iCope, an IAPT service in Islington, London, is dedicated to the provision of high-quality cognitive behavioural therapy (CBT), and other NICE-adherent psychological approaches, in the treatment of anxiety and depression for adults. It is a service that prides itself on service user involvement and innovations for which it has received several awards.

The challenge

iCope serves a population of 206,100 (2011 Census) and our referral rates are substantial (8,885 in 2016-2017). We work in GP surgeries and community settings to enable close working with GP colleagues and commissioners, and to be accessible to the local population. Forty-two per cent of referrals come from GPs which means it’s important iCope works closely with them to shape referrals for people who could benefit from face-to-face, Skype, computerised CBT groups and workshops offered by the service. This close working relationship also encourages a holistic approach to treatment plans, medication and risk management that supports patient wellbeing and recovery.

The initiative started by looking closely at one GP surgery where recovery rates were higher. One important contributing factor seemed to be the carefully considered referrals to Islington iCope made by those GPs, which was cultivated over time in mutual feedback and learning between the iCope clinician and the referring GPs. Based on what worked well, the following ideas have been put into action at this practice to establish good working relationships with the GPs. The following is the guidance we have established and share with new iCope staff as part of their induction.

Establishing the working relationship

New iCope staff setting up in a GP surgery: approaching new medical staff in the surgery to introduce our roles and the service can be helpful. Often the new trainee GP doctors appreciate a brief teaching session on the different psychology services at primary and secondary care. Both new and established GPs may wish to hear a refresher of our inclusion and exclusion criteria guidelines, and the wider mental health system in which the psychology service is positioned.

GP team meetings provide an opportunity to ask questions based on these materials, and to make sure it has been looked at by the GP surgery staff. We are encouraged to attend the occasional GP team meeting, even for just the first 10 minutes, for instance to inform GPs of new groups and workshops. Alternatively, attending the meeting for longer to discuss an IAPT case that is going well can be useful, or even an example of an IAPT-appropriate referral compared to a referral best referred to secondary care. Increasing referrals of older adults, BME (black and minority ethnic clients), clients with long-term health conditions or learning difficulties, pregnant clients and veterans can all be promoted in this forum in the spirit of increasing access.

Maintaining the working relationship

A great deal of the most useful talking can occur outside these meetings, informally, to discuss potential referrals and progress with cases. This is the kind of talking that will really enable you and your referrer to get to know each other, and help communicate who best to refer.

The open door approach involves simple little things like having your clinic room door open between client sessions, sitting where the GPs have their lunch, working on computers where the GPs do their administrative work, informing the GPs of a time when you are available in the surgery for a drop-in informal discussion, such as in the middle of the day when they are between clinics. All of this helps to create a culture of discussing referrals and joint working at primary care level. Keeping it brief helps, too, as this fits with their culture of brief consultation times they apply for patients in their surgeries.
If you see clients at their GP surgery, then with their consent write a short note on the appropriate patient records system to outline briefly the progress in the therapy and what approaches are being used. This can help to demystify what we do. Just three sentences leaving out anything sensitive would be enough, and using non-technical language such as ‘mood-lifting activities’ rather than ‘behavioural activation’ can make it more accessible. Assessment and discharge letters are the next best step for communicating something about what we do and how this maps onto meaningful change for the client.

Making the most of the working relationship

Although IAPT services work with people with common mental health conditions who fall into the mild to severe range, we sometimes receive referrals from GPs for people whose needs are more complex. In these situations we will ask the GP if they think the client is safe to manage together with them in primary care and plan with them how to do this together if appropriate and necessary. Furthermore, some referrers who tend to refer clients in crisis may be reminded that those are not necessarily the best candidates for an IAPT approach, whereas those being overlooked may be instead.

Clients with health anxiety (who seek GP reassurance) and clients with blood-injury-needle phobia offer an opportunity for joint working with the GP. The GPs are often already more involved with clients in these situations, and so working with them to manage these cases holistically in primary care can be empowering for the GP and informative about what we do. Generally, encouraging clients to see the same GP at their surgery seems to facilitate better mental and physical health care.

We continue to share these key ideas of joined-up working in our induction for each new member of staff, as well as reminding and supporting staff in this integrated approach via individual supervision, team meetings, and recovery consultations*. The greater proportion of CBT-ready clients with manageable risk levels that we have, the more able we have been to complete helpful pieces of therapeutic work effectively and in a shorter time-frame.

Staff who have taken on these ideas have noticed the initial extra time and effort employed can enable a greater satisfaction from joined-up working and mutual support in their relationship with their referring GPs, and facilitate more primary care appropriate and CBT-ready referrals, too.

Dr Isabella Foustanos, Clinical Psychologist & High Intensity Worker, with contribution from Dr Josephine Morgan, Dr James Gray, Rebecca Minton
Islington iCope Psychological Therapies Service Camden & Islington

• www.icope.nhs.uk
• For more information on recovery consultations: See case study Islington iCope – An IAPT Service with a Strong Focus on Recovery.