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REPORT Clinical psychology in primary care Dr Graham Durcan
Centre for Mental Health REPORT Clinical psychology in primary care
Contents
Executive summary 3
1 Introduction 4
2 Bradford Primary Care Wellbeing Service 7
3 Catterick and Shropshire’s GP style psychology services 10
4 Project Future: a community-based, psychology-led service 13
5 The economic case for clinical psychologists in a primary role 15
6 Conclusion 16
References 18
Acknowledgements
We would like to thank Cathy Byard, Suzanne Heywood-Everitt, Laura Fisk, Angela Moulson,
Vannessa Tobin, Annette Schlosser, Barry Ingham, Lawrence Moulin, Fatima Bibi and Suchi
Bhandari, and the teams and practice staff from Bradford, Catterick, Ludlow and Telford and
Project Future for supporting us with this project. The review was funded by a grant from the British
Psychological Society to Centre for Mental Health.
2Centre for Mental Health REPORT Clinical psychology in primary care
Executive summary
There is a growing recognition of the important All of the sites used core principles of clinical
role of primary care services in supporting psychology to understand people’s needs
people’s mental health, and of significant gaps and to develop strategies for meeting them,
in the current provision of mental health support complementing existing primary care services
in many areas. and psychological therapy provision.
This report describes two promising approaches These sites demonstrate the therapeutic and
in three local areas where clinical psychology cost benefits of clinical psychology being
has been provided in a primary care setting. offered directly in communities. It can offer
They are: effective support to people who previously got
little or no effective help for their mental or
• Bradford Primary Care Wellbeing Service:
physical health from the NHS.
a multi-disciplinary team led by a clinical
psychologist which supports people with From 2021, Primary Care Networks will be able
unexplained medical symptoms or a long to use additional funding from NHS England to
term condition employ mental health professionals directly,
including clinical psychologists (Naylor et al.,
• Catterick and Shropshire: offering direct
2020). This is an opportunity that must not be
access to a clinical psychologist within a GP
missed. In the wake of Covid-19, the importance
surgery.
of easily accessible clinical psychology will
We also describe Project Future in Haringey, a be greater than ever for individuals and
psychology-led community initiative working communities that have experienced trauma
with marginalised young people, as an through the pandemic.
alternative approach located outside primary
care.
3Centre for Mental Health REPORT Clinical psychology in primary care
Introduction
Primary care services are most people’s first Improving Access to Psychological
and most frequent point of contact with the
Therapies
NHS. Located in every community, GP surgeries
in particular are the places we go to when we’re Psychological interventions are, of course,
worried about our health and when we first not only delivered by clinical psychologists:
need help. A recent survey of over 1,000 GPs they have become very widely available in
found that 40% of contacts involved a mental England, primarily via Improving Access to
health element (Mind, 2018). Psychological Therapies (IAPT) services, during
the last decade. Around a million people a year
Primary care services are under pressure,
are seen by an IAPT service currently, and over
struggling to meet ever-growing demand with
half have a course of therapy (the remainder
limited resources. GPs themselves have variable
are assessed, and some will be signposted or
levels of knowledge and confidence in meeting
referred on to other services). The NHS Long
people’s mental health needs, especially when
Term Plan wants the service to expand to see
they are linked to other health or social issues
1.9 million people by 2024 (Clark, 2018 &
(Mind, 2018).
NHSE, 2019a).
The NHS Long Term Plan sets out a ten-year
To date, approximately 10,500 practitioners
vision that sees primary care growing and
have been trained to provide IAPT interventions
taking on ever greater levels of responsibility for
and their most common offer is Cognitive
people’s health care, including prevention and
Behavioural Therapy. Most people will be
managing complex needs outside hospital. It
supported to guided self-help or low intensity
requires all GP surgeries to cluster into Primary
sessions (perhaps 5 or 6 treatment sessions),
Care Networks that will take on responsibility
but more intensive offers are also available.
for a range of enhanced health services and it
Clinical psychology does have a presence in
pledges funding to enable them to meet these
these services, but the bulk of intervention
needs. This raises the question of what would
is delivered by practitioners who have
enable primary care services to meet more
received accredited IAPT training, usually at
effectively their patients’ mental health needs.
the postgraduate diploma level rather than
This report describes the potential benefits of the doctoral level training of the clinical
clinical psychology as a front-line health service psychologist.
in primary care. It does this by describing two
“…IAPT services are fantastic and are a fit for
different approaches to bringing psychology
a quite a number of patients I see, but CBT
into GP surgeries to meet two different, and
is not right for everyone and IAPT services
quite distinct, types of mental health need.
