Weeknotes 7: Analysing and tuning into mental health
20 June 2019, written by Josefeen Foxter, Graduate Service Designer at NHS Digital
Learning about mental health in urgent and emergency care
As part of our work designing a vision for better urgent and emergency care, we’re focused on working with people who have mental health needs. We’ve been looking to understand how these individuals access care in an urgent or emergency context and where digital can help.
90% of adults with mental health conditions are supported solely by their GP or primary care service (Royal College of General Practitioners, 2017). Healthwatch (2019) found that people want GPs to be able to diagnose and treat a wider range of mental health conditions while being treated with dignity and respect by all staff.
The contextual and reflective interviews we did with patients and staff in both rural and urban areas confirmed this and provided additional insights.
We found themes of wanting to be understood, needing someone to talk to urgently during moments of self-doubt and crisis, lack of specialist services (especially in rural areas) and difficulty getting GP urgent appointments. The people we spoke to often relied on 111 or 999/ A&E when in crisis or need of urgent support. The serious and episodic nature of some mental health conditions, combined with long waiting times for specialist care complicates the way that people can seek care when they need it urgently.
The insights we gained included:
GP services are not always able to support patients with mental health issues in the way that they need, as soon as they need it and where they need it.
“…the flipside of [moving to the countryside] is sometimes there’s not the response, amenities, GP access or anything for my special needs…” - Patient
“Trying to ring to get through… to make an appointment [at the GP’s]. It was 68 times… it was just on redial. By the time I got through there were no appointments available. And that’s happened 2–3 times.”- Patient
“I have an elderly doctor who doesn’t understand or see the way it is”- Patient
UEC services are under increased pressure to support patients with mental health issues, but are also unable to cope with demand and feel ill-equipped.
“Usually, you’d call the crisis team. But, you’re having to do the assessment yourself [because the crisis team are too busy to attend]”- GP
“We’re picking up people who are frequent callers, those who tried mental health services and can’t get through or on a waiting list already but haven’t been seen”- 111 Service Head of Nursing
“More and more people are coming to UEC to access their routine and their urgent mental health care, similarly to when they have with physical health” - Psych Liaison Team, Somerset
Digital has some potential, such as better access to the Directory of Services with information on cross-sector, on-demand mental health services. But there are limitations in how much purely digital tools can support patients with complex mental health needs. What is often needed is a human connection.
Support in the community
This pattern of patients turning to urgent care services because they haven’t been able to see their own GP quickly is something we’ve seen right across our work. For many patients, their clear preference is to be seen and treated by their own GP practice: the people they most trust with their care. But, we’ve also heard from GPs around the country about the pressures they face balancing capacity and demand. Given these capacity issues, the answer isn’t simply to “channel shift” patients from high acuity settings like ED, to low acuity ones like GP practices.
We’ve been inspired by how many practices and local care networks are adopting digital technology and new ways of working — in the broad definition of “digital” we discussed in our previous week notes — to help address these issues.
“Digital is about applying the culture, processes, business models, and technologies of the internet era to respond to people’s raised expectations.” — Tom Loosemore
For example:
- Adopting digital front-door ‘triage’ tools to stream patients requesting urgent appointments, so patients are seen based on need not who can get through on the phone first
- Addressing local capacity issues through remote “digital” ways of working, made possible by shared digital tools and records
- Using data to identify patients at risk of escalating health issues, so multidisciplinary community teams can provide the support they need early, so they don’t get to the point of needing urgent care or hospital admission
The most striking of these was Millbrook GP surgery in Castle Cary. Their implementation of the Enhanced Primary Care (ECP) model and unique approach to appointment booking yields benefits for all patients especially those with complex conditions such as mental health.
Patient-centred and proactive, this whole-system, collaborative approach provides increased levels of clinical and social support in the local community. Patients with complex needs are supported to live independent and healthier lives and have positive patient experiences. There is evidence that ECP reduces patients’ need for emergency care.
It was interesting to note that features of the care model at Millbrook Surgery had lots of parallels with digital and agile ways of working and collaborating. These include:
- Team-based care with co-location of multidisciplinary team members
- Multidisciplinary team ‘huddles’ (twice-weekly general and monthly safeguarding and cancer)
- Health coaches - health promotion, improve access and decision-making
- Treatment escalation plans: up-to-date, shared with ambulance service and a hard copy carried by patients
- Weekly walk-in GP clinic at the local community centre
- Complex care team: cross- network provision of supplementary ‘wrap-around’ care for people with complex needs
Millbrook’s approach to appointment booking means that all patients can be seen on the day that they call. Advance appointments are given in only a few instances, such as six-week baby checks. Patients call the surgery and speak to reception who arrange call-backs if needed. GPs can book their own appointments, adjusting the duration according to clinical need.
“You are always seen if needed. We can always offer an appointment the same day if you need to be seen. We can give you a longer appointment if necessary. Nurses based in our practice treat patients for a wide range of common conditions. You can expect to see a nurse within one to two working days. There is no need to book in advance.” — Millbrook Surgery website
This increased accessibility to a GP is helpful to all patients, but for patients in need of urgent support with mental health crises, it’s particularly valuable and provides them with a choice that is more appropriate than A&E, 999 or even 111 because it’s more personal and private.
“Flexible appointment durations mean doctors can give the right amount of time to patients, instead of having to rush appointments.” — GP Partner
The surgery has an almost non-existent DNA (Do Not Attend) rate: another positive effect of this approach. DNA rates increase proportionately to the delay between booking and the actual appointment:the shorter the delay, the better the attendance rate. This isn’t unique to Millbrook. Nationally the DNA rate for same day appointments is just 2%, rising to 5% for next day, 7% for appointments booked 2–7 days in advance and 9% for those booked over a week ahead.
We recognise that these approaches are not a complete answer to the pressures facing our primary and urgent care system. But they clearly show how “digital” done well — from technology to culture, to ways of working and organisational models — could help free up much-needed capacity.
Other things we’ve been doing (in pictures too!):
We’ve been getting together for 48-hour workshops in Leeds every week to analyse a lot of the data from data science, engagement and desk research.
We’re shaping artefacts to communicate an evidence-based picture of what the as-is situation for urgent and emergency care looks like and how digital comes into this.
We were lucky to run a two-day workshop with NHS Digital Academy, getting the heads of 116 NHS digital leaders into some of our insights, building their empathy for staff and patients, and shaping some of the opportunities and ideas for the future state of digital urgent and emergency care.
What’s next
Up next is synthesis. We’ll be making sense of our as-is understanding to define problems, causes, hypotheses and opportunities for digital that we can use to anchor our design of the target state — alongside being guided by the Long Term Plan and the NHS vision for the future of tech, digital and data.
Get in touch with Sophie Dennis or Joanna Choukeir if you’d like to chat through any of the work.
References
- Healthwatch England (2019) What matters most Healthwatch England Annual Report 2017–2018
- Royal College of General Practitioners, Mental health position statement, December 2017
