Introduction

TalkPlus is part of the Improving Access to Psychological Therapies (IAPT) service commissioned by North East Hampshire and Farnham Clinical Commissioning Group (NEHF CCG). The area has a population of 175,713 people over 16. NEHF CCG was selected in 2016 as one of 22 early implementer sites which received transformation funding to deliver IAPT-LTC (long-term conditions), leading the delivery of National Institute for Clinical Excellence (NICE)-recommended psychological therapies integrated in physical healthcare pathways. This means NEHF CCG committed to expanding TalkPlus so that 25 per cent of the population who have depression or an anxiety disorder can access the service each year by 2020/21. Two-thirds of this expansion will focus on improving access for people with LTCs.

The challenge

Both TalkPlus and a local GP practice were working towards integration of mental and physical healthcare for patients – specifically those recently diagnosed with chronic obstructive pulmonary disease (COPD), and had discussed partnership working. However, there were a number of challenges:

• TalkPlus was not able to recruit enough patients to run step 2 courses within the GP practice for patients with COPD
• TalkPlus planned to run a course in a central location but many patients with COPD were too unwell to travel
• TalkPlus did not have capacity to run such a course with low numbers.

In 2016 the local GP practice joined with another practice to form Oakley Health Group, a GP partnership with a larger catchment area, serving a population of 28,000 people, and with a higher proportion than national average of patients aged between 65 and 75. For its part, TalkPlus became an IAPT-LTC site with increased scope to expand. Therefore, TalkPlus and Oakley Health Group were well-placed to work together to form an integrated GP clinic.

How it worked

Oakley Health Group had hosted TalkPlus therapists from the core IAPT service for some years. A planned integrated clinic was set up where TalkPlus therapists would be embedded within the practice. Therapists, working as part of the IAPT-LTC pathway alongside Oakley Health Group, received specific training which equipped them with the skills to work with patients who had a LTC alongside anxiety and depression. The integrated therapists communicated with the GPs and practice nurses throughout treatment; this promoted shared decision-making and more integrated working.

Set-up

In early 2017 a number of initiatives were set up:

• Training sessions for practice nurses were well attended and helped form a link between TalkPlus therapists and the practice nurse team
• Courses and one-off workshops for patients, including a ‘Living well with pain’ course, were established. These received positive feedback from patients. Integrated therapists attended practice multi-disciplinary team meetings to introduce the new integrated clinics and referral processes.

Suitability for treatment at an integrated clinic

Patients with a LTC who are struggling to manage their condition in the context of anxiety and depression. Examples may include a COPD patient who is misinterpreting panic attacks as exacerbations and regularly attends A&E; a patient with diabetes who is feeling overwhelmed and not managing their diet or medication well; an elderly patient whose quality of life is impacted by fear of falling; a patient with Irritable Bowel Syndrome (IBS) who is avoiding going out due to anxiety over bowel control.

Referral process

Referrals are accepted from within Oakley Health Group, and a named therapist embedded within the practice can be contacted to discuss referrals. A LTC referral form is used which specifies the area of concern where the patient could improve the management of their LTC. Each referral is reviewed by the therapist to assess their suitability and, if suitable, they will contact the patient to arrange an initial assessment. To supplement the one-to-one clinics, a full programme of courses and workshops has been designed to facilitate promotion of integrated clinics as part of Oakley Health Group’s prevention agenda.

Impact

Although it is too early to conduct a full evaluation, the integrated clinics and workshops have received positive responses from staff and patients. A four-module ‘Living well with diabetes’ course received a good uptake, with 88 per cent of participants finding it ‘very helpful’ or ‘mostly helpful’. Positive responses included:

• Patient Services Manager: ‘We have heard positive feedback from participants who took away some useful strategies to help with their condition. They worked well together and enjoyed sharing their experiences and ideas over the four-week course.’
• GP: ‘We are always looking at ways we can work with other providers in a more integrated way and the recent initiative with TalkPlus is an excellent example of sharing our expertise to improve patient care.’
• Patient: ‘The course was helpful by helping me realise that my difficulties are common for others, too.’
• TalkPlus Therapist: ‘Everyone at Oakley Health Group is helpful and encouraging. I feel part of the team working together to support our patients.’

Next steps

In terms of the integrated GP clinic at Oakley Health Group, the next steps will be:

• Evaluation of the initial target site and the rolling out of integrated clinics to other sites within the CCG
• More physical health practitioners involved in the delivery of courses – for example physiotherapists in a COPD course. There will be engagement with hard-to-reach patients.

Conclusion

A possible consequence of an increase in demand on GP practices and IAPT services would be a reduction in co-operation and joint working. However, early evaluations of IAPT-LTC services show that where true integration occurs, health utilization is reduced in other areas of the health economy. The integrated clinics rely on the full engagement of the GP practice and without the drive and full support of Oakley Health Group the development of the integrated clinic would not have been possible.

Further information: www.talkplus.org.uk