cannot really help if the patient presents with
We have also described a model of community
any complexity…” (GP)
psychology to demonstrate the wider range of
ways that psychology can meet the needs of Several of the people we spoke to for this
the most marginalised groups of people ‘where review gave similar accounts of IAPT, i.e. that
they are at’. it did not accept clients with more complex
needs, and this in part was due to the access
There are currently 13,460 registered clinical
and recovery rate targets these services are
psychologists across the UK (HCPC, 2019), most
expected to deliver. In its current form, IAPT
of whom work in secondary and specialist care
does not typically offer the level of intervention
in the NHS. This report explores the impact of
required by people with more complex needs
extending and locating this valuable resource
and this represents a significant gap in many
differently, in GP surgeries and communities.
local areas.
4The unique role of clinical psychology distressing difficulties. Rather than labelling
Centre for Mental Health REPORT Clinical psychology in primary care
these experiences as symptoms of an illness or
Clinical psychologists are trained to reduce an indication of madness, clinical psychologists
psychological distress and to enhance and are curious about why these symptoms occur,
promote psychological wellbeing by the wanting to understand feelings, thoughts, or
systematic application of knowledge derived behaviours in their context. Our intention is to
from psychological theory and research. empower people to find a way to feel better, by
Interventions aim to promote autonomy and learning to tolerate, accept, or manage their
wellbeing, minimise exclusion and inequalities, distress differently, or by changing how people
and enable people to engage in meaningful see themselves and their situation…” (page XV)
interpersonal relationships and commonly
valued social activities such as education, work The training required to deliver the above is
and leisure. both broad and in-depth, and enables the
clinical psychologist to make autonomous
Clinical psychologists are highly trained to determinations (although often delivered as
Doctorate level and have a distinctive role to part of a multi-disciplinary effort):
play because of their broad training, which
covers the lifespan and equips them to work “…I think one of the distinguishing features
effectively with individuals, families, and of clinical psychology is the ability to be
organisational systems. They are trained to autonomous and to diagnose or rather make
work with a wide variety of mental health formulations…well actually we do this with
needs in various settings, including services the client or patient… to do that and to do it
for children, adults, older adults, families, across a range of people and of all ages you
people with developmental and intellectual do need a training in breadth of theories and
disability, physical health presentations, different practices…” (Clinical Psychologist
chronic conditions and forensic services. This working in primary care, interviewed for this
is in contrast to multiple, often sub-doctoral, project)
programmes which prepare graduates for work Formulation has its roots in Kelly’s personal
with only circumscribed groups, presentations construct theory (1955). Formulations are
or models of therapy. an attempt to understand an individual in
A defining feature of the clinical psychologist is their context, and to do so using ‘plausible
the capacity to draw from and utilise different account’ (Butler, 1998 cited in BPS, 2011) in
models of therapy, and evidence based the form of a shared narrative rather than a
interventions, as appropriate to the needs and categorical diagnosis. The formulation provides
choices of the service user. They are trained not a hypothesis to be tested and its narrative
just to deliver interventions, but also to promote changes as the individual does.
psychological mindedness and skills in other “…In the short period we have with the
health, educational and social care providers. patient…we are listening and testing ideas to
Llewelyn and Aafjes-van Doorn (2017) describe develop the formulation, and this guides the
clinical psychology as “dealing…with people’s intervention…” (Clinical Psychologist working
thoughts and emotions, and often their in primary care, interviewed for this project).
5Centre for Mental Health REPORT Clinical psychology in primary care
Formulations can be described as having the following characteristics:
• A summary of the service user’s core problems
• A suggestion of how the service user’s difficulties may relate to one another, by drawing on
psychological theories and principles
• The aim to explain, on the basis of psychological theory, the development and
maintenance of the service user’s difficulties, at this time and in these situations
• Indication of a plan of intervention which is based on the psychological processes and
principles already identified
• Being open to revision and re-formulation.
(Johnstone and Allen (2006) cited in British Psychological Society (2011) p. 6)
Reprinted from Durcan (2016)
Methodology in the case studies. For Bradford, this may be in
part due to the nature of the people they work
The case studies featured in this report were with, who may have sometimes been resentful
selected to explore the contribution of clinical that their problems were being “psychologically
psychology to primary care in areas that have framed” and thus reluctant to join in the
taken innovative approaches to meeting evaluation as a result. The Catterick service had
people’s needs close to home, embedded closed a few months before the stakeholder
within GP surgeries and working closely with interviews took place (it had originally been
primary care colleagues. In each we undertook planned as a one year pilot but was extended
interviews with stakeholders, including to collect further data on the model) but it had
clinical psychologists, GPs, service managers, conducted surveys of those using the service
commissioners and patients. Additionally, we and found very high levels of satisfaction (98%).
