful.”
(Louise Perkins, wellbeing coordinator)
“Coming from the voluntary sector, it really is a
good way to work, very collaborative, it feels like
one organisation. We all want the same thing,
to improve the mental health and wellbeing
of Sandwell.”
(Sue Vincent, IAPT manager, Sandwell MIND)
•encourage faith and hope
•restore significance and worth
•develop a sense of belonging
•provide support
•promote healthy life choices.
Fiona Collins, chaplain for wellbeing, explained:
“My role is to listen, offer spiritual support if
they want it and help the emotional side of a
person to be released. I support individuals to
understand that the resources within them are
sufficient for recovery.”
Collaborative/shared care
(Step 3–4)
At Step 3, the collaborative model demonstrates
close multi-agency working to support individuals
with mental health needs as a result of a physical
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A primary care approach to mental health and wellbeing
condition and/or complex social difficulty. These
include people who have dementia, drug and
alcohol addiction, those within the criminal
justice system, and the homeless.
This step supports both the individuals and
their families. The Sandwell mental health
and wellbeing model works with existing
agencies to join up care, working with their care
arrangements to ensure patients have access
to not only confidence and wellbeing services
and therapies, but also services that meet their
wider needs such as housing, benefits advice and
employment support.
The workforce consists of gateway and link
workers who stay with people until they have
their needs met or are signposted accordingly
through primary care. For example, staff
recently worked with two patients who were
frequent attendees in A&E. Both patients were
ex-offenders, on probation and had drink and
drug addiction. By supporting probation services
with the health and wellbeing offer, which
included family therapy, addiction services and
appropriate accommodation, both patients are
on the road to recovery, registered with a GP and
are no longer attending medical services.
Governance to support improvement
The collaborative care model in Sandwell also
upholds strong values around co-production
and continuous improvement. Dr Ian
Walton, Sandwell PCT PEC chair and lead on
mental health, explained: “The model is also
representative of a set of values; these are
pragmatism, always asking what works best,
listening to others such as patients, professionals,
clinicians and feedback, and always seeking to
improve what we have established.”
The approach has two governance arrangements
to support meaningful clinical and service user
involvement.
1. The primary care mental health clinical
steering group, formed in 2007, was set up to
lead the development and implementation
of the model and make recommendations
to the PCT board. It had representation from
a variety of clinicians and local authority
stakeholders with various interests; public
health, dementia, primary care (GPs), drug
and alcohol services, pharmacy, adult mental
health and child and adolescent mental
health. This group is critical for engaging GPs
within the collaborative care model.
Rita Gupta, mental health project
development manager, explained that
“the group plays a key role in steering the
development of Sandwell mental health
and wellbeing services, ensuring the referral
processes are working and talking to their
peers about the services. The relationship we
have with the GPs is co-productive, they know
we are filling a huge gap in services.”
2. Unique People was set up by a group of
mental health service users to ensure
commissioners responded to the concerns
of those who had been through the mental
health system. Unique People sits within the
resources of the PCT service user network but
is a voluntary group with 12 core members,
who hold specialist knowledge about services
and provide support and expertise to wider
service users. They are involved in educating
GPs about service user perspectives, lobby
for patient rights locally, have access to PCT
(and so CCG) governance structures and
have co-produced a self-help support group
programme called Flourish. Debbie Elwell,
a former member of the network, said: “We
believe no-one should have to fight the
system to get well. We are here to support and
advise, and we are now very well known as
a point of contact. In fact a lot of the people
in Sandwell think Unique People is human,
honest and..... best of all, ‘bostin’ (good).”
A primary care approach to mental health and wellbeing
Learning points
for implementation
The Sandwell primary care approach to mental
health and wellbeing has shown some promising
early outcomes. According to Dr Ian Walton,
“since the mental health and wellbeing services
started in Sandwell, over 4,000 people have
completed prevention, wellbeing and health
improvement programmes. For commissioners,
this equates to a saving of around £800,000 in
prevention costs. In addition, over 3,000 people
have accessed talking therapies, which using
the same formulae, suggests a saving of around
£600,000.”
