Complex mental health cases that are not deemed suitable for the NICE-recommended therapies provided by IAPT services, are often referred on to secondary care services provided by Mental Health Trusts. London IAPT services work and interact with secondary care to varying extents; some of the relationships that we explored are given below. We learnt that working with secondary care is easier when the IAPT service is provided by a MH Trust and the patient records are accessible to the IAPT service for cross-referencing.
Kensington & Chelsea
Have integrated with the primary care step 4 psychology, primary care liaison nursing (provided by secondary care) and peer support team in the Community Living Well (CLW) service. All the services within CLW use SystemOne electronic patient record system hosted by the secondary care MH Trust, so all have access to patient records for referencing. [see case study]
Both IAPT and Primary Care Plus (PCP) are delivered by Oxleas NHS Trust; both services can access secondary care patient records, which helps with treatment delivery and facilitates referrals between services where appropriate.
The service is recruiting to an ‘interface post’ which will sit across both IAPT and PCP, to meet the needs of patients that are too severe for IAPT, but not severe enough for PCP. Often patients with Personality Disorder fall into this ‘gap’ between services, and the post-holder may develop a service that delivers step 2 – type interventions for Personality Disorder.
The borough has had regular meetings with community mental health locality teams before Covid, to support relationships and have dialogue regarding patients.
Work closely with secondary perinatal psychiatry, attending multidisciplinary team (MDT) meetings to discuss cases.
The development of Primary Care Networks (PCN) within Tower Hamlets presented an opportunity for the IAPT service to engage with secondary care colleagues. The service has found it is very important for IAPT to be present at the discussions, otherwise there is a risk that the PCN becomes focussed on secondary mental health. IAPT can then contribute to discussions regarding care pathways and provide input regarding where IAPT fits within them.
Within Tower Hamlets, the IAPT service took a proactive approach, and used existing contacts (for example through secondary care, psychological therapies director, mental health transformation manager) to ask to be invited to the PCN discussions. Please see case study for more information.
Talking Together Wirral
Wirral IAPT service work in partnership with Cheshire and Wirral Partnership NHS Foundation Trust and other partners to deliver a holistic approach to IAPT. The IAPT service have a subcontract arrangement with the Trust to provide a step 4 service to bridge the gap between IAPT and secondary care. Patients often fall through this gap because of the highly prescriptive nature of IAPT provision. This step 4 model provides an opportunity for a joined up community approach that links up with IAPT.
Croydon and Lambeth IAPT
During the COVID-19 pandemic, like other IAPT services, experienced a drop in referrals therefore, had spare resource capacity within the team for redeployment to community mental health teams (CMHTs) who were struggling due to staff redeployment and absenteeism due to COVID illness.
The IAPT services offered a step 4 model where PWPs provided low interventions, within the IAPT remit to CMHT clients who are regarded as not suitable for IAPT with more complex difficulties such as self-harm, emotional instability, social and personality issues. Because these were complex cases, therapy sessions were increased to 8 instead of the standard 6 sessions offered to IAPT-suitable clients.
This collaborative working ended in October following the first wave of COVID-19 and is currently being evaluated. It was a very useful collaboration as both services benefitted from the joint team meetings which provided an opportunity for stable CMHT clients to be referred back to IAPT services for maintenance. The IAPT services have recommended that Clinical Associate in Psychology roles are created within CMHTs in the context of the Community Mental Health Framework for Adults and Older Adults to carry forward this step 4 model.
Please see specific population groups: long-term conditions for more examples of working with secondary care.
- NHS England guidance on the new Community Mental Health Framework for adults and older adults.
- Newcastle and Gateshead ‘Together in a Crisis’ model evaluation, looking at improving crisis pathways.