describe a model of community psychology that
operates outside of primary care in order to In the case of Project Future, which we have
demonstrate the value of engaging with people presented as an additional model working
from the most marginalised communities in the outside primary care but within a community,
most accessible and acceptable ways for them. we have the views of over 40 young people
involved in the project, taken from an
For all sites we were able to access some independent evaluation by Centre for Mental
reports and policy documents (internal and Health (Stubbs et al., 2017).
external) and from one (Catterick) we were able
to collect quite detailed audit data from the This report was written prior to the global
service’s routine data collection, as well as data outbreak of coronavirus in 2020. It is, however,
(where appropriate) on other local GP practices. very likely that its findings and conclusions
will be more applicable than ever given the
Few patients or users of the three services were evidence of the impact of the pandemic on
accessible, and their voice is underrepresented mental health.
6Centre for Mental Health REPORT Clinical psychology in primary care
Bradford Primary Care Wellbeing Service
The Bradford Primary Care Wellbeing “I think if you ask most of our colleagues in
Service (PCWBS) is a psychology-led multi- the acute hospital they will tell you that a
disciplinary team, including clinical psychology, not insignificant group of their patients are
occupational therapy, physiotherapy, dietetics unlikely to benefit from further assessment
and a Personal Support Navigator (employed by and investigation and have a significant
Age UK). psychological component, but that they,
like us, feel pressure to offer some care and
The function of PCWBS is to work with patients
treatment and do not have the knowledge
with unexplained medical symptoms and
and confidence in psychology and mental
long-term conditions, who GPs have identified
health to do otherwise…PCWBS offers that…”
as frequent attenders of their service; and,
(GP)
critically, where they suspect there is a
significant psychological component and where PCWBS works with a wide range of clients of all
the frequent service use is not beneficial. ages; for example, at the time we visited, the
service was working with a family where the
PCWBS is funded as a Cost Improvement Plan
identified patient was a toddler.
(CIP) by the local Clinical Commissioning Group
(CCG). It was funded to initially work with four Some PCWBS patients are also frequent users of
general practices to pilot whether an alternative emergency services, accessed via dialling 999
psychological formulation informed approach as well as accident and emergency departments.
would lead to more appropriate care and bring
In addition, PCWBS offers a community
about savings. The service has been evaluated
tertiary service for people with chronic fatigue
twice (Bestall et al., 2017 & Pemberton, 2018)
syndrome. In the past these patients may have
and shown both positive clinical outcomes and
been referred out of area.
significant savings. The service has developed
and expanded to cover further practices. A service user and chronic fatigue sufferer
interviewed as part of the Shropshire case
PCWBS’s primary function is to support GPs
study described how psychological intervention
by providing a formulation to a group of
and specifically the intervention of clinical
patients who individually and collectively use a
psychology had helped:
considerable amount of NHS resources, usually
to no benefit and indeed sometimes to their “…I had years of no or very limited help…
detriment. It is common for PCWBS patients then I experienced a residential programme
to have received numerous assessments, of care…which helped at the time but which
treatments, and some to have undergone I experienced relapses after discharge…
invasive and traumatic surgical procedures. the psychological help I received there but
also since then in the community has been
”…I’m about to conduct some radical surgery
a significant help to me and has helped me
on a young person…I think we all knew
move on…I still have problems, but I have
that there was a significant psychological
been helped to manage them…”.
component to this… but we do not have the
skills and knowhow within our service. If we
had PCWBS involvement earlier we might
have been able to avoid this, but now it is
a necessity…” (Consultant in acute medical
care).
7Identifying patients for the PCWBS This is where formulation comes to the fore,
Centre for Mental Health REPORT Clinical psychology in primary care
as a key component will be understanding
Each of the practices PCWBS works with has how the patient views the links between their
gone through a process of identifying frequent physical and psychological health and how
users of their general medical services for they understand causes, triggers, maintenance
whom there is a history of unresolved and factors and what steps they need to make to
unexplained medical symptoms and long term work towards their goals. This enables PCWBS
conditions: to attempt to deliver any interventions in an
“…Before I refer to PCWBS I do a detailed acceptable way to the patient. Sharing the
review of the patient’s full history, and it is a formulation with other professionals in contact
very demanding and labour intensive task… with the patient is also vital.