In terms of outcomes, initial results show
reductions in lengths of stay and hospital
episodes alongside clinical improvements and
a rise in wellbeing. Sandwell is currently having
further outcomes evaluated as part of a study
on integrated care for complex needs being
undertaken by the King’s Fund.
For new commissioners wishing to adopt a
similar approach in their localities, there are
some important learning points to consider
from the Sandwell example.
The influence of primary care in
relation to secondary care in mental
health is still to be addressed
While the team have made considerable
progress on primary care-led provision and
referral, there is more work to be done to
ensure a consistent primary and secondary care
interface. In particular, this concerns aligning
the care models in secondary care (psychiatry)
with the holistic primary care model, to ensure
both approaches lead to smooth referrals and
are patient-centred.
‘Commissioners responded
to specific skills needs among
the workforce in order to
ensure smarter referrals and
increased motivation.’
The importance of consistent
education and training
The Sandwell model trains and educates
staff that provide services, service users
and the primary care workforce to work in a
bio-psychosocial manner. Commissioners
responded to specific skills needs among the
workforce in order to ensure smarter referrals
and increased motivation.
For example, two academic courses were
developed with local universities, Royal College
of General Practitioners and primhe (Primary
Care Mental Health and Education). The first
was an advanced diploma to meet the needs
of GPs, the second was a certificate in primary
care mental health and wellbeing for the
primary care workforce, which included nurses,
therapists, independent domestic violence
advisers and link workers. Around 20 per cent
of the GPs that attended the diploma course
increased their confidence and decreased
referrals by up to 50 per cent from these GPs
into secondary care.
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A primary care approach to mental health and wellbeing
Securing clinical and service
user engagement
The example illustrates through its set-up phase
(listening events) and governances structures that
clinical and patient involvement are essential for a
collaborative care model to work. This is to ensure
legitimacy for service approaches and to support
quality implementation.
Creating an environment that makes
change possible
The Sandwell wellbeing team is an example
of the importance of having champions on
the ground who make new models of care
possible. Many staff, clinical leads and service
users from the Sandwell example, highlighted
the importance of having a team that support
creative thinking, listen and act on feedback.
Robust evidence and data collection
The Sandwell approach started with little or no
evidence base to support their commission of
low-intensity services. To build the evidence
base, they have been collecting individual
outcome data and analysing it. The interpretation
of this data will be vital for the sustainability of
the approach in the new commissioning system.
‘Clinical and patient involvement
are essential for a collaborative
model to work.’
A note on transitional arrangements
The integrated model remains a priority as the
PCT cluster is in transition to new commissioning
arrangements. The existing relationships with
GP clinical leads has meant that Sandwell and
West Birmingham Clinical Commissioning
Group is working with Sandwell’s primary care
mental health and wellbeing lead to develop the
model in the new system, and is supporting the
development of new pathways with links to acute
services, the first of which is cancer.
A primary care approach to mental health and wellbeing
Conclusion
The NHS Confederation supports the view
that the social and economic determinants
of health, such as employment, housing,
education and environment, as well as lifestyle,
play a key part in influencing health and
wellbeing. Poor socio-economic circumstances
can affect health and wellbeing throughout life,
producing health inequalities.
Sandwell’s primary care approach to mental
health and wellbeing is a direct and practical
response to stark health inequalities within
its locality – challenges that many health
service commissioners across England face.
The case study shows that collaborative and
co-located services for mental health and
wellbeing can ensure organised referrals,
allowing clinicians to spend more time
delivering high-quality preventative, clinical
and specialist care. This is about restructuring
services to a primary care-led model based
on need and the adoption of an integrated,
holistic lifestyle and person-centred approach.
Under new commissioning arrangements,
the Sandwell example highlights the need
to respond to strong evidence of local health
inequalities. At a local level, CCGs along with
health and wellbeing boards may wish to
utilise the evidence within joint strategic
needs assessments to drive a primary
care-led approach to mental health and
wellbeing services. At a national level, the
NHS Commissioning Board and Public Health
England will need to work together to enable
this type of local innovation and priority setting.