it might take quite a few hours spread over
a week or two…but as demanding as it is, Working with GPs and other health
it is also an extremely useful task…This is care teams
not an opportunity we get very often and
it is not until you review the case notes in PCWBS clients may be in contact with one or
such detail that you start to see the patterns more acute medical care teams, and the team
and explanations…I mean at the back of my and GPs stress the importance of all those
head I will have known that there must be working with the client to develop a shared
some psychological explanation for their understanding and, where appropriate, a
behaviour, but the case review provides the ‘script’ for all services involved in the patient’s
evidence…” (Bradford GP) care (e.g. reception staff; GPs; ambulance crew;
police etc) to understand the formulation and
grounding techniques:
Engagement and formulation
“…everyone working with the patient needs
Once the GP file review is complete, where all
to be saying the same thing, otherwise they
‘red flags’ have been explored and alternative
go further down an unhelpful and potentially
diagnosis eliminated, this is shared with the
harmful route…it’s a difficult task because
multidisciplinary PCWBS team and the patient
everyone in all teams who is likely to have
is offered an assessment appointment within
contact needs to be brought on board…and
two weeks. This is not always a straightforward
that is hard enough in general practice, let
process:
alone with more than one acute care team…”
“…most of those we work with are heavily (Bradford GP)
invested in seeing the issues they bring into
The scripts are about reinforcing the
the practice as being physical, and often
formulation and wellbeing with each client,
there are genuine physical components,
and helping them utilise the psychological help
perhaps quite serious and/or chronic
rather than a focus on symptoms and an illness
ailments, and [they] consequently may be
message/model.
resistant to being offered an assessment
by a psychological service…” (Clinical “…it is enormously difficult not to offer
psychologist) more [physical] investigation, even when
you doubt it will help…we have very little
“…some people may resist the idea that
psychological or psychiatric knowledge
there is a psychological component to
and so we tend to offer what we have in
their problem, throughout their contact,
our ‘tool kit’, which will be more tests and
but it doesn’t mean they can’t be helped…
investigation…the involvement of PCWBS
Sometimes people can be engaged with if
gives us confidence and reassurance and
they come to understand that everything,
fills the gap in knowledge we don’t have…”
including their physical or medical issues,
(Acute care consultant).
also have a psychological component…and
that support with this might help manage
pain for example…” (Clinical psychologist)
8At the time of writing, PCWBS was working In some cases, the PCWBS has worked with
Centre for Mental Health REPORT Clinical psychology in primary care
across four GP practices. The degree to which the patient and the Frequent Attenders Police
each practice participated was perceived to be and Ambulance Teams to help patients avoid
variable. It was reported that some GP partners prosecution or further prosecution. One
had less knowledge and interest in the links example given was of a woman who was
between physical and mental health and were calling emergency services, when in distress,
less inclined to use the service, and some may sometimes several times a day or at least daily.
have found the requirement for intensive case She has been supported to dramatically reduce
review prior to referral off-putting. this so that it is now an occasional occurrence.
“…we have a big educational function; a lot “…this is someone in their 50s, they
of people see a referral as a resolution of a have had years of domestic violence and
problem, but we expect quite a lot of work to attachment issues and these behaviours
go into that referral and to continue working have been going on for some time …you
in partnership with the GP and patients after cannot expect to completely transform them
this… We see the GP as part of the team and overnight…it’s about taking first steps and
not all those we want to work with see that…” then some more, it’s a gradual process of
(Clinical psychologist) progression…” (clinical psychologist)
“…when we were establishing the team we
initially had psychiatry, but we changed
this…we already have the medical model
well represented, we are all doctors!… What
we wanted was an alternative way of viewing
patients’ needs, something that was different
and complementary and helped us achieve a
fuller understanding… ” (Bradford GP)
9Centre for Mental Health REPORT Clinical psychology in primary care
Catterick and Shropshire’s GP style psychology services
The models of provision in Catterick, North Both models were described as offering “a GP
Yorkshire, and in Ludlow and Telford, of the mind service” where they largely offered
Shropshire were broadly similar, though not a fairly rapid access and unrestricted service. In
identical. The services in Shropshire were both services, professionals or patients could
provided by a single clinical psychologist, freely and directly book appointments to see
with some trainee psychologist support, and the clinical psychologist. In the Telford service,
operated in one general practice in each area the majority of appointments were booked by
(two days per week in each practice). The the patient’s GP and fewer appointments were
service in Catterick was provided by a single booked for the under-18 age range. In Catterick
clinical psychologist, also with some trainee and Ludlow, however, appointments were mainly
support. booked by the patients and there were a greater
number of young people accessing the service.
Catterick is a small town known for both its
racecourse and for its large military garrison, “…the intention was to provide a genuine GP-
and it is the latter which perhaps has the most style service and to deal with a large volume
impact on the GP practice. Veterans have of patients, just as we do…” (GP, Catterick)
chosen to retire and settle in Catterick and there
Both services offered much shorter
is also a significant military and ex-military
appointments than would be typical of clinical
family population, and in the case of the
psychology (usually hour-long appointments).
former often with a family member on a lengthy
At Catterick the appointment times on offer
deployment.
were 15 minutes in length (these accounted
Ludlow is a market town, also famous for its for 42% of appointments), but with the option
racecourse, in Shropshire. It serves a similar of the patient choosing to have two 15-minute
size population to that of Catterick and whilst slots together (i.e. a 30-minute slot – these
it is more affluent, it does have one area within accounted for 58% of all appointments). A
the town in the top 20% of deprived areas total of seventy 15-minute appointments were
nationally and another in the top 30%, both available over a week (this could increase when
close to the GP practice where the clinical a trainee psychologist was in post).
psychologist was based. The practice, one of
At both Ludlow and Telford, 30-minute appoints
two serving the town, has a population drawn
were offered:
from the town and the surrounding rural areas.
“…the way it worked was that you just
Telford is a large new town, developed mainly in
had to work at a more rapid pace….so we
the 1960s and '70s. It has areas with significant
would spend 10 minutes listening to the
deprivation and the GP practice where the
patient describe the problem, 10 minutes
project was based was one of these. The
developing a formulation and 10 minutes
practice also served communities affected by a
offering the intervention…so we are basically
recent sexual exploitation and abuse scandal,
doing things at twice the standard pace…”
and this was reflected in some of the patients
(trainee psychologist)
who used the project.
“…This is why it requires someone with
The services in Catterick and Telford have both
both considerable experience and training…
closed; Catterick closed a few months before
and it is very similar and indeed based on
data collection began and Telford soon after
how GPs work…they are just the same, they
data collection completed. Both had been pilots
have a very broad training and like us are an
and had non-recurring funding. The service
expensive resource… but it is the skill level
at Ludlow has also changed and the practice
you need to work successfully at that pace…”
now funds a single day of a mental health
(clinical psychologist).
practitioner.
Telephone consultation was also a significant
part of the offer on all sites.
10Centre for Mental Health REPORT Clinical psychology in primary care
“…if you want to deliver a message to a
Working with a range of needs patient and want them to take it on board,
The style of working on all sites was essentially it is vital that you know how they perceive
similar and the vast majority of people attending things and think…you have to adapt the
appointments were accepting of there being a message and coat in the language that the
significant psychological, emotional or mental patient you are with speaks…” (Clinical
wellbeing component to the issue that they were Psychologist, Shropshire)
seeking help with. This is of course in contrast “…I had a mother and their child with me
to many of the patients attending the Bradford just last week…they been through some
project, who often had heavily invested in their difficult times and had been to various
issue being solely a physical condition. services…essentially the things they were
The range of clients and presenting problems experiencing were entirely normal reactions
was very similar both in Catterick and to traumatic events…and other services had
Shropshire. At Catterick, the youngest patient told them this. Possibly what I did differently
had been under one year of age and the oldest was to listen, not just to their story, but
well into their 90s. The types of problems seen also how they told their story and how they
on all sites included: thought about [it], and I essentially delivered
the same message again, but tailored to
• Forms of psychological trauma
how they thought…the reaction I got was
• Depression or low mood enormous relief from both and they relayed
• Anxiety symptoms that this is the first time they had been told
this….” (Clinical Psychologist, Catterick)
• Relationship and emotional difficulties
• Grief reactions Benefits of the approach
• More severe mental health symptoms
All three sites reported positive feedback
(including those with suicidal ideation)
from both patients and families, and we
• Drug and or alcohol problems found professionals in primary care to be very
• Chronic physical health problems enthusiastic about the services offered:
• Symptoms of chronic pain “…the patients and their families like the
• Autistic spectrum disorders service…I get really positive feedback…” (GP,
Shropshire)
• Personality disorder
“ …There were a number of patients I’d see
• A mixture of some of the above issues.
every day [before the service started] who I
was never really helping…” (GP, Shropshire)
The importance of formulation
“…In the past I might have offered extra time
“…we often won’t know the outcomes of our but probably not have helped patients much
consultations, as much like with GPs, people and some I might have referred on to IAPT or
come and consult and don’t see a need to secondary care, sometimes with little hope
come back… Very often I am helping someone they would be accepted…” (GP, Shropshire)
start off a new way of thinking about their
problem or need…” (Clinical Psychologist,
Catterick)
Data from the Catterick service
Data on actual service use had been collected
For all three sites where this model was offered,
for local audit and evaluation purposes
it was important to understand, quite rapidly,
(covering a 22-month period) and was made
the way in which each patient ‘mentalises’, i.e.