For more information about the Sandwell
collaborative primary care model, please
contact Lisa Hill, primary care mental health
and wellbeing lead, Sandwell and West
Birmingham Clinical Commissioning Group,
at [email protected]
For more information on the issues covered in
this report, contact [email protected]
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A primary care approach to mental health and wellbeing
Acknowledgements
We would like to give special thanks to the
team we interviewed at Sandwell:
•Lisa Hill – Primary Care Mental Health
and Wellbeing Lead – Sandwell and West
Birmingham Clinical Commissioning Group
•Terri Rutter – Self-Help Coach, Confidence
and Wellbeing Team, Health for Living
•Dr Ian Walton – GP, Mental Health Lead,
Sandwell and West Birmingham Clinical
Commissioning Group
•Debbie Elwell and members of Unique People
– Service User Network
•Sasha Gelpi - Mental Health Promotion Lead
– Sandwell and West Birmingham Clinical
Commissioning Group
•Louise Perkins – Wellbeing Coordinator
•Sue Vincent – IAPT Manager Sandwell MIND
•Rita Gupta – Mental Health Project
Development Manager – Sandwell and West
Birmingham Clinical Commissioning Group
•Dr Pauline Naughton – GP and Clinical Lead
for Esteem Team
•Primary Care Mental Health GP Steering
Group – Sandwell and West Birmingham
Clinical Commissioning Group
•Malcolm Hanson – Psychotherapist
•Fiona Collins – Wellbeing Chaplain
•Report author – Julie Das, Policy Manager
(Commissioning), NHS Confederation
A primary care approach to mental health and wellbeing
References
1. NHS Confederation (2011) Public mental
health and wellbeing – the local perspective.
4. Friedli L (2009) Mental health resilience and
inequalities. WHO Europe.
2. Huppert, F.A and Whittington. J.E (2003)
‘Evidence for the independence of positive
and negative wellbeing: implications for
quality of life assessment’ in British Journal
of Psychology, 8, 107–122.
5. Sandwell Trends website (2010):
www.sandwelltrends.info
3. New Economics Foundation (2011) Five
ways to wellbeing: new applications, new
ways of thinking.
6. Sandwell health profile (2011) Network of
Public Health Observatories.
7. Clinical Outcomes Routine Evaluation
Information Management System.
Further information
Mental Health Network (2012) Defining mental health services: promoting effective
commissioning and supporting QIPP.
Mental Health Network (2012) Mental health and homelessness: planning and delivering mental
health services for homeless people.
Mental Health Network (2012) No health without mental health: implementation framework.
Mental Health Network (2011) Developing an outcomes-based approach in mental health.
Mental Health Network (2011) Housing and mental health.
Mental Health Network (2011) Key facts and trends in mental health.
Mental Health Network (2011) Investing in emotional and psychological wellbeing for patients with
long-term conditions.
Mental Health Network (2011) No health without mental health: the new strategy for mental health
in England.
New Economics Foundation (2011) Five ways to wellbeing.
NHS Confederation (2011) Public mental health and well-being – the local perspective.
Mental Health Network (2008) Delivering race equality in mental health.
21
A primary care approach
to mental health and wellbeing
The importance of mental health and wellbeing
cannot be understated. It affects and influences
the lives of individuals, families, communities and
societies. There is growing evidence that positive
mental health and wellbeing at a population level
can reduce health inequalities and improve wider
outcomes in relation to physical health, social
cohesion and economic productivity.
This report presents a detailed case study of the
journey that health service commissioners, located
in Sandwell in the West Midlands, went through
to respond to a number of important health
inequalities within its local population. It focuses
on how its health service commissioners responded
to specific health inequalities to develop a primary
care-led approach to improving mental and physical
wellbeing. The specific health inequalities the trust
sought to address included poor levels of mental
and physical health, social deprivation, poor access
to low-intensity community mental health and
wellbeing services, and heavy use of secondary care
mental health services.
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