available from Catterick for this report.
the way they think about things and the way
they understand others:
11Centre for Mental Health REPORT Clinical psychology in primary care
Appointments and consultation (including Trainee appointments etc) Total¹
Appointments/consultations offered (number of patients) 3,190 (887)
Appointments/consultations attended (number of patients seen) 2,141 (790)
Non face to face consultation² 403 (218³)
Phone intervention 394 (2114)
Total appointments/consultations and patients receiving intervention 2,535 (979)
Did not attend (DNA – unplanned) 295 (233)
Cancelled 360 (273)
¹ Less than 5% of appointments offered were with a trainee psychologist, the vast majority of offers were with the senior
clinical psychologist.
² These were consultations offered about specific patient given to another professional.
³ These are included in the total figure above
4
89 patients received only intervention by phone consultation. The phone contacts are in addition to the appointments/
consultations offered.
Had the project run for two years rather than 22 referrals (mental health and non-mental health)
months, the number of appointments offered were accepted. So, whether the Catterick
would have equated to 1,955 per year, or 163 service reduced referrals to some services
per month. These appointments would have or increased them to others, it appeared to
been offered to an estimated 1,064 individuals significantly increase the likelihood of any
(532 each year). onward referral being accepted, which, as
previous quotes reveal, was not the experience
Of patients who were seen by the service, 63%
prior to the pilot.
were female. Twenty-three per cent of patients
were aged 17 or less, 74% were 18-65 and 3% Though data was not available for onward
were over 65. referrals in Shropshire, the clinical psychologist
there felt they had made an impact on other
The service had a dramatic effect on referrals to
services by ensuring onward referrals were only
other services. Referrals overall to services in the
made when necessary:
local mental health trust reduced over the course
of the pilot by 27%, and even more dramatically “…the vast majority of referrals that we make
to community mental health teams by 47%. are accepted and ‘stick’ with the service we
Referrals also reduced to the local Improving refer to…”
Access to Psychological Therapies service (IAPT),
This was due to quite detailed work being done
where there was a 60% reduction.
by the clinical psychologist in ensuring that the
Some services, in contrast, received an increase case was appropriate for referral, but also due
in referrals, for example CAMHS increased by to the psychologist preparing the patient on
a third, but all those referrals were accepted what to expect from secondary care (or other)
by CAMHS. Referrals to a separate Primary services, so that they more were accepting of
Care Mental Health Service also increased by a any offer made to them: this was described as
similar margin (29%). These are teams of link “psychological readiness”.
workers and counsellors, provided by Tees,
Referrals from the GP practice in Catterick to
Esk and Wear Valleys NHS Foundation Trust,
secondary care have increased since the closure
working with primary care and providing brief
of the project and it was estimated this increase
interventions for adults with mild to moderate
would be 28% by the end of the year post project.
mental health problems. Virtually all onward
12Centre for Mental Health REPORT Clinical psychology in primary care
Project Future: a community-based, psychology-led service
Project Future is a psychologically led mental young person stated, “…everyone is police until
wellbeing project delivered directly to a proven otherwise…”. Another key feature is that
community in Haringey. (It is a partnership that young people do not have to be identified as
includes Barnet, Enfield & Haringey Mental having a problem with their mental wellbeing
Health NHS Trust, Haringey Council, Haringey and are never obliged to take up offers of
Mind and formerly MAC-UK.) It was developed psychological support but can still use and
from three previous projects, in two other benefit from the project.
London boroughs (Camden and Southwark) by
the charity MAC-UK. It is included in this report Coproduction
to demonstrate the value of clinical psychology
being located in a community of people who do The project is a partnership between the local
not readily engage with primary care and do not NHS trust (Barnet, Enfield & Haringey Mental
trust statutory services. Health NHS Trust), Haringey Council and Mind
in Haringey. The project began with clinical
The project features clinical psychologists psychologists building relationships with young
working alongside other professionals such people and, having identified a safe space (a
as youth workers, but critically it works with property owned by the council), co-designed
young people to coproduce the project. Some what the project would be like and what its
of these young people will be employed to focus would be. As with previous projects,
work as part of the core project team. Centre for young people wanted to develop creative skills
Mental Health has evaluated all four projects (through music and film), fitness, cooking and
and recruited from the young people using the support in finding work amongst other things.
project peer researchers (Stubbs et al., 2017 & The young people also got involved in social
Durcan et al., 2017). activism and have met with local and national
The project works with young men aged 16 to politicians and policy makers to champion the
25, with experiences of the criminal justice needs of young people and their community
system, specifically those exposed to serious more generally.
youth violence and often labelled "gang-
affiliated”. Most of the young people do not Therapy in ‘bite sized chunks’
seek help from formal services, often even when
Whilst the everyday activity of the project is
in severe need, for issues surrounding mental
often not directly about psychological wellbeing
wellbeing, general wellbeing and for social and
or even wellbeing more generally, all of the
broader issues.
interactions with the young people are clearly
thought through, and this even includes text
Peer referral messages and emails. The founder of the
The project is unusual in a number of ways original MAC-UK project and charity, Dr Charlie
and the referral route to the project, through Howard, described the therapeutic approach as
peers, is a key example. Friends bring friends being “…evidence based interventions divided
to the project and this ensures safety (young up into bite sized chunks…” which are designed
people from rival and conflicting peer groups around the needs of the young people they
do not mix) and helps in engagement; young are working with. This is not all that dissimilar
people attend the project on recommendation to the approaches in Bradford, Catterick and
from friends. This is particularly important as Shropshire, where likewise an understanding of
the young people largely do not trust anyone the how the person ‘mentalises’ their world is
outside of their family or peer group: as one felt to be crucial to effecting change.
13Formulation and mapping Stigma around mental health was very high
Centre for Mental Health REPORT Clinical psychology in primary care
among the young people at the outset and
As with the primary care models described, this changed over the course of the project.
formulations form a key part of how the The initial stigma meant that many and indeed
psychologists work with the young people. most young people would not seek help for any
Understanding the wider context and social problems they experienced.
determinants for each young person is vital.
This is referred to in the project as ‘mapping’ “…I don’t know how long I could have carried
and is a process the whole team engages in on sweeping things under the carpet, but
weekly; this allows the whole team to share now I can bring it here and talk about it and
the same understanding of the young person. feel free, get peace of mind, pour out what
The mapping, as with formulation in the other I’ve been keeping in for many years…”
projects, enables the team to draw on theory
and evidence-based approaches to develop the
intervention that best fits.
14Centre for Mental Health REPORT Clinical psychology in primary care
The economic case for clinical psychologists in a primary role
There is a lot of evidence that psychological A published small scale evaluation of the
interventions work and are cost effective. The Bradford PCWBS (Bestall et al., 2017), in the
Washington State Institute for Public Policy first year of its operation and using a small
(WSIPP, 2014-2016) found that for every £1 sample of 19 patients, found that it reduced
spent on interventions such as Cognitive use of both secondary and primary care and
Behavioural Therapy, for depression and within nine months had reduced the cost of
anxiety, anything between £15 and £50 can intervention for those patients by £63,950
be saved, and with at least an 84% likelihood (i.e. a potential £85,267 over 12 months).
that the benefits of programmes will exceed Some costs such as out of hours contacts and
the costs. The case for IAPT is based on such prescriptions were not fully included (they
evidence. were too resource-intensive to fully collect for
the evaluation) and service use data was not
Delivering such interventions in primary
available for all of the patients using the service.
care is also cost effective. For example,
It is therefore possible that the total savings
‘collaborative’ primary care (which involves a
may have been significantly greater. Pemberton
mental health/psychology professional working
(2018) also evaluated the service and, reviewing
in collaboration with primary care) for people
costs for care of 65 patients, found a mean
with depression has a spend to benefit ratio of
saving of £577 per patient (a saving in total of
£1:£12, with a 98% chance that costs will not
£37,496), made up of reductions in elective and
exceed benefits. Similar care for people with
non-elective admissions and use of Accident &
co-occurring medical problems has a spend to
Emergency departments.
benefit ratio of £1:£7.50, and a 100% chance
the cost will not exceed the benefits. The model in Bradford is working with the
costliest patients in primary care and is
A recent UK case study of a pilot project
showing promising results from an economic
addressing persistent physical problems in
perspective. Evidence from Catterick (which
primary care in Nottingham demonstrated that
will likely apply in a large part to Shropshire,
the service produced savings equivalent to 72%
too) indicates that such a service can see a
of the total costs of delivering the service and
significant number of patients and this reduces
111% of the cost of staffing the service (O’Shea,
referrals to other services significantly, while
2019).
those who are referred are more likely to be
A local review of the model in Catterick found accepted by receiving services. We do not have
that the cost per contact for the clinical sufficient evidence here to state that there is
psychologist in the practice was £66, which was a proven cost-benefit case for the particular
36% less than the average psychology contacts models we have explored, but it is likely that
(£103) and 253% more productive (i.e. seeing such models will have cost as well as clinical
considerably more clients) than the mean across and human benefits.
mental health services. This is due to the high-
volume nature of the service. The degree of
difference in cost and productivity would likely
be less (but still significant) in Shropshire, due
to longer appointments. What we do not have is
an evaluation of the clinical outcomes produced,
but satisfaction among those who used the
service was high.
15Centre for Mental Health REPORT Clinical psychology in primary care
Conclusion
All of the services featured in this report offered to communities. The lessons from the Catterick
help to people who may get little or no benefit project are being applied to local thinking on
from other health services, in some cases at a Integrated Care Systems: at the time of the
very high cost to them and to the NHS. interviews for this report, this included the
contribution clinical psychology can bring to
Newbigging and colleagues (2018) describe
a primary care led ‘one stop shop’ for children
a huge gap between primary and secondary
and young people.
mental health care, where cases are too
complex for IAPT services but yet fall short of Primary Care Networks are currently funded
secondary care thresholds (which have risen in to employ additional physiotherapists,
recent years). The clinical psychologists in all pharmacists and some other professionals,
of the services we have described were able to and from April 2021 this will be extended
make an offer to many of the people falling into to mental health professionals, including
this ‘chasm’, and for others were able to offer clinical psychologists (Naylor et al., 2020). This
an intervention that would improve engagement represents a major opportunity for the NHS
with other services: to benefit from the knowledge, expertise and
distinctive approach that psychology can bring
“…a lot of the people that attend the surgery
to primary care. The services featured in this
have complex needs and GPs will find them
report show the benefits that taking this step
very difficult to deal with, but these same
can bring.
patients often fall below the threshold of
entry into secondary care and will not be The Community Mental Health Framework (NHS
accepted by them, or are also going to be too England, 2019b) creates a further opportunity
complex for IAPT… I was able to make an offer to expand primary care clinical psychology
to many of those patients and found that the provision. It sets out an expectation that the
referrals to both secondary care and IAPT gaps between primary and secondary mental
were accepted…in addition, prior to referral health care will be closed with the development
I worked with the patients to help them of a ‘whole person, whole population’ approach
understand how the service worked and how to community mental health services for adults
it might help. This is actually really important in England. The services described in this report
and helps with engagement…” (Clinical will be essential to bridge the gaps and offer
Psychologist) a genuinely ‘whole population’ approach to
mental health in primary and community care.
The models described in this report have
all brought psychological intervention and The models we have described show that
formulation closer to communities, either different approaches can be applied to meeting
through GP surgeries or in alternative locations. different types of need in different places:
In so doing, they may have an important there is no one-size-fits-all to primary care
contribution to current developments in the psychology, and in some cases, such as Project
provision of health care, such as Integrated Future, it need not be in primary care settings
Care Systems, Primary Care Networks and the at all. But by bringing clinical psychology into
implementation of the NHS Long Term Plan. the heart of primary care and into communities,
the NHS could reach people whose needs have
The aim of Integrated Care Systems is to
rarely been well met and provide better care
support joined up care from a variety of
close to home.
providers and sectors, and to bring this closer
16Recommendations the needs of the local populations, taking
Centre for Mental Health REPORT Clinical psychology in primary care
account of demographic and diversity
The recommendations set out below will help characteristics. The psychological workforce
to extend and embed clinical psychology within should include clinical psychologists
primary care in England. Similar approaches can and other applied psychologists and
be taken in the devolved nations to bring about psychological professions to support a more
equivalent outcomes in each part of the UK. balanced and integrated workforce to better
• NHS England/Improvement should ensure meet people's mental and physical health
that the implementation of the NHS care needs.
Community Mental Health Framework • Primary Care Networks should take the
is aligned with the development of opportunity to offer clinical psychology to
Primary Care Networks to maximise the their patients by employing mental health
opportunities to bring clinical psychology professionals from April 2021.
expertise into primary care, drawing on the
models presented in this report. This should • Clinical commissioning groups and
include robust and independent evaluation integrated care systems should develop
and impact measurement to assess which plans and local recruitment strategies for
models work in which places and in what extending clinical psychology provision in
circumstances. primary care as part of the implementation
of the NHS Community Mental Health
• The Department of Health and Social Framework.
Care should ensure that the national
recruitment campaign for 26,000 more • Integrated care systems, clinical
primary care professionals working over commissioning groups and local authorities
the NHS in the next 5 years has a focus should explore the potential for innovative
on psychological approaches. This would community psychology projects to address
include family and community approaches unmet needs in the most marginalised
and population-based prevention initiatives. communities whose members do not
The psychological workforce profile should routinely seek help from statutory services.
be considered in the context of meeting
17Centre for Mental Health REPORT Clinical psychology in primary care
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19Clinical psychology in
primary care
Published September 2020
Photograph: FatCamera, iStock
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